Information Handouts Research Articles

Partnering With Families Through Shared Decision-Making to Increase Connected Pen Use: A Quality Improvement Success Story.

Quality Improvement Success Stories are published by the American Diabetes Association in collaboration with the American College of Physicians and the National Diabetes Education Program. This series is intended to highlight best practices and strategies from programs and clinics that have successfully improved the quality of care for people with diabetes or related conditions. Each article in the series is reviewed and follows a standard format developed by the editors of Clinical Diabetes. The following article is part of a special article collection from the T1D Exchange Quality Improvement Collaborative. It describes efforts at an academic pediatric diabetes clinic in Memphis, TN, to increase both the use of connected insulin pens (CIPs) and shared decision-making around diabetes technology aided by patient information and self-reflection handouts.

A Randomized Controlled Trial of Consent for Patients Undergoing Transobturator Slings.

Improving patients' recall and understanding of their planned surgery is essential for fully informed consent. The objective of this study was to assess if the addition of an information handout to the standard preoperative consent process for the transobturator midurethral sling procedure improved patient understanding, recall, and satisfaction. This is a randomized controlled trial of adult women undergoing a transobturator midurethral sling procedure for the treatment of stress urinary incontinence. After standard counseling, participants were randomly assigned to either the control or the intervention group, with the latter receiving an extra informational handout detailing surgical information. Before surgery, all participants filled out a questionnaire assessing key points discussed during the surgical consent, which was used to calculate a knowledge score, the primary endpoint. Secondary outcomes included perception of the consent process and patient satisfaction. Of 98 randomized participants (50 control, 48 intervention), knowledge scores were 43% for controls and 57% for the intervention group (P = 0.015). Despite low scores, high self-rated understanding and satisfaction were noted across both groups (78% control, 71% intervention, P = 0.4). Notably, younger individuals, those with some college education, and patients undergoing additional prolapse surgery benefited most from the handout. The informational handout improved knowledge scores, though overall knowledge scores were low in both groups. High satisfaction and perceived understanding of the planned procedure persisted, but the addition of a handout was not associated with a significant difference in knowledge scores.

Knowledge regarding disaster preparedness among nursing interns undergoing clinical training at R.L. Jalappa Hospital and Research Center. Kolar, to develop information handout

The study was to understand knowledge regarding disaster preparedness among nursing interns and to determine the association between the knowledge scores with socio demographic variables. A descriptive survey design was adopted by using Purposive Sampling techniques among 75 Nursing Interns and collected data using structured knowledge questionnaire was used to collect the data based on expert’s validation and inclusion criteria of the study. The study highlighted that majority 58.66% (44) of the samples belongs to moderate knowledge and 38.6% (29) samples belongs to inadequate knowledge, 2.66% (2) samples belong to adequate knowledge. There are many studies conducted which supporting to the study. Finally, the researchers concluded the findings of the study clearly showed that there was Moderate Knowledge on disaster preparedness among nursing interns, thus study recommended to conduct seminar and simulation training programme to the nursing interns on current practice to save the lives of the nation through disaster preparedness.

Comprehension and usefulness of Spanish language health information about depression treatment.

US Latine adults who prefer the Spanish language for healthcare encounter communication have high risk of health disparitiesm in part from low organizational health literacy, mental health stigma and discrimination. Organizational health literacy includes the provision of culturally responsive, language concordant health information, which supports good comprehension and usefulness and could mitigate some health disparities. We conducted a pilot study to assess commonly provided patient health information handouts about depression treatment and antidepressant consumer medication information sheets. Thirty Latine adults with a Spanish language preference and a history of depression and antidepressant use participated in one phone interview. Descriptive statistics and thematic analysis were used to assess comprehension and usefulness of selected sections extracted verbatim from these documents. Overall, 83% (n = 25) participants reported that all sections were easy to understand, and 97% (n = 29) said that they were useful. Yet, responses to open-ended questions for 53% (n = 16) of participants revealed 'confusing' terminology in at least one section, and 10% (n = 3) expressed concerns about or misunderstood an idiomatic phrase as reinforcing mental health stigma. The seriousness of the organizational health literacy-based issues identified in this and previous studies require that government and health service organizations make necessary and timely revisions to address them.

Perspectives of pregnant women on maternal health information handouts at KwaZulu-Natal sub-district.

Maternal health information handouts are used by midwives to facilitate health education of pregnant women during their antenatal care (ANC) period. South Africa's Saving Mothers Report 2014 showed that delay in accessing medical help, as a patient-related avoidable factor, accounted for 27% of maternal and neonatal mortality. To ascertain the perceptions of pregnant women attending ANC in the Msunduzi sub-district in uMgungundlovu District, towards the maternal health information handouts. The study was conducted at three primary health care (PHC) clinics (two PHC and one CHC [Community Health Care]) that provided ANC in the Msunduzi sub-district KwaZulu-Natal, in 2019. Using a qualitative approach, focus group discussions (FGDs) were conducted with 10 participants from each clinic. Data were transcribed and analysed using thematic analysis. The themes explored included: availability and access of handouts, usefulness, review of handouts, alternative methods available, and family involvement. The authors concluded that although the maternal information handouts were given to the mothers during their maternal health visits, few of them were aware of these handouts. New strategies should be employed to deliver this vital information, as suggested by mothers.Contribution: The awareness of pregnant mothers about the information handouts contributes to the positive perinatal outcomes at clinic levels.

Olympiads as an Innovative Teaching Method

The use of interactive forms of training in the educational process helps students to develop professional and general cultural competencies. The educational process, based on the use of interactive methods in the teaching process, is organized on the basis of involving all students of the group in mastering the educational material. Joint activity means that during this exercise, each student shares his knowledge, ways of working, makes his individual contribution to solving the situation. By applying pedagogical technology methods in modern lessons, additional information (handouts, tests, problems, riddles, questions and answers, various crosswords, experiments, etc.) should cover the main topic during the lesson. At the end of the lesson, the students will have sufficient knowledge about the scientific information, the place in the field of science and technology development, as well as the encyclopedic scientists who lived in the past. they should also have information about their contributions to the development of this field. For this, it is necessary to use methods of pedagogical technology that are appropriate and convenient for the subject being taught in each lesson. In the implementation of this activity, high pedagogical skills are required from the teacher

The Importance of Educational Technologies in Students' Acceptance and Mastery Of The Subject

By applying pedagogical technology methods in modern lessons, additional information (handouts, tests, problems, riddles, questions and answers, various crosswords, experiments, etc.) should cover the main topic during the lesson. At the end of the lesson, the students will have sufficient knowledge about the scientific information, the place in the field of science and technology development, as well as the encyclopedic scientists who lived in the past. they should also have information about their contributions to the development of this field. For this, it is necessary to use methods of pedagogical technology that are appropriate and convenient for the subject being taught in each lesson. In the implementation of this activity, high pedagogical skills are required from the teacher.

Emergency Nursing Didactics – Opinions, Resource, and Skill Exchange (E.N.D.O.R.S.E) – A collaborative academic initiative in the Emergency Department

Introduction: Emergency Physicians and Nurses often work together as the two most prominent figures at the patient bedside, involved in clinical decision making, procedures, and medication administration. However, they are not afforded many opportunities to debrief and share educational knowledge and resources surrounding decisions, implementation, and protocols. After preliminary discussions on interest and knowledge gaps, a collaboration between Emergency Physicians and nurses was established under an academic initiative entitled ‘Emergency Nursing Didactics – Opinions, Resource, and Skill Exchange (E.N.D.O.R.S.E.)' at Mediclinic City Hospital, Dubai. Aims/Objectives: We aimed to provide a platform within the Emergency Department (ED) to promote interpersonal communication and feedback between healthcare providers. The initiative sought to improve skills, confidence, and standardize workflows around essential procedures/protocols. Materials/Methods: A structured 30-minute session break-down was created and customized information handouts were prepared, with evidence-based references. Sessions were conducted once a month, with in-person teaching within the ED alongside a video conference set up. Post-session questionnaires were utilized to determine knowledge reception, ideas on improvement, and future direction of E.N.D.O.R.S.E. sessions. Results: Topics included waveform capnography, Inotropes and infusion settings, SVT management, Right/posterior ECG placement, high-risk pattern recognition, and Intubation workflow. Sessions lasted 30 minutes, did not interfere with actual patient care, and were attended in-person, online, with recordings viewed later by all department members. Post-session questionnaires revealed that 92.3% of participants found the sessions provided them with new information, with approximately 88% of them ‘Very confident' (5/5) in using the skills taught thereafter. 77% of participants rated the quality of the sessions as ‘Excellent' (5/5), and 88% indicated they would like for the topics to be repeated in future sessions. Participants also reported that sessions offered them a safe, structured environment within which to ask questions and improve knowledge. Discussion: Creation of a safe, structured learning environment allows ED healthcare providers to identify knowledge and skill gaps that may otherwise not be unmasked. While Nursing education is ubiquitous, this is often delivered amongst nurses and by nurses. E.N.D.O.R.S.E. is a first-of-its-kind platform where physicians and nurses work together to develop soft skills. What seemed to be trivial tasks became optimized through collaborative learning and idea exchange. Conclusion: Collaborative learning allows for ‘practiced proficiency' of skills and offers an opportunity to enhance ED workflow and patient care.

Artificial Intelligence Chatbots in Patient Communication: Current Possibilities.

Twenty-seven (n=27) periodontists were surveyed on the accuracy and usefulness of AI-generated documents comprising patient information handouts on surgical risks and post-operative instructions sheets for dental implant placement either in smokers or patients with diabetes. They were also asked in a blinded fashion about their preferences between the generic dental implant placement consent form currently used at Boston University and two AI-generated consent forms: one generic and one tailored to patients with diabetes. A vast majority of participants found that the information in the AI-generated forms was accurate, useful and would feel comfortable using them with their own patients. The AI-generated generic consent performed as least as well as the human-written one, while the personalized informed consent for patient with diabetes performed significantly better (p<0.001). Within the limitations of this study, ChatGPT was able to independently generate accurate and useful patient information and management documents.

A Multifaceted Implementation Strategy to Increase Out-of-Office Blood Pressure Monitoring

Few primary care patients complete guideline-recommended out-of-office blood pressure (BP) monitoring prior to having hypertension diagnosed. To evaluate the effectiveness of a behavioral theory-informed, multifaceted implementation strategy on out-of-office BP monitoring (ambulatory BP monitoring [ABPM] or home BP monitoring [HBPM]) among patients with new hypertension. This 2-group, pre-post cluster randomized trial was conducted within a primary care network of 8 practices (4 intervention practices with 99 clinicians; 4 control practices with 55 clinicians) and 1186 patients (857 intervention; 329 control) with at least 1 visit with elevated office BP and no prior hypertension diagnosis between October 2016 and September 2017 (preimplementation period) or between April 2018 and March 2019 (postimplementation period). Data were analyzed from February to July 2023. Usual care (control group) or a multifaceted implementation strategy consisting of an accessible ABPM service; electronic health record (EHR) tools to facilitate test ordering; clinician education, reminders, and feedback relevant to out-of-office BP monitoring; nurse training on HBPM; and patient information handouts. The primary outcome was patient completion of out-of-office BP monitoring within 6 months of an eligible visit. Secondary outcomes included clinician ordering of out-of-office BP monitoring. Blinded assessors extracted outcomes from the EHR. A total of 1186 patients (857 intervention; 329 control) were included, with a mean (SD) age of 54 (16) years; 808 (68%) were female, and 549 (48%) were Spanish speaking; among those with race and ethnicity documented, 123 (10%) were Black or African American, and 368 (31%) were Hispanic. Among intervention practices, the percentage of visits resulting in completed out-of-office BP monitoring increased from 0.6% (0% ABPM; 0.6% HBPM) to 5.7% (3.7% ABPM; 2.0% HBPM) between the preimplementation and postimplementation periods (P = .009). Among control practices, the percentage of visits resulting in completed out-of-office BP monitoring changed from 5.4% (0% ABPM; 5.4% HBPM) to 4.3% (0% ABPM; 4.3% HBPM) during the corresponding period (P = .94). The ratio of relative risks (RRs) of out-of-office BP monitoring in the postimplementation vs preimplementation periods for intervention vs control practices was 10.5 (95% CI, 1.9-58.0; P = .01). The ratio of RRs of out-of-office BP monitoring being ordered was 2.2 (95% CI, 0.8-6.3; P = .12). This study found that a theory-informed implementation strategy that included access to ABPM modestly increased out-of-office BP monitoring among patients with elevated office BP but no hypertension diagnosis. ClinicalTrials.gov Identifier: NCT03480217.

Optimizing opioid prescribing practices after minimally invasive lung resection through a quality-improvement intervention.

In their 2019 guideline on the prescribing and management of opioids after elective ambulatory thoracic surgery, the Canadian Association of Thoracic Surgeons (CATS) recommended 120 morphine milligram equivalents (MME) after minimally invasive (video-assisted thoracoscopic surgery [VATS]) lung resection. We conducted a quality-improvement project to optimize opioid prescribing after VATS lung resection. We assessed baseline prescribing practices for opioid-naive patients. Using a mixed-methods approach, we selected 2 quality-improvement interventions: formal incorporation of the CATS guideline into our postoperative care pathway, and development of a patient information handout regarding opioids. The intervention was initiated on Oct. 1, 2020, and was formally implemented on Dec. 1, 2020. The outcome measure was average MME of discharge opioid prescriptions, the process measure was proportion of discharge prescriptions exceeding the recommended dosage, and the balancing measure was opioid prescription refills. We analyzed the data using control charts, and compared all measures between the pre-intervention (12 mo before) and postintervention (12 mo after) groups. A total of 348 patients who underwent VATS lung resection were identified, 173 before the intervention and 175 after the intervention. Significantly less MME was prescribed after the intervention (100 v. 158, p < 0.001), and a lower proportion of prescriptions were nonadherent to the guideline (18.9% v. 50.9%, p < 0.001). Control charts showed special cause variation corresponding with the intervention, and system stability existed after the intervention. There was no statistically significant difference in the proportion or dosage of opioid prescription refills after the intervention. After implementation of the CATS opioid guideline, there was a significant reduction in opioids prescribed at discharge and no increase in opioid prescription refills. Control charts are a valuable resource for monitoring outcomes on an ongoing basis and for assessing the effects of an intervention.

Assessing Knowledge and Attitude of Staff Nurses regarding Perceived Benefits and Barriers of Investing in Nursing, in Selected Hospitals of Hyderabad to Develop an Information Handout on Methods of Improving Nursing Workforce

Assessing Knowledge and Attitude of Staff Nurses regarding Perceived Benefits and Barriers of Investing in Nursing, in Selected Hospitals of Hyderabad to Develop an Information Handout on Methods of Improving Nursing Workforce

PUMPING IRON: A QUALITY IMPROVEMENT STUDY FOR THE TREATMENT OF IRON DEFICIENCY ANEMIA IN AMBULATORY HEART FAILURE PATIENTS

PUMPING IRON: A QUALITY IMPROVEMENT STUDY FOR THE TREATMENT OF IRON DEFICIENCY ANEMIA IN AMBULATORY HEART FAILURE PATIENTS

Effects of additional context information in prescription drug information sheets on comprehension and risk and efficacy perceptions

ObjectiveTo determine how additional explanatory text (context) about drug side effects in a patient medication information handout affected comprehension and perceptions of risk and efficacy.MethodsWe conducted an online experiment with a national sample of 1,119 U.S. adults with rheumatoid arthritis and related conditions, sampled through random-digit dialing, address-based sampling, and online ads. We randomized participants to receive one of several versions of a patient information handout for a fictitious drug, either with or without additional context, then measured comprehension and other outcomes.ResultsAdditional qualitative context about warnings and side effects resulted in lower comprehension of side effect information, but not information about uses of the drug or warnings. The effect of additional context on risk perceptions depended on whether the medication handout was delivered online or through the mail. Those who received a hardcopy of the handout with additional context had higher perceived risk of side effects than those who saw the version without additional context.ConclusionMore clarifying information is not always better and may lead to cognitive overload, inhibiting comprehension.Practice implicationsAdditional research should further explore effects of context in online vs. hard-copy formats before practice implications can be determined.

Preparation and support for physical activity following hospital discharge after coronary artery bypass graft surgery: A survey of current practice in New Zealand

AbstractBackground and PurposeEngagement in physical activity following coronary artery bypass graft (CABG) surgery has many benefits and also many potential barriers, especially during the first few months. It is important to explore current clinical practice before investigating ways to optimally prepare and support people to progressively increase their physical activity post‐hospital discharge and to navigate the challenges. The aim of the study was to explore current practice in New Zealand hospital services for preparing and supporting people who have had CABG surgery to engage in physical activity following hospital discharge.MethodsLocality authorisation to participate in the study was sought from all 11 hospitals providing cardiac surgery services in New Zealand. The most senior health professional responsible for preparing people to engage in physical activity following CABG surgery was invited to participate by completing a purpose designed questionnaire on behalf of their hospital service. Respondents were also requested to provide any patient information handouts regarding progressive physical activity engagement following CABG surgery.ResultsResponses were received from all nine hospitals that granted locality authorisation. All nine hospitals prepared people to engage in aerobic exercise prior to discharge, predominantly through the provision of a walking schedule. In contrast, no hospitals provided information about engagement in resistance exercise. There was wide variability in both the advice provided regarding sternal precautions and time to return to activities of daily living. Additionally, the facilitation of some elements of self‐management for physical activity, in particular problem solving and providing follow up support outside of the cardiac rehabilitation setting was provided infrequently.DiscussionThe findings demonstrated variability in service delivery in a number of areas and highlighted potential areas for improvement in light of what is known from the literature. Provision of follow up support for those unable to access outpatient cardiac rehabilitation is a key need.

Community education and health promotion activities of naturopathic practitioners: results of an international cross-sectional survey

BackgroundHealth promotion and patient education are crucial to improved population health and are also among the core principles that define naturopathy. Yet, the activities of naturopathic practitioners (NPs) with regards to health promotion and community education have not been widely studied.MethodsA cross-sectional online survey of an international convenience sample of NPs was conducted through disseminating a 15-item questionnaire prepared in five languages. Correlates of most frequently mentioned NP activities were studied.ResultsThe survey was completed by 813 NPs representing all world regions. Almost all participants (98%) reported at least one health promotion activity. Most reported were information sheets and handouts (92.7%) or social and professional network communications (91.8%) and information talks presented to community members (84.9%). The majority of NPs (79.5%) indicated that the ‘health issues individuals in NPs’ community have said they need help with’ were a ‘very important’ consideration when they designed health promotion activities. NP characteristics associated with the likelihood of engaging in specific health promotion activities varied between activities but include gender, time since first qualification, factors considered to identify need when designing an activity, and stakeholder involvement in activity design.ConclusionsHealth promotion is a key activity of the global naturopathic profession. There are a wide range of patient education tools utilized by NPs.

Pharmacy Hydroxyurea Education Materials for Patients with Sickle Cell Disease: An Environmental Scan and Assessment of Accuracy

BACKGROUND: Hydroxyurea (HU) remains a cornerstone of sickle cell disease (SCD) therapy however its clinical efficacy may be limited by poor patient acceptance and adherence. While barriers to HU use are multifold, patients often relay fears relating to potential side effects of HU as a contributor to drug non-adherence. A common source of information on HU side effects is the patient information handouts (PIHs) that are routinely distributed by pharmacies when dispensing a prescription. We sought to formally evaluate the content and accuracy of HU pharmacy PIHs, including comparison of content with a reference standard PIH developed by the Canadian Haemoglobinopathy Association.METHODS: We obtained a comprehensive list of all accredited pharmacies in Ontario, Canada in 2016 from the Ontario College of Pharmacists (OCP), which totalled 4,150 pharmacies. A representative sample of pharmacies were subsequently contacted by telephone or in-person to obtain pharmacy PIHs on HU. PIHs were assessed according to listed uses of HU, number of inaccurate statements, essential statements based on comparison to the CanHaem reference standard PIH, and reading level (using Flesch-Kincaid and SMOG scales).RESULTS: Six unique HU PIHs were identified, which represented approximately 95% of Ontario pharmacies; PIH A and B were used by 58% and 36.7% of pharmacies, respectively (Table 1). While most of the PIHs listed uses for HU (60% of Ontario pharmacies in total), only 58.3% identified SCD as an indication for drug use. All PIHs contained statements that could be classified as inaccurate and misleading. The number of inaccurate statements ranged from 2-5 per PIH; 95% of distributed PIHs had an average of 4 inaccurate statements per handout. The most frequently encountered inaccuracy related to development of cancer in patients taking HU, namely acute leukemia. Additional inaccuracies included special handling precautions, vaccine inefficacy and overstating the likelihood of developing rare side effects such as, “deadly bleeding problems and infections,” hepatic insufficiency and infertility.On average, pharmacy PIHs included 45% of essential statements present within the reference standard HU patient handout. Missing information themes involved use of HU for management of SCD and specifically, benefits of HU in preventing SCD complications, long term safety data on HU and differentiation between common and uncommon side effects of HU use.The reading level of each pharmacy PIH was also assessed and compared to the grade 6 reading level formally advised for written patient information materials by the National Work Group on Literacy and Health. The average reading level across pharmacy PIHs was 7.85 and 7.83 according to the Flesch Kincaid and SMOG scales, respectively. However, 58% of Ontario pharmacies distributed PIHs with a reading level of 9.2 and 8.2 (Flesch Kincaid and SMOG, respectively) in comparison to the grade 6.2 and 6.7 (Flesch Kincaid and SMOG, respectively) reading level of the CanHaem PIH.CONCLUSION: SCD patients in Ontario who are prescribed HU are likely to receive written information materials from pharmacies that contain inaccurate and misleading statements weighted heavily toward risks of HU therapy and run contrary to published literature. Moreover, the PIHs reviewed in this study contained only 45% of the content deemed necessary for patient education on HU by a panel of experts in SCD. Oftentimes, this information requires a comprehension level beyond that recommended for patients. Through the itemization of written information provided to patients when obtaining their HU prescription, this study identifies a potential gap in the care of SCD patients and an opportunity to improve on the quality of HU PIHs to help patients make well-informed decisions about their health. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

What's Important: What I Learned as My Spouse's "Recovery Partner" Following Rotator Cuff Surgery.

What's Important: What I Learned as My Spouse's "Recovery Partner" Following Rotator Cuff Surgery.

Evaluating the Readability of Veterinary Client Handouts from Vetlexicon, Veterinary Partner, and ClientEd

Ready-to-use animal health information handouts are a valuable service that have the potential to enhance veterinarian-client relationships and animal healthcare. Evaluating the readability of handouts is integral to ensure the information needs of veterinary clients are met. In this study, we describe the significance of client handout readability and review readability studies in veterinary medicine. We then present our analysis of the readability of 150 client handouts from three services: Vetlexicon from Vetstream, Veterinary Partner from VIN, and ClientEd from Lifelearn. With a few exceptions, the handouts scored were found to be written at a 9th through 11th grade reading level, above the recommended 6th grade reading level for human medical handouts, limiting the value and potential for enhancing communication about pet health and supporting the veterinarian-client bond.

Plugging into Play: A VAD Playgroup

Our institution experiences a high volume of children supported on paracorporeal Ventricular Assistive Devices (VAD), presenting a high demand for Allied Health support. To increase efficiency of Allied Health support we piloted a VAD playgroup twice weekly for children aged 0-3 years. We wanted to explore how this would impact on parental confidence in providing developmental opportunities, children achieving nominated goals, and perceived opportunities for socialisation in a hospital environment. A secondary outcome was to evaluate the safety of a VAD playgroup. We scheduled a playgroup twice weekly using the play space on the cardiac ward. It involved a rotating roster of physiotherapists, occupational therapists, speech therapists, child life therapists and music therapists, with two therapists attending each session. Parents were given information handouts, and individualised goals were set for each child with the parents using the Goal Attainment Scale (GAS). The format included welcome and goodbye songs, books, individualised developmental play, and a group activity. Our pilot group consisted of 4 children whom had been on VAD for varying lengths of time (29-204 days). Parent confidence, and opportunities for socialisation were assessed using pre- and post-surveys. Therapeutic benefit was assessed using each child's GAS goals. Safety was evaluated through adverse events. Parents reported increased confidence in positioning their child for play (average 7.75 to 9.25 out of 10), encouraging their child's mobility (average 7.25 to 9.25 out of 10), opportunities to play with hands (average 7.5 to 9.75 out of 10), developing communication skills (average 6.5 to 8.5 out of 10) and in supporting their child's development (average 7.25 to 8.75 out of 10). All parents reported an increase in providing socialisation opportunities for their child, and increased satisfaction in providing developmental play opportunities. All children showed improvement in their individualised goals.There were no adverse events requiring medical attention during the pilot period. The VAD playgroup pilot was found to be safe and beneficial for children's neurodevelopment whilst on VAD. It has continued as part of our routine clinical service.