Current Health Care Providers Research Articles

Limitations and perspectives of the novel salivary test for endometriosis: an open web-based survey study of German gynecologic healthcare providers.

The description of a salivary miRNA signature for endometriosis has led to the development of a non-invasive diagnostic test. Current healthcare provider practices regarding the test remain uncaptured. The application of this test in practice was examined in a web-based survey, with the aim to provide their opinions on it. We conducted an open web-based survey study between November 2023 and January 2024. Members of the German society of gynecologic endoscopy (Arbeitsgemeinschaft gynäkologische Endoskopie, AGE), society of endometriosis (Arbeitsgemeinschaft Endometriose, AGEM), and the endometriosis research foundation (Stiftung Endometriose Forschung, SEF) were contacted per e-mail twice. Participants' data were anonymized. Differences in responses based on self-reported expertise in the field (basic knowledge, specialized knowledge, expert) were assessed using the χ2-test or Fisher's exact test. Statistical significance was set as p < 0.05. In total 141 of 190 respondents completely responded to the survey (> 75% of the questions of the survey). Twenty-one physicians reported having experience with the test, while most participants had at least specialized knowledge on the field (112/141). In terms of specific questions, more than 90% found the costs high; almost 85% did not believe that the test replaces standard diagnostic tools (histology, clinical examination, and sonography). Eighty-six providers supported the use of the test in adolescents. Gynecologists with basic knowledge had a more positive attitude compared with more experienced ones in terms of usefulness (Fisher's exact test, p < 0.001). Significant differences were demonstrated between expertise groups regarding (not only) applicability in adolescents (Fisher's exact test, p = 0.004), and using the test for screening purposes (χ2-test, p = 0.002). Despite the promising benefits of a salivary test for endometriosis, German healthcare providers would not change current practices. Nevertheless, less experienced colleagues were more positive towards the test.

Expanding Environmental Care Competencies for Future and Current Healthcare Providers.

The multiple impacts of the environment on the health of populations can oftentimes be clouded by the daily care practices of healthcare providers. This case study describes an innovative graduate level elective course that uses a problem-based approach to apply evidence-based principles of environmental health to the care of populations. Initial implementation of the course, over two cohorts in 2023, had primarily second-degree undergraduate nursing students. Lessons learned included the necessity to provide peer-to-peer support for several of the graduate level assignments. Positive student outcomes included an expanded understanding of the three main content areas of the course: (1) how soil, air, and water must be considered in individual and population-centered care; (2) the impact of the design of the built and healthcare built environment; and (3) considerations of planetary health for sustainability and mitigation. Faculty outcomes included coaching of undergraduate students in this graduate course and the development of peer-to-peer mentoring activities.

Preferences of people with diabetes for diabetes care in Germany: a discrete choice experiment

ABSTRACT Objectives The objective of this study is to elicit health care preferences of people with diabetes and identify classes of people with different preferences. Methods A discrete choice experiment was conducted among people with diabetes in Germany comprising attributes of role division in daily diabetes care planning, type of lifestyle education, support for correct medication intake, consultation frequency, emotional support, and time spent on self-management. A conditional logit model and a latent class model were used to elicit preferences toward diabetes care and analyze preference heterogeneity. Results A total of 76 people with diabetes, recruited in two specialized diabetes care centers in Germany (mean age 51.9 years, 37.3% women, 49.1% type 2 diabetes mellitus, 50.9% type 1 diabetes mellitus), completed the discrete choice experiment. The most important attributes were consultation frequency, division in daily diabetes care planning, and correct medication intake. The latent class model detected preference heterogeneity by identifying two latent classes which differ mainly with respect to lifestyle education and medication intake. Conclusion While the majority of people with diabetes showed preferences in line with current health care provision in Germany, a relevant subgroup wished to strengthen lifestyle education and medication intake support with an aid or website.

Raising awareness of anti-fat stigma in healthcare through lived experience education: a continuing professional development pilot study

BackgroundAnti-fat attitudes and weight-based discrimination are prevalent in healthcare settings and among healthcare practitioners and clinical trainees, and can result in immense harm to patients. There is increasing recognition that anti-fat bias in healthcare is a critical issue that must be addressed, but there is a dearth of evidence demonstrating sustained attitude and behavioural change among clinicians, illustrating a need for more innovative educational approaches and rigorous evaluation. We describe the co-design and delivery of a narrative-based continuing professional development curriculum aimed at raising awareness of weight-based bias and stigma.MethodsOur research team of lived experience educators, clinicians and researchers collaboratively developed a series of seven podcast episodes comprised of narrative descriptions of lived experiences with and impacts of weight bias, stigma and discrimination in healthcare settings, as well as a post-podcast workshop to facilitate reflection and discussion between participants. The curriculum was piloted among 20 clinicians practicing at a large urban hospital in Mississauga, Canada. We explored feasibility, acceptability and learning impact by analyzing responses to questionnaires completed following each podcast episode and responses shared during the workshops and follow-up feedback sessions.ResultsWe observed high acceptability and feasibility of the curriculum. Participants experienced the podcast as a practical and convenient learning format and the workshop as a valuable opportunity to collectively debrief and reflect. The learning impact of the curriculum was strong; participants described a range of emotions elicited by the podcasts, engaged in self-reflection, and expressed a desire to modify clinical approaches. Barriers to the application of learnings identified by participants include pervasiveness of the use of body mass index (BMI) as an indicator of risk and a criterion for referral; discomfort with difficult conversations; prevalent biomedical understandings about the association between weight and health; and clinicians’ defensiveness.ConclusionThis pilot study yielded promising findings and demonstrated potential impact on weight bias and stigma among healthcare providers. Necessary next steps include conducting larger scale, rigorous evaluations of the curriculum among broader populations, both health professions trainees and current healthcare providers.

From pelvic radiation to social isolation: a qualitative study of survivors' experiences of chronic bowel symptoms after pelvic radiotherapy.

We explored survivors' experiences of chronic bowel symptoms following pelvic radiotherapy, strategies employed in living with these symptoms, effects on daily activities, and roles at home and in the workplace. Semi-structured interviews were conducted with 28 individuals (10 gynaecological, 14 prostate, four anal/rectal cancer survivors) who had completed pelvic radiotherapy at least six months prior to data collection and who had experience of bowel symptoms during this post-treatment period. Reflexive thematic analysis was undertaken. We propose four themes describing a process leading from experience of symptoms to withdrawal from activities and roles. These are (1) losing control (the experience of unintended anal leakage or discharge); (2) experiencing embarrassment and fear (the experience of embarrassment or fear of embarrassment as a result of discharge becoming public); (3) managing and reacting (acting to reduce the likelihood of discharge or to prevent this becoming public); and (4) restriction and withdrawal (avoiding specific activities or situations so as to reduce or remove the risk of embarrassment). Returning to the workplace presented additional challenges across these themes. Impacts of chronic bowel symptoms can be severe. Survivors employ a variety of methods and strategies in living with their symptoms. Some of these support continued role fulfilment but some constitute a withdrawal from pre-treatment roles. Current healthcare provision and statutory protections fail to fully meet needs following pelvic radiotherapy. There is a need to develop and implement evidence-based services and supported self-management programmes for survivors experiencing chronic bowel problems post-radiotherapy.

Qualitative Evaluation of Treatment Partners for People With HIV in Botswana: Current Healthcare Provider Practices and Recommendations for Improvement.

Botswana has an adult HIV prevalence of 20.8% and annual incidence of 0.2%. We aimed to evaluate current practices and advance recommendations for treatment partners (informal adherence supporters) for people with HIV in Botswana. In January-February 2020, we conducted seven focus groups with 36 healthcare providers at seven HIV clinics in Gaborone, Botswana. Providers perceived treatment partners to be critical for quality patient care. They shared that in the new era of universal antiretroviral therapy (ART) initiation immediately after diagnosis ("test-and-treat"), providers no longer require patients to select treatment partners at ART initiation. Providers suggested a renewed emphasis on treatment partners. They believed that standard guidance for providers around treatment partner selection would ensure that providers cover similar topics across patients and endorsed implementation of workshops to educate treatment partners on how to support patients. However, streamlined ART initiation policies require innovative strategies, including eHealth interventions, to engage treatment partners.

Current definitions of advanced multimorbidity: a protocol for a scoping review

IntroductionPeople living with and dying from multimorbidity are increasing in number, and ensuring quality care for this population is one of the major challenges facing healthcare providers. People with multimorbidity...

Exploring the experiences of parents of Autistic children when attending the diagnostic imaging department for an X-ray examination

IntroductionAutism is a neuro-developmental condition which affects the social-emotional skills, behaviour, language, communication skills and flexibility of thoughts of an individual and their sensory processing. This can result in Autistic service users finding it difficult to navigate current healthcare provision and cope with the unpredictable environment. This paper explores the experiences of parents of Autistic children when attending the diagnostic imaging department for an X-ray examination. MethodsA cross sectional, mixed methods approach was adopted and the initial phase consisting of an online survey for parents to complete is the subject of this paper. The quantitative data was analysed using descriptive statistics and cross comparison between questions was also completed. Thematic analysis was taken to analyse the data from the two open questions at the end of the survey. ResultsThe online survey results are presented in this paper under four key themes; waiting times and environment, forms of communication, lack of understanding of staff regarding Autism and preparation for the X-ray examination. ConclusionThe overall rating of the parents' experience whilst in the X-ray/diagnostic imaging department was positive, however there are several areas which received low scores which need further attention. These were waiting areas, waiting times, staff development and patient preparation. Implications for practiceThe development of more inclusive waiting areas is needed, more effective lines of communication between staff to expedite the patient journey where possible, staff development of both radiographers and also support staff and the review of design of more accessible and inclusive patient information.

Ensuring health and wellbeing of Ukrainian refugees in the UK: the role of initial health assessments and local authority involvement

Abstract Since the beginning of the crisis in Ukraine, local authorities in the UK have facilitated the resettlement of over 150,000 Ukrainian refugees (as of February 2023) to the country. In this presentation, Anna Deal will discuss a UK case study based on her recent research working closely with local authorities in London to conduct a health and wellbeing needs assessment, exploring the situation facing Ukrainians and other key nationality groups on arrival. This presentation will focus on identified health and social needs of Ukrainians and current healthcare provision, including initial health assessments and catch-up vaccination delivery, for Ukrainians on arrival and how this varies under different local authorities. It will conclude by summarising key challenges faced in delivery of services and recommendations and implications for improving service delivery, both in the UK and other European countries hosting Ukrainian refugees.

An Introductory Tutorial on Cardiovascular Pharmacogenetics for Healthcare Providers.

Pharmacogenetics can improve clinical outcomes by reducing adverse drug effects and enhancing therapeutic efficacy for commonly used drugs that treat a wide range of cardiovascular diseases. One of the major barriers to the clinical implementation of cardiovascular pharmacogenetics is limited education on this field for current healthcare providers and students. The abundance of pharmacogenetic literature underscores its promise, but it can also be challenging to learn such a wealth of information. Moreover, current clinical recommendations for cardiovascular pharmacogenetics can be confusing because they are outdated, incomplete, or inconsistent. A myriad of misconceptions about the promise and feasibility of cardiovascular pharmacogenetics among healthcare providers also has halted clinical implementation. Therefore, the main goal of this tutorial is to provide introductory education on the use of cardiovascular pharmacogenetics in clinical practice. The target audience is any healthcare provider (or student) with patients that use or have indications for cardiovascular drugs. This tutorial is organized into the following 6 steps: (1) understand basic concepts in pharmacogenetics; (2) gain foundational knowledge of cardiovascular pharmacogenetics; (3) learn the different organizations that release cardiovascular pharmacogenetic guidelines and recommendations; (4) know the current cardiovascular drugs/drug classes to focus on clinically and the supporting evidence; (5) discuss an example patient case of cardiovascular pharmacogenetics; and (6) develop an appreciation for emerging areas in cardiovascular pharmacogenetics. Ultimately, improved education among healthcare providers on cardiovascular pharmacogenetics will lead to a greater understanding for its potential in improving outcomes for a leading cause of morbidity and mortality.

The voice of healthcare: introducing digital decision support systems into clinical practice - a qualitative study

BackgroundThere is a need to accelerate digital transformation in healthcare to meet increasing needs and demands. The accuracy of medical digital diagnosis tools is improving. The introduction of new technology in healthcare can however be challenging and it is unclear how it should be done to reach desired results. The aim of this study was to explore perceptions and experiences of introducing new Information Technology (IT) in a primary healthcare organisation, exemplified with a Clinical Decision Support System (CDSS) for malignant melanoma.MethodsA qualitative interview-based study was performed in Region Stockholm, Sweden, with fifteen medical doctors representing three different organisational levels – primary care physician, primary healthcare centre manager, and regional manager/chief medical officer. In addition, one software provider was included. Interview data were analysed according to content analysis.ResultsOne central theme “Introduction of digital CDSS in primary healthcare requires a multidimensional perspective and handling” along with seven main categories and thirty-three subcategories emerged from the analysis. Digital transformation showed to be key for current healthcare providers to stay relevant and competitive. However, healthcare represents a closed community, very capable but with lack of time, fostered to be sceptical to new why change needs to bring true value and be inspired by people with medical background to motivate the powerful frontline.ConclusionsThis qualitative study revealed structured information of what goes wrong and right and what needs to be considered when driving digital change in primary care organisations. The task shows to be complex and the importance of listening to the voice of healthcare is valuable for understanding the conditions that need to be fulfilled when adopting new technology into a healthcare organization. By considering the findings of this study upcoming digital transformations can improve their success-rate. The information may also be used in developing a holistic approach or framework model, adapted to primary health care, that can support and accelerate the needed digitalization in healthcare as such.

Physical Healthcare for People with a Severe Mental Illness in Belgium by Long-Term Community Mental Health Outreach Teams: A Qualitative Descriptive Study on Physicians', Community Mental Health Workers' and Patients' Perspectives.

People with a severe mental illness (pSMI) often have comorbid physical health problems, resulting in a lower life expectancy compared to the global population. In Belgium, it remains unclear how to approach health disparities in pSMI in a community setting. This study explores the perspectives of both care professionals and patients on physical healthcare in Belgian community mental services, aiming to identify good practices, barriers and points of improvement. An exploratory qualitative design that used a semi-structured focus group interview with physicians combined with individual face-to-face interviews with physicians, mental health professionals and patients. We identified care professional-, patient-related and organizational factors, as well as points of improvement. The identified themes linked to care professionals were communication, task distribution, knowledge, time and stigmatization. The co-location of services was the main theme on an organizational level. As community-based mental health services in Belgium emerged in the past decade, addressing physical health in pSMI is still challenging. Our findings suggest that there is a need for improvement in the current healthcare provision. Multidisciplinary guidelines, shared patient records, enlarging nurses' tasks, providing financial incentives and a structural integration of primary and psychiatric care were perceived as major points of improvement to the current Belgian healthcare organization.

Patient-Partners as Educators: Vulnerability Related to Sharing of Lived Experience.

Patient-partners are invaluable in health professions' education. Sharing their lived experiences with prospective and current healthcare providers can provide an opportunity for these participants to hone their patient-centric skills. However, sharing stories publicly is a vulnerable role and may feel emotionally risky for patient-partners. Using reflective dialogue, this manuscript outlines recommendations through the Sender-Receiver Model of Communication for Patient-Partners encounters when working with patient-partners in health professions' education. These recommendations include recognizing that: Patient-partners need to consider if they are ready to share their story. Some stories are wounds requiring further healing; other stories are scars fully processed by patient-partners and ready to be shared publicly.The audience should differentiate between questions that can promote critical thinking versus feel like a "personal attack." Audiences should recognize vulnerability patient-partners may experience in sharing their stories and engage accordingly.Pre-session and post-session debriefs are important. Shared stories may elicit intense emotions from patient-partners and audiences. Both groups should be given an opportunity to process and work through emotions.

Psychological and Cognitive Effects of Long COVID: A Narrative Review Focusing on the Assessment and Rehabilitative Approach.

Long COVID is a clinical syndrome characterized by profound fatigue, neurocognitive difficulties, muscle pain, weakness, and depression, lasting beyond the 3-12 weeks following infection with SARS-CoV-2. Among the symptoms, neurocognitive and psychiatric sequelae, including attention and memory alterations, as well as anxiety and depression symptoms, have become major targets of current healthcare providers given the significant public health impact. In this context, assessment tools play a crucial role in the early screening of cognitive alterations due to Long COVID. Among others, the general cognitive assessment tools, such as the Montreal Cognitive assessment, and more specific ones, including the State Trait Inventory of Cognitive Fatigue and the Digit Span, may be of help in investigating the main neurocognitive alterations. Moreover, appropriate neurorehabilitative programs using specific methods and techniques (conventional and/or advanced) through a multidisciplinary team are required to treat COVID-19-related cognitive and behavioral abnormalities. In this narrative review, we sought to describe the main neurocognitive and psychiatric symptoms as well as to provide some clinical advice for the assessment and treatment of Long COVID.

Prescribing and using vitiligo treatments: lessons from a nested process evaluation within the HI-Light vitiligo randomized controlled trial.

BackgroundThe HI‐Light Trial demonstrated that for active, limited vitiligo, combination treatment with potent topical corticosteroid (TCS) and handheld narrowband ultraviolet B offers a better treatment response than potent TCS alone. However, it is unclear how to implement these findings.AimWe sought to answer three questions: (i) Can combination treatment be used safely and effectively by people with vitiligo?; (ii) Should combination treatment be made available as routine clinical care?; and (iii) Can combination treatment be integrated within current healthcare provision?MethodsThis was a mixed‐methods process evaluation, including semi‐structured interviews with a purposive sample of trial participants, structured interviews with commissioners, and an online survey and focus groups with trial staff. Transcripts were coded by framework analysis, with thematic development by multiple researchers.ResultsParticipants found individual treatments easy to use, but the combination treatment was complicated and required nurse support. Both participants and site investigators felt that combination treatment should be made available, although commissioners were less certain. There was support for the development of services offering combination treatment, although this might not be prioritized above treatment for other conditions. A ‘mixed economy’ model was suggested, involving patients purchasing their own devices, although concerns regarding the safe use of treatments mean that training, monitoring and ongoing support are essential. The need for medical physics support may mean that a regional service is more practical.ConclusionCombination treatment should be made available for people seeking treatment for vitiligo, but services require partnership with medical physics and ongoing training and support for patients.

Chronic illness and critical care-A qualitative exploration of family experience and need.

People with chronic illnesses such as cancer and cardiovascular disease are living longer and often require the support of critical care services. Current health care provision means patients may be discharged home once clinically stable despite still having high care demands including social, emotional, or physical needs. Families are often required to assume caregiving roles. Research into family burden using quantitative methods has increased awareness, however, little qualitative work exists and the development of support interventions for families is required. To explore the experience and needs of family members of people with an existing chronic illness who are admitted to the Critical Care Unit (CCU), and to identify the desired components of a family support intervention in the form of a resource toolkit. A qualitative exploration of family experience and need, and content development for a resource toolkit using focus group methodology. Two focus groups and one face-to-face interview were conducted involving nine adult (≥18 years) family members of adult patients with chronic illness admitted to critical care in the preceding 9 months across two specialist hospitals in the UK. These were digitally recorded, transcribed, and thematically analysed. Four themes were identified: importance of communication, need for support, trauma of chronic illness, and having to provide "Do-it-Yourself" care. The immense responsibility of families to provide care throughout the illness trajectory is highlighted. Understandable information is essential for a family support toolkit. Family members often view a critical care episode broadly from diagnosis through to recovery/rehabilitation. Basic communication training skills within critical care should be ensured, alongside coordination of simple solutions. The potential traumatic impact on families should be highlighted early within the pathway, and positive aspects used to harness essential family support. A simple and coordinated approach to a toolkit is preferred. This study highlights that a critical care experience may impact broadly beyond CCU, and the importance of informing patients and families of this potential experience, prior to or on admission, to aid preparation. Further highlighted is the need for contemporaneous and accurate information from clinicians involved in care. Families report a better experience when there is good collaboration across critical care services and admitting clinical teams. Early involvement of families in overall discharge planning is essential to allow patients and families to adjust and plan for recovery.

CT Colonography and Colorectal Carcinoma: Current Trends and Emerging Developments.

Colorectal carcinoma is the third most malignant and second leading cause of death from cancer. The cruelty of this entity is that it takes decades to be symptomatic and is known to be detected late in its timeline by a screening technique. The fatality of this carcinoma only means heightened importance of screening guidelines to be laid down and strict follow-ups by the healthcare providers. A novel method, a potential competitor that could now replace the present screening techniques for colorectal carcinoma, is computed tomographic colonography (CTC) or virtual colonoscopy. Though it first came into existence in 1994, this method is yet to be deeply studied and scrutinized for it to be the next benchmark modality. This review has mainly focused on the various features of CTC. It is contrasted against the gold standard colonoscopy for its superiority, efficacy, cost-effectiveness, patient logistics, and role in detecting extra-colonic lesions. The main focus would be laid on CTC being a screening modality. The review also emphasized why there is a need for the current healthcare providers to incorporate this modality into their practice widely. Although much has been said about CTC and its various aspects of cost-effectiveness, about it being replaced or supplemented for cancer screening, a collaborative effort has to be made by both the fields of radiology and gastroenterology to investigate the outcomes of this not so new technique in daily practice and to avoid misinterpretation of the results due to lack of skill and proficiency.

E-health: Evaluation of the implementation of the Personal Electronic Health Record by family doctors in Greece

Introduction&#x0D; Ε-health (eH) is a basic component of current health care provision. The cornerstone of eH is the electronic health record (EHR) system.&#x0D; Material and methods&#x0D; The purpose of this survey is to assess the Greek EHR application by Greek family doctors, taking into consideration the brief period of EHR implementation in Greece. We adapted a preexisting questionnaire, with permission, translating and standardizing it in Greek. The questionnaire focused on computer use capability, EHR usage, and efficiency in daily clinical practice, user satisfaction and global user evaluation of the application. 175 family doctors filled out the questionnaire in February 2019.&#x0D; Results&#x0D; Low usage rates, minimal facilitation in daily practice, competency issues, and moderate user satisfaction were among our findings.&#x0D; Conclusions&#x0D; Greek EHR has several problems and inadequacy areas. Reversing these problems and optimizing the application, then reevaluating the results after a wider period of implementation is important.

Modelling the cost-effectiveness of essential and advanced critical care for COVID-19 patients in Kenya

BackgroundCase management of symptomatic COVID-19 patients is a key health system intervention. The Kenyan government embarked to fill capacity gaps in essential and advanced critical care (ACC) needed for the...

Understanding needs and expectations of heart failure patients and their caregivers regarding digital health - the PASSION-HF project

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): INTERREG-NWE Background/Introduction Current heart failure (HF) healthcare provision is not sufficient. Due to demographic changes and subsequent increases in comorbidities, along with unequal distribution of medical care in rural areas, alternative approaches need be sought. The use of eHealth applications has potential to enable patients to become more self-sufficient. The "PASSION-HF" project aims to develop an interactive decision-making system – a virtual doctor – that provides solutions based on current guidelines and artificial intelligence. Patient independence is maximized through 24/7 access to personalized HF-management. Furthermore, the application defines decision points, where medical professionals need to be included. Purpose To understand needs and expectations of HF patients and their informal caregivers in regard to a virtual doctor. Methods We conducted an exploratory mixed-methods study within the Netherlands, UK, Ireland and Germany. Semi-structured qualitative interviews were supplemented by a standardized questionnaire. The interviews focused on i) acceptance and motivation to use a virtual doctor and ii) experience and perception of current health care provision. The interviews were analysed using the content analysis according to Mayring (2010) with the help of "ATLAS.TI" software. Additional information about the role of informal caregivers, technology acceptance and decision-making processes was collected via questionnaires. Results A total of 49 patients and 33 informal caregivers were interviewed. Most patients were male (76%), aged between 60 and 69 years (43%). Three key themes were identified in regard to an interactive decision-making system: 1) Reassurance, because patients felt uncertain about their condition and their symptoms, they had a strong desire for an application that could monitor their health 24/7, was able to spot deteriorations, before they occured and gave them instant feedback about their current health status; 2) Personalized advice, e.g. patients wanted the virtual doctor to adapt medication, sport activities and food recommendations to their current health status; and 3) Transparency, e.g. patients wanted to know, where the recommendations are coming from and justifications for management modifications. Interview findings also identified that the HF-nurses play a significant role in the care and management of the condition. Across all countries with HF-nurses, they were the primary point of contact, when patients had any HF related concerns. Conclusion The findings provide valuable information for the development and implementation of eHealth solutions. Patients want reassurance, independently of the availability of healthcare services, combined with personalized advice regarding day-to-day management of their HF. For the next step, we are planning a multicentre clinical trial to test the prototype of the application. Here all decisions are examined by a clinical committee and benefits are evaluated.