Inconsistent Practices Research Articles

Endotracheal Tube Cuff Pressure Management: An Observational Study Guided by the SEIPS Model.

The aim of the rigorous endotracheal tube cuff pressure (ETTCP) management is to maintain cuff pressures within the recommended values during the mechanical ventilation period. However, hyperinflation or hypoinflation of cuff has been reported because of inconsistent clinical practices in intensive care unit (ICU) settings. Furthermore, there is no available best evidence for clinical decision-making regarding the ETTCP management provided by international institutes. The aim of this study was to examine the ETTCP management work system in ICU settings in urban hospitals of Turkey and the United States using the Systems Engineering Initiative for Patient Safety model. This was a direct observational, prospective field study, in which the COREQ (Consolidated Criteria for Reporting Qualitative Research) tool was used. The direct observations and follow-up interviews were conducted, and the results were reported using the Systems Engineering Initiative for Patient Safety model. We identified important characteristics of the ETTCP management work system in each of the 4 ICU and differences across the settings. Common use of the evidence-based and internationally used protocols may standardize the management of ETTCP, improve communication among ICU staff, and promote desired patient outcomes. There is a need for developing strategies to provide standardized ETTCP management and to improve patient's quality of care. To improve the patient outcomes and quality of care, ICU managers should consider clear expectations for ETTCP management in each job description, structured and evidence-based protocols, and effective communication among disciplines and provide teaching opportunities to encourage physicians, nurses, and respiratory therapists to meet their educational needs.

Psychosocial, neurodevelopmental, and transition of care practices provided to children with CHD across North American cardiac clinics.

Children with CHD are at risk for psychosocial and neurodevelopmental difficulties, as well as lapses in care during their transition from paediatric to adult CHD providers. The American Heart Association and American Academy of Pediatrics released guidelines for best practices in the neurodevelopmental and transitional care for children with CHD in 2012 and 2011, respectively. CHD providers from 48 (42.1% response rate) geographically diverse cardiac clinics completed a 31-item electronic survey designed to assess the cardiac teams' consistency with neurodevelopmental evaluation and management recommendations, consultation/liaison patterns for psychosocial services, and procedures regarding transitional services for emerging adults. Responses suggest most cardiac teams refer patients to psychosocial services as needed, and 39.6% of teams screen for psychosocial distress. CHD providers at 66.7% of cardiac clinics reported a formal neurodevelopmental programme/clinic. Nearly half of cardiac teams conduct routine neurodevelopmental evaluations, most frequently occurring at 9 months of age. Less than 10% of cardiac clinics have resources to meet the American Heart Association and American Academy of Pediatrics 2012 neurodevelopmental evaluation and management guidelines. Formal paediatric to adult CHD transition programmes were reported at 70.8% of cardiac clinics and were associated with younger ages of transition to adult CHD care. Care practices varied across the 48 represented cardiac clinics, indicating inconsistent practices for patients with CHD. Barriers and facilitators to the provision of care for children in these areas were reported and are presented. More support is needed for cardiac clinics to continue improvements in psychosocial, neurodevelopmental, and transitional care services.

Untapped Potential for Safer Conception Messaging to Transform PrEP Rollout and Promote Service Engagement Among Serodiscordant Couples.

Uptake of pre-exposure prophylaxis (PrEP) fell short of targets for Sub-Saharan Africa's initial rollout, revealing the need for more effective promotion strategies. In Uganda, we explored potential benefits and challenges of integrating safer conception messaging to promote PrEP among serodiscordant couples. In-depth interviews were conducted with clients and personnel at three clinics and analyzed thematically. Participants (n = 58) valued PrEP as a safer conception method (SCM) but described lack of integration of safer conception and PrEP services as well as inconsistent practices in prescribing PrEP to couples pursuing conception. Participants reported that the wider population remains largely unaware of PrEP and SCM or harbors misconceptions that PrEP is primarily for highly stigmatized groups like sex workers. Participants further described how heterosexual couples can still be reluctant to test for HIV, unaware of tools like PrEP and SCM that would allow them to continue their relationship and/or pursuit of childbearing. Overall, findings suggest that integrating PrEP and SCM in messaging and services targeting serodiscordant couples holds untapped benefits throughout the HIV prevention cascade.

BITES study: A qualitative analysis among emergency medicine physicians on snake envenomation management practices.

IntroductionAntivenom is currently considered standard treatment across the full spectrum of severity for snake envenomation in the United States. Although safe and effective antivenoms exist, their use in clinical practice is not universal.ObjectiveThis study explored physicians’ perceptions of antivenom use and experience with snake envenomation treatment in order to identify factors that influence treatment decisions and willingness to administer.MethodsWe conducted a qualitative study including in-depth interviews via online video conferencing with physicians practicing in emergency departments across the United States. Participants were selected based on purposive sampling methods. Data analysis followed inductive strategies, conducted by two researchers. The codebook and findings were discussed within the research team.FindingsSixteen in-depth interviews with physicians from nine states across the US were conducted. The participants’ specialties include emergency medicine (EM), pediatric EM, and toxicology. The experience of treating snakebites ranged from only didactic education to having treated over 100 cases. Emergent themes for this manuscript from the interview data included perceptions of antivenom, willingness to administer antivenom and influencing factors to antivenom usage. Overall, cost-related concerns were a major barrier to antivenom administration, especially in cases where the indications and effectiveness did not clearly outweigh the potential financial burden on the patient in non-life- or limb-threatening cases. The potential to decrease recovery time and long-term functional impairments was not commonly reported by participants as an indication for antivenom. In addition, level of exposure and perceived competence, based on prior education and clinical experience, further impacted the decision to treat. Resources such as Poison Center Call lines were well received and commonly used to guide the treatment plan. The need for better clinical guidelines and updated treatment algorithms with clinical and measurable indicators was stated to help the decision-making process, especially among those with low exposure to snake envenomation patients.ConclusionsA major barrier to physician use of antivenom is a concern about cost, cost transparency and cost–benefit for the patients. Those concerns, in addition to the varying degrees of awareness of potential long-term benefits, further influence inconsistent clinical treatment practices.

Something Ventured, Nothing Gained?—Remedies before the ECtHR and Their Potential for Climate Change Cases

Abstract The European Court of Human Rights stands before what may be its greatest challenge: addressing current and impending human rights violations stemming from climate change. As the first climate cases trickle into the Court’s docket, and speculation about the Court’s response grows, many questions remain to be answered. Perhaps the matter of greatest uncertainty relates to the type and degree of redress that the Court can offer in this context. This article argues that the Court’s often deferential, inconsistent and unreasoned remedial practice is in urgent need of overhaul. It studies the Court’s remedial practice in environmental cases to draw conclusions about the Court’s existing approach to remedies and its self-perception in this context, i.e. its own understanding of the possibilities and limitations of its role. From this, it extrapolates the remedial approaches that could potentially be taken in climate cases, and discusses the advantages and disadvantages of each one.

Process evaluation of the Disability Allowance programme in the Maldives

AbstractLimited evidence on the design and implementation of social protection programmes for people with disabilities in low‐ and middle‐income countries constrains understanding of how their impacts could be improved. The Disability Allowance programme in the Maldives is a non means‐tested, monthly cash transfer targeting people with disabilities. Using qualitative methods, process evaluation was used to examine the intervention design, implementation, and likelihood of achieving its intended objectives. There were important strengths of the programme, including the broad definition of disability. We find that delivery could be strengthened through providing greater clarity on eligibility criteria and strengthening human resources to widen the programme’s reach. Intervention fidelity was challenged by inconsistent practice among implementers and lack of established protocols. Most importantly, the absence of linkages with the Medical Welfare scheme that provides assistive devices potentially limits the likelihood of the programme achieving intended objectives.

Practice pattern of minimal invasive surgery in Saudi Arabia: a national cross-sectional study

Background: Despite the improvement of minimal invasive surgery (MIS) training programs over the last two decades, there is still inconsistent practice among surgeons at different centers. Thus, this study aimed to assess the practice pattern of MIS and the factors that influence MIS training among healthcare providers of general surgery, gynecology, and urology in Saudi Arabia. Methods: A national cross-sectional study based on survey questionnaires was conducted from May to October 2021. The survey was obtained from healthcare providers in different regions of the kingdom for the three specialties: general surgery, urology, and gynecology; who are practicing in Saudi Arabia. The main outcome measure was the confidence level of performing MIS alone. Different covariates were used to study the factors contributing to the confidence level of practicing MIS. Results: Around 73.9% of healthcare providers were confident enough to perform MIS alone. General surgeons were most confident to perform MIS alone as compared to other surgical specialties. Factors that affect the confidence level are experience, MIS training during fellowship period, current practice hours of MIS, and kingdom's regions. The independent factors including experience represented by age of more than 45 years [14.9 times (95% CI 0.79-29.14; p-value 0.03)] and involvement in laparoscopic and robotic surgery during fellowship training [25.5 times (95% CI 4.71-46.3; p-value 0.01)]. Conclusion: The practice pattern of MIS for healthcare providers varied among different regions and surgical specialties. The confidence to practice MIS independently was affected by the experience period and the working region in the kingdom.

Sustainability reporting in the airline industry: Current literature and future research avenues

Sustainability reporting (SR) allows organisations to communicate their non-financial impacts to stakeholders. It has also become a widespread business practice in aviation, a transport sector that contributes significantly to global warming. Academia has begun to examine SR in the context of airlines surprisingly late, and no comprehensive reviews of its respective developments have been made so far. Consequently, a systematic literature review was performed with an exclusive focus on airline SR to synthesise its associated scholarly research and distinguish the common concerns and gaps that have emerged from it. The analysed publications indicate that the industry has lacked a unified policy and common understanding of how to define and measure sustainability, which has led to inconsistent SR practices. This causes ambiguity between the real actions and promotional communication through which airlines may legitimise their operations. Academia and various airline stakeholders would benefit from more in-depth studies examining the stakeholder views and quality of disclosures, helping the industry improve its SR.

Development and evaluation of an electronic medical device training passport to identify nurses' training needs.

All nurses, particularly those working in critical care settings, are required to use medical devices when providing patient care. However, inconsistent practice and variations in documentation can make it challenging for nurses and nurse managers to identify what medical device training is required and when. To develop and evaluate the use of an electronic medical device training passport to identify the training needs of nurses in intensive care units (ICUs). A pilot study was conducted in a multi-unit critical care department in London, England, to determine if the passport could make it easier to identify ICU nurses' medical device training needs compared with existing practice. Nine participants were first asked to identify their needs using existing spreadsheets or paper records, then asked to identify them using the passport. The participants were also interviewed to identify their training requirements before and after using the passport. The data were analysed quantitatively and qualitatively. The electronic passport significantly improved identification of medical device training needs compared with paperwork or spreadsheets for all device groups, except for medical devices used on high dependency units ( P ≤0.005). However, there may be issues related to nurses' behaviours and expectations, particularly that staff do not always recognise their need for training. The findings of this pilot study suggest that the use of an electronic medical device training passport has many benefits and could make it easier to identify ICU nurses' training needs in clinical practice.

Exploring Knowledge, Attitude and Practice (KAP) Towards Vitamin D among Arts and Commerce Students in Vistas Chennai

Introduction: Vitamin D is an essential nutrient and a group of fat-soluble pro-hormones with multiple functions in the body including bone health, regulation of serum calcium and phosphate levels, as well as roles in immune function, cell proliferation, differentiation, and apoptosis. The two major biologically inert precursors of vitamin D are vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol). Vitamin D3 is also formed when the skin is exposed to solar ultraviolet B and then converted to pre-vitamin D3 (Sunshine Vitamin). The severe vitamin D deficiency in adults and children’s causes softening of bones, muscle weakness and fractures.
 Aim: The aim of the study is to explore knowledge, Attitude and Practice towards Vitamin D among Arts & Commerce students in Vels University Chennai.
 Methods and Materials: The study was a prospective cross-sectional, carried out in the department of arts and commerce students in VISTAS Chennai. The questionnaire then underwent a series of validation process that included content, face validity and exploratory part. Item response theory (IRT) analysis was utilized for the validation of the knowledge domain. Exploratory factor Analysis (EFA) used for attitude and practice validation. Institutional Ethical Committee (VISTAS-SPS/IEC/VI/2020/05) approval was obtained before conducting the study. Self-online questionnaires link was sent via mail after registration. The questionnaire was divided based on Knowledge, Attitude and Practice with 5 questions each. Completed questionnaires were reviewed, entered into a database (SPSS) and analysed using descriptive and inferential statistics.
 Results and Discussion: In our study, a total of 362 students were included where majority were males from first year commerce department around 18 to 19 years of age. Majority of the students had knowledge on vitamin D, attitude towards every day sun exposure and practice of using sun screens.
 Conclusion: Our study concluded that the students’ knowledge on vitamin D is good. There was an inconsistent practices towards managing its deficiency. Despite widespread, concern about vitamin D, still attitude and practice towards Vitamin D is yet to known for young generations.

Midwives perceptions of managing pregnancies complicated by obesity: A mixed methods study

The growing prevalence of obesity is a concern for midwives. In Canada, the absence of regulatory standards, varying protocols and consultant preferences shape clinical decision making for the midwife and may lead to inconsistent practice. Our aim was to understand the barriers, enablers, and knowledge gaps that influenced experiences of midwives in Ontario, Canada when providing care to clients impacted by obesity. Mixed methods design using a sequential, explanatory approach. Surveys conducted with midwives were administered using an online platform, followed by semi-structured interviews to understand the perspectives elicited in the survey in greater detail. Interviews were audio recorded and transcribed verbatim. Survey data were analyzed using descriptive statistics, and thematic analysis was used for generating codes, categories and themes from the interview data. 144 midwives completed the survey and 20 participated in an interview. The participants described their clinical management when caring for those with obesity which included considerations regarding additional tests/investigations, consultation and transfer of care, and place of birth. Up to 93% of surveyed midwives believed that clients with obesity were appropriate for midwifery-led care however there was less certainty about suitability as BMI increased to higher ranges such as > 45). The care management was influenced by beliefs and attitudes, knowledge, and system-level factors. Midwives experienced barriers such as inconsistent practices and role confusion, and felt ill equipped to care for pregnancies affected by obesity due to unclear guidelines. Overall, midwives believe clients with obesity are suitable for midwifery-led care due to its individualized, non-judgmental approach to care. Additional training for midwives and other obstetric care providers would be beneficial to help overcome barriers in providing effective care to pregnancies affected by obesity.

Understanding Precautionary Allergen Labeling (PAL) Preferences Among Food Allergy Stakeholders

The United States does not have clear requirements for the use of food precautionary allergen labeling (PAL). The Food Allergen Labeling and Consumer Protection Act requires the names of 8 allergens (peanut, tree nuts, milk, egg, wheat, soy, fish, and shellfish), if present, to be listed in English on ingredient labels. Additional PAL, such as “may contain” or “made on shared equipment,” is voluntarily placed on products. In the current study, researchers aimed to understand patient and family knowledge of and preferences for PAL statements.Individuals with a personal history of food allergy (FA) or those with a relationship with a patient with FA (including caregivers, partners, and teachers) were invited to participate in the current study through a survey delivered through the Food Allergy Research and Education’s membership listserv. Researchers initially conducted a focus group to understand shopping experiences, understanding of PAL, and preferences for labeling language, format, and placement. A survey draft was sent to 9 additional stakeholders to refine survey reliability and comprehension. Of the ultimate recipients, 25 208 opened the e-mail, 3541 began the survey, and data from 3008 respondents were analyzed. Respondents were primarily female (84.7%), caregivers of a patient with FA (77%), non-Hispanic White (78.4%), had a graduate degree (40.6%), and had an annual household income >$100 000 (48.5%).Queried demographics included sex, race/ethnicity, education, household income, living location, relationship to FA, type of FA, number of FAs, severe adverse reaction history, and PAL knowledge. Survey domain outcomes included shopping habits, frequency of purchasing products with PAL, PAL preferences, confidence when purchasing PAL products, and PAL discussions with health care providers. Logistic regression analysis evaluated associations between respondent characteristics and PAL outcomes.Of respondents, 24.2% correctly answered 4 knowledge questions surrounding PAL. The majority of respondents never purchase products labeled “may contain traces of allergen” (85.5%), in comparison with never purchasing products labeled “good manufacturing practices used to segregate ingredients in a facility that also processes allergen” (35%). The top preferences for desired PAL statements were “not suitable for people with [blank] allergy” (29.3%) and “may contain” (22.1%). Respondents favor labeling with specific allergens versus a category of allergens. Most respondents favored PAL immediately after the ingredient list. Of individuals with FA, 32% were instructed to avoid foods with PAL, whereas 44.5% did not discuss PAL with their health care provider. Respondents who were told to avoid all PAL were 59% less likely to purchase products with PAL than patients who did not discuss PAL with their provider were.Responses revealed lack of awareness of PAL policies and suggest that consumers purchase products with PAL on the basis of specific language used. Consumers desire clarity, specificity, and consistency in labeling. Provider discussions influence purchasing.The authors acknowledge limitations of the current study to include potential bias in a sample of patients and caregivers from an advocacy group, which may not accurately represent all patients with FA. Inconsistent labeling practices currently cause confusion and may increase risk for patients with FA. Physician advocacy for improved labeling requirements may benefit patients and families.

Caregivers’ Executive Function and Negative Childrearing Practices: The Moderating Role of Authoritarian Childrearing Beliefs

In accord with social information processing theory, executive function and childrearing beliefs may play significant roles in preventing negative childrearing practices. Still, the interplay of these two components is not well understood. The current study tested the moderating role of authoritarian childrearing beliefs in the relation between caregiver executive function and negative childrearing practices. The sample included 50 predominantly low-income caregivers of children between 3 and 5 years of age. The results indicated that executive function was significantly and inversely related to inconsistent and hostile childrearing practices only among caregivers who reported high levels of authoritarian childrearing beliefs. Executive function and childrearing practices were unrelated among caregivers who reported low levels of authoritarian childrearing beliefs. The findings suggest that intervention programs for caregivers may need to target childrearing beliefs.

Is there consensus on the perioperative management of Xa inhibitors in patients undergoing elective spine surgery?-A survey of current spine surgeon practices.

Factor Xa inhibitors (Xai) are an increasingly common consideration in perioperative anticoagulation management. However, there no existing guidelines established for use in Spine Surgery. This survey study aims to capture current practice trends regarding the perioperative management of Xai among spine surgeons. An 11-question survey was sent to all surgeon members of 3 spinal surgery societies. Responses were remitted anonymously. Questions characterized the background and experience of the respondent and inquired into their current perioperative Xai and other anticoagulant management. Questions were all single-best option, multiple-choice. A total of 116 surveys were received. Twenty-six (22.4%) were from neurosurgeons and 90 (77.6%) were from orthopedic surgeons. Practiced preoperative Xai hold length tended to be longer than recommended by the respondent's medical colleagues. Only 65.2% (P≤0.0001) of respondents practiced in agreement with the recommendations of their medical colleagues. Postoperative Xai holds trended toward longer holds than that of other anticoagulants with 37.9% (P=0.0125) of respondents showed differences within their own practice between length of Xai hold and length of other anticoagulant holds. One out of four respondents reported noticing a change in the rate of perioperative bleeding complications among Xai patients. Despite reported increased bleeding issues, only 39% of those who noted this increase in bleeding complications reported they would hold a Xai longer than other anticoagulants. There exists a wide range of recommended and practiced chronic anticoagulant hold lengths. This inconsistency likely highlights conflicting risk aversion among surgeons, between complications which are viewed as medical (i.e., thromboembolism and stroke) vs. surgical (i.e., compressive hematoma). Yet, survey responses suggest the length of Xai hold times did not necessarily reflect the surgeon's experience with postoperative bleeding complications in Xai patients. These inconsistent practices highlight the need for further research that can establish guidelines for perioperative management of Xai patients undergoing spine surgery. Anticoagulants; factor Xa inhibitors (factor Xai); spine; orthopedic surgery; neurosurgery.

Cardiac monitoring in memory clinics: national survey of UK practice.

People diagnosed with dementia are often started on acetylcholinesterase inhibitors (AChEIs). As AChEIs can be associated with cardiac side-effects, an electrocardiogram (ECG) is sometimes requested before treatment. Previous work has suggested there is little consensus as to when or how ECGs should be obtained. This can create inconsistent practice, with patient safety, economic and practical repercussions. We surveyed 305 UK memory clinic practitioners about prescribing practice. More than 84% of respondents completed a pulse and cardiac history before prescribing AChEIs. Opinion was divided as to who should fund and conduct ECGs. It was believed that obtaining an ECG causes patients inconvenience and delays treatment. Despite regularly interpreting ECGs, 76% of respondents did not update this clinical skill regularly. The variation in practice observed has service-level and patient implications and raises potential patient safety concerns. Implementing national guidelines or seeking novel ways of conducting cardiac monitoring could help standardise practice.

Reconciliation of budgeting and accounting

IMPACT Using an archival study of financial statements prepared in accordance with International Public Sector Accounting Standards (IPSAS), this article reports on inconsistent practices and the lack of explanation of the differences between budget execution and accrual accounting. If the recommendations in this article are followed, public sector financial statements will be more accessible and comparable, adding to the credibility of public sector financial reporting.

Development of a Pathway for Multidisciplinary Neurodevelopmental Assessment and Diagnosis in Children and Young People.

There is a variable standard of access to quality neurodevelopmental assessment and diagnosis. People may have negative experiences, encountering lengthy waiting times, and inconsistent practices. Practitioners need guidance on standards and practices for assessment and diagnosis matched to new ways of working. In this paper, we present a new pathway and recommendations for multidisciplinary neurodevelopmental assessment and diagnosis for children and young people (<19 years), developed by the Scottish Government funded National Autism Implementation Team (NAIT). Our research used the Medical Research Council guidance for the development of complex interventions and included several iterative stages. Stage 1: n = 44 stakeholders attended an event on developing new practices for diagnosis and assessment. Stage 2: a literature synthesis was completed by the research team of clinical guidelines and diagnosis and assessment tools. Stage 3: an event with n = 127 stakeholders included discussion and debate of the data from stages 1 and 2. Recommendations and a draft pathway were written. Stage 4: successive drafts of recommendations and the pathway documentation were circulated among an advisory group, including multidisciplinary clinical experts and people with lived experience, until the final pathway was agreed upon. The finalised pathway includes guidance on terminology, assessment, diagnosis, triage, time standards and engagement of people with lived experience. The new pathway has been adopted by the Scottish Government. The pathway and associated documentation are freely available online for use by others.

Semi-automatic geometry modelling: faster and streamlined building simulation models

The architecture, engineering, and construction (AEC) industry experiences a growing need for building performance simulations (BPS) as facilitators in the design process. However, inconsistent modelling practice and varying quality of export/import functions entail error-prone interoperability with IFC and gbXML data formats. Consequently, repeated manual modelling is still necessary. This paper presents a coupling module enabling a semi-automated extract of geometry data from the BIM software Revit and a further translation to a BPS input file using Revit Application Programming Interface (API) and visual programming in Dynamo. The module is tested with three test cases which shows promising results for fast and structured semi-automatic geometry modelling designed to fit today’s practice.

Law enforcement suicide: The depth of the problem and best practices for suicide prevention strategies

The purpose of this research study was to review the current literature on the prevalence of suicide deaths, attempts, and ideation, and resistance for seeking help among law enforcement officers by examining current suicide prevention programs among those that support the country's police officers. The exact number of law enforcement officer deaths by suicide is unknown due to inconsistent data collection practices. Approximate estimates range from being at or significantly above the national average; one study reported the rate of suicide to be twice the rate of officers who die in the line of duty, another study reported three times the rate and another reported to be eight times that of the general population. The inconclusive nature of the literature has made obtaining the number of officer suicide deaths challenging. A comprehensive examination of the law enforcement mental health and suicide prevention literature revealed a lack of consistency in reporting; a multitude of maladaptive behaviors; and a lack of adequate suicide prevention programing for this profession. • Law enforcement officer rates of suicide are higher than the general population. • Relationship problems and job stress are the top variables among officer suicides. • Critical events contribute to officers' trauma and stress, increasing suicide risk. • Leadership must instill a department mentality of help-seeking from a top-down response. • Suicide prevention for law enforcement officers requires unique interventions.

Trace the Untraceable: Online Image Search Tools for Researching Late Antique Art

In the context of digital humanities and access to cultural heritage online, this paper explores the discoverability of Late Antique material in some searchable museum collections and in some major archaeological and art historical image and object databases. It follows an exploratory approach by using simple keyword searches, such as ‘late antique’ or ‘byzantine’, and comparing the results with chronological searches when a date or period filter is available. Although Late Antique material often comprises a smaller number of objects compared to more popular periods like the Roman and the Renaissance, these are difficult to research due to inconsistent labelling practices and the frequent lack of a customizable date range filter. The ongoing debates on proper periodization and nomenclature also need to be taken into consideration.