Alcohol Treatment Unit Research Articles

Pharmacological Treatment of Alcohol Withdrawal

Excessive chronic alcohol users, and particularly patients with alcohol use disorder, may present an alcohol withdrawal syndrome if they abruptly stop drinking. Alcohol withdrawal syndrome requires pharmacological treatment for the treatment of withdrawal symptoms and to prevent withdrawal complications. Medically assisted withdrawal treatment is used in alcohol treatment units, but it is also frequently required in patients admitted to hospital for other conditions. Review of major guidelines covering treatment of withdrawal syndrome with the aim to describe recent evidence and recommendations about the pharmacological treatment for alcohol withdrawal syndrome. Four major guidelines concerning treatment of withdrawal syndrome were selected (National Institute for Health and Care Excellence, American Society of Addiction Medicine, World Federation of Societies of Biological Psychiatry and American Psychiatric Association) and screened for the recommendations and level of evidence on drug prescribing for alcohol withdrawal syndrome. The Maudsley guidelines were also considered in this review. All the four reviewed guidelines recommended benzodiazepines as the first line treatment for alcohol withdrawal syndrome. The association of anticonvulsivants, adrenergic alpha-2 agonists, betablockers and antipsychotics with benzodiazepines is recommended for symptom reduction in severe alcohol withdrawal syndrome. Thiamine should be administered to all patients to prevent Wernicke-Korsakoff encephalopathy. If there is any electrolytic imbalance it should be corrected. Maintaining a high level of suspicion for alcohol withdrawal syndrome is important across all clinical settings, and it should be promptly treated.

Hepatitis C virus micro-elimination in vulnerable populations before and during a global pandemic.

to analyze a hepatitis C virus (HCV) microelimination strategy targeting vulnerable populations and the influence of the pandemic on its maintenance and outcomes. in 2018, the Hepatology Unit implemented an HCV microelimination strategy for patients attending drug addiction care centers and Psychiatry Units such as the Alcoholism Treatment Unit. These centers reported suspected or confirmed cases of HCV infection directly to the hepatologists, who, after reviewing the clinical records, cite those patients if necessary. from June 2018 to February 2020, hepatologists were consulted on 37 anti-HCV positive patients, 31 of them were from Drug Addiction Care Centers, 5 from the Alcoholism Disorders Unit and 1 from the Department of Psychiatry. Fibrosis stage: F0-F1, 18 (50%); F2, 9 (25%); F3, 2 (4.2%); F4, 8 (20.8%). Female sex, 6 (16.7%). Required attending: Yes, 27 (73%). 25 (92.6%) went. Outpatient consultation: 10 (27%). Required treatment: 19 (51.3%). Sustained virological response: 19 (100%). Fibrosis stage of treated patients: F0-F1, 13 (68%); F2, 2 (11%); F3, 1 (5%); F4, 3 (16%). Patients from the Psychiatry Department during 2021: 11. 9 (82%) do not need to attend; 2 (18%): their situation is unknown. sustained communication with centers that care for populations at risk of active HCV infection is needed to detect cases, increase adherence to treatment, and rescue patients who require screening for hepatocarcinoma.

Outcome in Relation to Drinking Goals in Alcohol-Dependent Individuals: A Follow-up Study 2.5 and 5 Years After Treatment Entry.

To evaluate the long-term treatment outcome (up to 5 years) with respect to different drinking goals of patients. Alcohol-dependent individuals (n = 349) were recruited from three alcohol treatment units. They were interviewed using the Addiction Severity Index (ASI). They were sub-grouped according to their goal at treatment entry: abstinence, low- risk drinking and no decided goal. Patients with abstinence as a goal at treatment entry reported at 2.5 years follow-up a higher abstinence rate, a more pronounced reduction in alcohol consumption, reduction in total number of DSM-IV criteria, higher frequency of low-risk drinking and fewer diagnoses of alcohol dependence compared to the groups who had low risk drinking as a goal or no decided goal. This improvement remained basically unchanged in all three groups at 5 years follow-up, suggesting long-term stability after the treatment interventions. The findings suggest that: (1) alcohol-dependent patients who have abstinence as their own drinking goal have a more favorable treatment outcome than those who have low-risk drinking as a goal or no decided goal. (2) Abstinence as a drinking goal should be considered for those who have a longer duration (for example more than 10 years) of their alcohol-related problems. (3) Patients who have no decided goal should be recommended abstinence as a drinking goal.

Addiction Lives: Moira Plant.

Addiction Lives: Moira Plant.

Evaluation of sleep quality of early buprenorphine/naloxone treatment in opioid addicted patients

Objective: Opioid addiction is a chronic, relapsing and psychosocial disorder. In opioid addiction patients, studies show that sleep disorders, deteriorated quality of sleep and sleep architecture changes might be seen. In addition, comorbid psychiatric disorder and depression are frequently seen in opioid addicts. Comorbid psychiatric disorders and symptoms worsen of sleep quality in opioid addicts. This study aims to evaluate the quality of sleep during the periods of pre-treatment and in early opioid agonist maintenance treatment in the opioid addicts. Methods: The research included 29 patients in the Alcohol and Substance Addiction Treatment Unit of Trakya University Faculty of Medicine who have met diagnostic criteria for opioid addiction according to DSM-5, completed 28-day treatment, and admitted for control to Alcohol and Substance Addiction Treatment Unit after 1 month from discharge. The Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Pittsburgh Sleep Quality Index are administered to all the patients who participated to the study on the day 1, day 28, and in the month 2. All the patients were treated with buprenorphine and naloxone combination. Results: In our study, a time-dependent significant de-crease from day 1 to month 2 was determined in the average scores of the Pittsburgh Sleep Quality Index, which evaluates the sleep quality. In addition, the Pittsburgh Sleep Quality Index average scores showed differences in all time periods. Our study also determined a time-dependent significant decrease in the average scores of the Hamilton Depression Rating Scale and the Hamilton Anxiety Rating Scale, which evaluates respectively the depressive symptoms and anxiety symptoms on the day 0, day 28 and day 60. Discussion: In our research, we evaluated the sleep quality and the symptoms of depression and anxiety of the patients diagnosed with opioid addiction in pre-treatment and early period of opioid agonist maintenance treatment, and showed that those symptoms were getting better with treatment. We think that these findings can guide further research, as they show that opioid treat-ment does not only serve for addiction treatment but also for the treatment of the symptoms accompanying the opioid addiction.

Housing First or no housing? Housing and homelessness at the end of alcohol and drug treatment

BackgroundThe rate of alcohol and drug dependency is high among homeless persons in Norway as well as in other Western societies. National homeless surveys also show a certain correlation between discharge from institutions and homelessness. However, the rate of homelessness versus the rate with fixed abode at the end of specialised alcohol and drug treatment has not been examined using quantitative methods. MethodsA cross-sectional survey was conducted in alcohol and drug treatment units in the national health services and private clinics. The survey investigates the housing outcome at the end of treatment compared to the situation at the start of treatment using an individual questionnaire for patients ending treatment in a specific time window. Housing outcome is measured by the odds ratio of having a fixed abode at the end of treatment in relation to main intoxicating substance, type of treatment (in- and outpatient), completing versus cutting short the treatment, housing situation at the start of treatment, socioeconomic capital, mental health problems, individual plan, medical assisted treatment, and a set of background variables. ResultsThe housing versus homeless situation hardly changes during the treatment period. In both a bivariate analysis and a simple multivariate model, principal intoxicating substance is the strongest predictor of having a fixed abode both before and after treatment. However, a more sophisticated analysis indicates that socioeconomic resources and social capital play along with the preferred intoxicating substance as predictors of having permanent housing. ConclusionAfter more than a decade of a housing-led national homeless policy, and wide embracement of Housing First approaches in the European Union, homeless persons entering specialised alcohol and drug treatment are likely to return to the streets and hostels at the end of treatment. Access to housing after treatment is very limited for those lacking resources to solve their housing problem without assistance.

Hereditary influence in alcohol dependence

IntroductionAlcohol dependence is one of the psychiatric disorders for which hereditary influence is strongest. In fact, the importance of genetic factors in transmission of vulnerability to alcohol dependence was first described in literature many years ago by psychiatrists who dedicate to its study. That vulnerability may be explained by an epigenetic model in which biological hereditary factors associate with environmental factors to cause alcohol dependence.ObjectivesStudy the influence of genetic factors on alcohol dependence.MethodsDuring 4 consecutive months a sample of alcoholic patients was collected from the Alcohol Treatment Unit of CHPL (inpatients and outpatients). Biographic data, patient's psychiatric diagnosis and family history of alcohol dependence or of dependence of other drugs were recorded.ResultsInitial sample included 122 patients. After exclusion of patients who were also hospitalized in that period, the final sample included 102 patients (26% female), with a mean age of 48 years old. Main patients’ diagnosis was alcohol dependence but most of them (52%) presented psychiatric comorbidity. Most patients (55%) had family history of alcohol dependence or dependence of other substances, 26% did not have and 19% did not know. For 61% of patients, the father and/or mother were the affected relative. Most patients (61%) who had a family history of alcohol dependence or dependence of other substances had 2 or more affected relatives.ConclusionsMost patients with alcohol dependence have family history of alcohol dependence or dependence of other substances, usually in more than 1 relative, which must be taken in account during treatment.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Building the connections between science, practice and policy: Griffith Edwards and the UK National Addiction Centre

Building the connections between science, practice and policy: Griffith Edwards and the UK National Addiction Centre

Using the SF-6D to measure the impact of alcohol dependence on health-related quality of life.

Alcohol dependence not only reduces life expectancy, but also causes considerable loss of quality of life of the dependents of and persons around those with alcohol dependence. This article presents new evidence on the impact of alcohol dependence on health-related quality of life in Spain. Three samples were recruited: 150 alcoholics and 64 family members of alcoholics, with both samples taken from an alcoholism treatment unit, and 600 persons from the general population. We used the short form 6D, a preference-based generic instrument, applying the utility scores estimated for Spain. It was found that the annual mean loss of quality-adjusted life years associated with alcohol dependence was 0.144 and 0.083 for the alcoholics and their close family members, respectively. This impact becomes more notable after controlling for socio economic variables and was higher than that estimated in similar studies. Possible explanations for these differences are discussed. The results from this work can be applied to economic evaluation studies measuring benefits from policies targeted at reducing the prevalence of alcohol dependence.

Cognitive behavioral therapy treatment for smoking alcoholics in outpatients

OBJECTIVE: Cognitive Behavioral Therapy is a therapy based on cognitive and behavioral techniques: cognitive psychological education, cognitive restructuring, interoceptive exposure, breathing exercises and relaxation, all aiming at behavioral changes. The objective of the study was to determine the effectiveness of a specific model of Cognitive Behavioral Therapy for alcoholic outpatients in the treatment of smoking. METHOD: Sessions were carried out in two stages: (1) a “stop smoking” stage lasting four weeks, with 3 sessions/ week; (2) a maintenance stage beginning with 2 weeks of a single weekly session, followed by monthly sessions until the end of the one-year treatment. RESULTS: Forty patients participated in this study, 22 men and 18 women. After a year of treatment, 24 patients had stopped smoking, whereas 16 relapsed during the course of the year; two abandoned treatment. Women showed better results: 77.8% stopped smoking by the end of the treatment, but only 45.4% of the men reached this goal. CONCLUSION: Patients under treatment for alcoholism submitted to the tobacco treatment program; a majority of them achieved the treatment goal. A growing population of alcoholics and smokers are looking for treatment; this points to the need for a follow-up treatment program for smoking in an Alcoholism Treatment Unit. Cognitive Behavioral Therapy proved to be effective in the treatment of tobacco dependency mainly in women.

Treatment-seeking for alcohol problems: The influence of mirroring events and windows of opportunity

The current study aimed to investigate the range of influences on people's decisions to seek alcohol treatment and develop a model of treatment-seeking based on participants’ accounts. Understanding these influences could inform clinical practice and aid development of effective motivational interventions for the majority of people with alcohol problems who avoid or delay seeking treatment. Individual, semi-structured interviews were conducted with 30 participants who had been referred to an NHS alcohol treatment unit. To ensure, a broad range of treatment-seekers was investigated; participants were recruited according to the principles of maximum variation sampling whereby we interviewed participants at varying stages of engagement. Verbatim transcripts of the interviews were analysed within a thematic analytic framework. Contrary to expectations participants had not worked up gradually to seek help. Rather, participants described the decision to seek treatment as sudden and prompted by events that mirrored the extent of their drinking. Participants described their response to these mirroring events as both passive and autonomous. Furthermore, a window of opportunity was initiated by these events, during which participants were responsive to suggestions to make changes to their drinking and practitioners could influence the treatment-seeking process. This evidence is inconsistent with influential models of treatment-seeking behaviour. It suggests an alternative view that treatment-seeking is externally influenced and the result of a step-wise rather than gradual process. The findings indicate how practitioners might encourage treatment-seeking, particularly for participants who may not appear ready to change.

Prevalence and correlates of major depression among Nepalese patients in treatment for alcohol‐use disorders

This study investigated the prevalence of major depression (MD) and its sociodemographic and alcohol-related correlates among Nepalese patients receiving treatment for an alcohol-use disorder (AUD). A cross-sectional survey was carried out among 188 consecutively admitted AUD patients in eight residential alcohol treatment units in Kathmandu. We recorded sociodemographic data and administered the alcohol use and depression modules of the World Health Organization Composite International Diagnostic Interview 2.1 and the Alcohol Use Disorder Identification Test. Analyses were performed with χ(2) -tests, Student's t-tests, Mann-Whitney U-tests and logistic regression analyses. The lifetime and 12-month prevalence of MD among AUD patients were found to be 45% and 36% respectively. Living with a spouse and low-frequency drinking (2-3 days/week) showed negative associations with reporting MD in the preceding 12-month period, whereas a history of alcohol-induced blackout and problem drinking in the individual's parents were independently predictive of having a comorbid MD. MD is common among patients with AUDs in Nepal. Among AUD patients who sought treatment, a few factors, such as marital status, history of alcohol-induced blackout and drinking frequency, seem to correlate well with comorbid MD. Study results suggest that transgenerational underpinning of AUD-MD comorbidity may exist in those sections of the population who have strong taboos about the use of alcohol.

Ways of problem solving as predictors of relapse in alcohol dependent male inpatients

Aim The purpose of this study was to identify how remitters and relapsers view their everyday problem solving strategies. Method A total of 128 male alcohol dependent male inpatients who were hospitalized at the Ankara University Psychiatry Clinic, Alcohol and Substance Abuse Treatment Unit were recruited for the study. Subjects demographic status and alcohol use histories were assessed by a self-report questionnaire. Also, patients were evaluated with The Coopersmith Self-esteem Inventory (CSI), The Spielberger State-Trait Anxiety Scale (STAI-I-II), and The Problem Solving Inventory (PSI). Patients were followed for six months with monthly intervals after hospital discharge. Drinking status was assessed in terms of abstinence and relapse. Data were assessed with Student t-test, and univariate and multivariate analyses. In the logistic regression analysis, age, marital status, employment status and PSI subscores were taken as the independent variables and drinking state at the end of six months as the dependent variable. Results There were significant differences in reflective and avoidant styles, and monitoring style of problem solving between abstainers and relapses. It was found that subjects who perceived their problem solving style as less avoidant and less reflective were at greater risk to relapse. Conclusions The findings demonstrated that active engagement in problem solving like utilizing avoidant and reflective styles of problem solving enhances abstinence. In treatment, expanding the behavior repertoire and increasing the variety of ways of problem solving ways that can be utilized in daily life should be one of the major goals of the treatment program.

Alcohol Withdrawal Syndrome: Symptom-Triggered versus Fixed-Schedule Treatment in an Outpatient Setting

To investigate whether, in the treatment with chlordiazepoxide for outpatient alcohol withdrawal, there are advantages of symptom-triggered self-medication over a fixed-schedule regimen. A randomized controlled trial in outpatient clinics for people suffering from alcohol dependence (AD) and alcohol-related problems; 165 adult patients in an outpatient setting in a specialized alcohol treatment unit were randomized 1:1 to either a symptom-triggered self-medication or tapered dose, using chlordiazepoxide. Alcohol withdrawal symptoms, amount of medication, duration of symptoms, time to relapse and patient satisfaction were measured. Patients assessed their symptoms using the Short Alcohol Withdrawal Scale (SAWS). Patient satisfaction was monitored by the Diabetes Treatment Satisfaction Questionnaire. We used the Well-Being Index and the European addiction severity index for the 1-year follow-up. We found no differences in the quantity of medication consumed, time to relapse, well being or treatment satisfaction. Symptom-triggered self-medication was as safe as fixed-schedule medication in treating outpatients with AD and mild to moderate symptoms of AWS. The SAWS is a powerful monitoring tool, because it is brief and permits the subject to log the withdrawal symptoms.

'Stuck in a rut': A case study detailing the application of cognitive analytic therapy with alcohol use disorders

Research has demonstrated the outcome and treatment effectiveness of a range of psychosocialinterventions in the treatment of alcohol use disorders including, cognitive behavioural therapy,motivational enhancement therapy, and brief intervention. There do not appear to be any studiespublished regarding the effectiveness of cognitive analytic therapy within an addiction setting. A casestudy detailing 17 sessions of cognitive analytic informed therapy conducted within an alcoholtreatment unit with a 57-year-old female client who met the criteria for diagnosis of alcohol dependencyis presented to illustrate the applicability of this approach to clients who relapse and for whomtreatment as usual may not be beneficial in the first instance. The assessment and treatment proceduresare reported and two year follow up data is presented. Considerations for clinical practice arehighlighted.

Modulation of Impulsivity by Topiramate

Topiramate (TP), an anticonvulsant drug, has been widely used in the treatment of disorders characterized by impulsivity symptoms, so it goes to reason that it might be useful in addictive disorders. Recently, TP has been used to treat alcohol dependence, but it is still not known whether the effects of TP on alcohol consumption are related with its action on impulsivity. The aim of this preliminary study was to investigate which dimension of behavioral impulsivity is associated with the effects of TP. A 12-week, double-blind, placebo-controlled pilot study of TP for the treatment of alcohol dependence was conducted. Subjects were men recruited from alcoholism treatment units (TP = 31; placebo = 32). Diagnoses were made using the Structured Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Behavioral inhibition was assessed using the continuous performance test (CPT) and the stop-signal task. Differential reinforcement for low-rate responding (DRLR) was used to evaluate the delay-discounting dimension. Alcohol craving and alcohol consumption during the study were evaluated. Patients treated with TP presented lower rates of alcohol consumption in the number of drinks per drinking day (P < 0.05) and the number of heavy drinking days (P < 0.001). Scores on alcohol craving scales decreased significantly, and there was more improvement on the continuous performance test (total omissions and total commissions) and on the stop-signal task in the TP group than in the control group. Improved alcohol consumption behavior was associated with performance on the behavioral inhibition paradigm. The results of this study indicate that TP reduces drinking and that the mechanisms underlying this effect may involve, at least in part, modulation of the behavioral inhibition paradigm.

Thrombocytopenia in Early Alcohol Withdrawal is Associated with Development of Delirium Tremens or Seizures

In several studies, possible risk factors/predictors for severe alcohol withdrawal syndrome (AWS), i.e. delirium tremens (DT) and/or seizures, have been investigated. We have recently observed that low blood platelet count could be such a risk factor/predictor. We therefore investigated whether such an association could be found using a large number of alcohol-dependent individuals (n = 334). This study is a retrospectively conducted cohort study based on data from female and male patients (>20 years of age), consecutively admitted to an alcohol treatment unit. The individuals had to fulfil the discharge diagnoses alcohol dependence and alcohol withdrawal syndrome according to DSM-IV. During the treatment period, 3% of the patients developed DT, 2% seizures and none had co-occurrence of both conditions. Among those with DT, a higher proportion had thrombocytopenia. Those with seizures had lower blood platelet count and a higher proportion of them had thrombocytopenia. The sensitivity and specificity of thrombocytopenia for the development of DT during the treatment period was 70% and 69%, respectively. The positive predictive value (PPV) was 6% and the negative predictive value (NPV) was 99%. For the development of seizures, the figure for sensitivity was 75% and for specificity 69%. The figures for PPV and NPV were similar as those for the development of DT. Thrombocytopenia is more frequent in patients who develop severe AWS (DT or seizures). The findings, including the high NPV of thrombocytopenia, must be interpreted with caution due to the small number of patients who developed AWS. Further studies replicating the present finding are therefore needed before the clinical usefulness can be considered.

P01-19 Comorbid borderline personality disorder and alcohol use disorder: A case of combined psycotherapeutic and pharmocotherapeutic interventions

Background:The increasing attention given to dual diagnosis does not correlate with well defined and consensual therapeutic interventions. This issue is particularly evident in the case of comorbid severe personality disorders with clear indication for psychotherapy.Aim:To report a case of comorbid borderline personality disorder and alcohol abuse disorder, underlining the impact of dysfunctional personality traits in a specific dangerous pattern of alcohol abuse. To present and discuss a combined psychotherapeutic and pharmocotherapeutic approaches in a dual diagnosis case.Methods:Case study and review of the literature.Results:A 37 year old woman with a history of alcohol abuse and self-destructive behaviour was referred to an alcohol treatment unit. She had a personal history of childhood parental sexual abuse, alcohol abuse since adolescence and a high risk self-destructive behaviour. A brief psychotherapeutic intervention (weekly 4 months sessions) was started, along with treatment as usual (psychiatric consultation and psychopharmacological treatment). The psychotherapeutic intervention (Person-Centered therapy) focused on her relational difficulties, corresponding to her request - “dealing with unresolved issues in my life”. After the psychotherapeutic intervention, she was able to stop the episodes of alcohol abuse and to reorganize her life at several levels.Discussion:Choosing a psychotherapeutic and pharmacological approach for comorbid addiction disorder and personality disorder cases, presents difficulties due to lack of empirical evidence on dual diagnosis treatment. This case of combined psychotherapeutic and pharmacotherapeutic interventions had acknowledged success, in contrast to several prior treatment attempts focused mainly on the alcohol use disorder.

Double-Blind, Randomized Comparison of Memantine and Escitalopram for the Treatment of Major Depressive Disorder Comorbid With Alcohol Dependence

The aim of the study was to evaluate possible new treatments for major depressive disorder in patients with comorbid alcohol dependence in a municipal alcohol treatment unit. The efficacy of memantine, a noncompetitive glutamate N-methyl-D-aspartate (NMDA)-receptor blocker used for the treatment of moderate to severe Alzheimer's disease, was compared with that of escitalopram, a selective serotonin reuptake inhibitor antidepressant. Eighty alcohol-dependent outpatients with major depressive disorder (DSM-IV criteria) seeking treatment from municipal alcohol treatment clinics in Helsinki, Finland, were randomly assigned 1:1 to receive memantine 20 mg/day or escitalopram 20 mg/day. During the study period, patients continued their routine treatment at the clinics. Abstinence was not required. Concomitant interventions or imposed treatment goals were not offered by the study physician. The patients returned to the treatment clinics at weeks 1, 2, 4, 12, and 26 for data collection and for medication checking and dispensing. Outcome measures were the Montgomery-Asberg Depression Rating Scale (MADRS) and Beck Depression Inventory-II for depression, Hamilton Rating Scale for Anxiety (HAM-A) and Beck Anxiety Inventory for anxiety, Consortium to Establish a Registry for Alzheimer's Disease test battery for cognitive functions, and Social and Occupational Functioning Assessment Scale for social and occupational functions and quality-of-life measures. Twenty-nine patients in each group completed the study. All primary and secondary outcome statistical analyses were performed by an independent source for intent-to-treat populations, which included all patients randomly assigned to treatment. The study was conducted from December 2004 to May 2006. Both treatments significantly reduced the baseline level of depression and anxiety according to MADRS and HAM-A, which were the primary measures (p < .0001). There was no significant difference between the memantine and escitalopram groups. Assessed cognitive functioning scores were primarily within the normative range and were unchanged in both groups. Quality-of-life outcomes equally improved in both treatment groups. These data provide new evidence for the safety and potential efficacy of memantine and escitalopram for major depressive disorder in patients with comorbid alcohol dependence. ClinicalTrials.gov identifier NCT00368862.

Developing a controlled drinking programme for people with learning disabilities living in conditions of medium security

This article describes the development of an Alcohol Awareness programme based on a controlled drinking model within a medium secure service for people with Learning Disabilities (LDs). The broad therapeutic context of the service is described, together with some of the limited literature in relation to alcohol use and people with LDs. The origins of the programme, derived from working in a mainstream Alcohol Treatment Unit, are then described, followed by the rationale for development of the programme in the context of a medium secure service for people with an LD. The content of the programme is outlined and current and future issues are considered.