PREP Self-Assessment Research Articles

The 36th Year to Come

The 36th Year to Come

Change is in the Air

Although the primary goal of Pediatrics in Review ( PIR ) is to keep the pediatrician up to date across the broad spectrum of pediatric knowledge, the journal serves other purposes. One function is to allow the reader to earn continuing medical education (CME) credits. Reading the journal and taking the quizzes, learners can earn up to 36 credits per year; taking the companion PREP Self-Assessment in learning mode can add up to 43 additional credits. Many physicians can fulfill all of their CME requirements by using these two learning tools. As most readers are aware, specific criteria must be met before accrediting educational organizations will grant CME credit. For instance, the Accreditation Council for Continuing Medical Education (ACCME) in 2011 awarded the American Academy of …

Change is in the Air

Although the primary goal of Pediatrics in Review (PIR) is to keep the pediatrician up to date across the broad spectrum of pediatric knowledge, the journal serves other purposes.One function is to allow the reader to earn continuing medical education (CME) credits. Reading the journal and taking the quizzes, learners can earn up to 36 credits per year; taking the companion PREP Self-Assessment in learning mode can add up to 43 additional credits. Many physicians can fulfill all of their CME requirements by using these two learning tools.As most readers are aware, specific criteria must be met before accrediting educational organizations will grant CME credit. For instance, the Accreditation Council for Continuing Medical Education (ACCME) in 2011 awarded the American Academy of Pediatrics accreditation “with commendation” for the next 6 years, based on the quality of its CME offerings, which continue to meet the ACCME requirements for outcomes-based learning designed to improve quality of care.Another key agency, the American Medical Association (AMA), in 2010 strengthened its requirements by issuing several new standards and re-interpreting a few old ones, in order for accredited CME providers to cocertify activities for AMA PRA Category 1 Credits™. Among these is the requirement of a minimum performance level (a minimum passing score) and a “1 article = 1 credit” rule. Both are designed to ensure mastery of content. Both will entail changes for PIR readers.Currently, all quiz questions are written by designated question writers, must undergo peer review, and are published only after final approval by the authors and editors. Each question is designed to help readers focus on salient elements of the CME article and on general pediatric knowledge. Questions are constructed to help learners evaluate information and select a course of action, recommend treatment modalities, or entertain a diagnosis. This approach will not change.What will change is the method for submitting quiz answers and claiming credit. Until now, readers have been able to submit answers in two ways: on a paper form or online. The print version of the journal had listed the correct answers inside the front cover. The online quiz had indicated the correct answers electronically and highlighted the part of the article that forms the basis for the answer.Starting in January 2012, readers may submit quiz answers online only. Online confirmation of the correct answer will remain the same, but in the print issues, correct answers will not appear until the following month.An advantage of the online method of answering is that readers may review the material and retake the quiz until questions are answered correctly. Not only will repeated attempts reinforce the correct information, but the reader will be able to achieve the percentage of correct answers required to claim CME credit. The minimum passing score that must be achieved is 60% for each article designated for credit. Once learners achieve a 60% score, they will be prompted to claim credit.Under new requirements, each quiz that follows a specific article will be worth 1 AMA PRA Category 1 Credit™; the older method of stating the hours spent reading each issue will no longer apply. With few exceptions, the articles chosen to have quizzes will be full-length reviews. Occasionally, quizzes may be appended to shorter articles.Readers should know that there is a strong trend toward measuring changes that learners might make in their practice habits. Going a step further, efforts will be made to measure changes in outcomes that result from participating in PIR as an educational activity.We trust these changes will not require a great deal of adaptation on the part of our learners and that they will result ultimately in an improvement of our educational capability.

Research and Statistics: Reliability and Validity in Pediatric Practice

1. Nikeea Copeland-Linder, PhD, MPH* 1. Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University, Baltimore, Md Welcome to a new series in Pediatrics in Review ! The Pediatrics Review and Education Program (PREP The Curriculum®) includes Pediatrics in Review (PIR) and PREP Self-Assessment and is based on the American Board of Pediatrics’ (ABP) 3,700 content specifications. These content specifications are the focus of the Board's Program for Maintenance of Certification. PREP The Curriculum® commits to covering all of the 3,700 content specifications over a 5-year period, helping the pediatrician prepare for the cognitive examination based on these knowledge statements. In late 2008, the ABP added 26 new content specifications on research and statistics. To cover these, we introduce a new series. Clinician researchers from the Johns Hopkins University Division of General Pediatrics and Adolescent Medicine will be writing brief case-based or practice-oriented articles to address these topics. We hope that these articles will be useful for readers in evaluating the scientific literature and adopting evidence-based practice. We welcome your feedback on this new endeavor!— Tina L. Cheng, MD, MPH, Associate Editor

Entering Our Fourth Decade

1. Lawrence F. Nazarian, MD, Editor-in-Chief The first issue of Pediatrics in Review ® was published in 1979, and this present issue begins our fourth decade of serving children through those who care for them. The fundamental aspects of the journal have not changed. Our primary mission remains to keep the general pediatrician current with the broad spectrum of pediatric medicine. Our primary tool is the review article, written by experts, with a high premium placed on clarity and utility in caring for patients. We continue to partner with PREP Self-Assessment ® to expand the subject matter we can cover together and to allow readers an in-depth opportunity to evaluate their knowledge. Those who read the journal and complete the self-assessment program can earn up to 76 continuing medical education credit hours, which is one of the few bargains still available. At the end of this commentary, we outline the procedure for obtaining credit online. However, there have been significant changes, as well. New sections have been added to the journal that have specific foci and, sometimes, a different way of teaching. These innovations include “Index of Suspicion,” “What's New,” “Back to Basics,” “Question from the Clinician,” “Visual Diagnosis,” technical tips, critical analyses of complementary and alternative therapies, articles on evidence-based medicine, reports on community pediatric projects, and “Focus on Diagnosis.” The latter two features have been written by residents, a group with …

Meeting the Need for Continuing Education

Meeting the Need for Continuing Education

Meeting the Need for Continuing Education

1. Mary E Rimsza, MD, FAAP, Editor, PREP Self Assessment In January 2008, the Josiah Macy, Jr, Foundation issued a report on the current status of continuing education systems for health professionals. The report criticized the medical profession's traditional emphasis on continuing medical education (CME) hours earned in lecture format and recommended that continuing education programs be designed to help physicians examine and improve their own practices and answer the questions that arise during patient care. 1 When I read the report, I realized that for almost 30 years, PREP® The Curriculum has provided just such an educational program! We certainly were ahead of our time, and having more than 27,000 subscribers worldwide suggests that many health-care professionals agree that this approach to CME meets their educational needs. PREP is a learning system based on the American Board of Pediatrics’ (ABP) content specifications, which are the focus of the Board's Program for Initial Certification and Maintenance of Certification™ (MOC)—Pediatrics. PREP Self-Assessment (SA) questions as well as Pediatrics in Review ( PIR ) articles are mapped to the ABP's content specifications, and if you subscribe to both PREP SA and PIR continuously over a 5-year period, you will have had the opportunity to review almost …

Changing for the Better

One of my uncles maintained a perpetual pot of soup to which he would add some new foods each day, constantly creating a fresh taste from the same batch of soup. Although the analogy cannot be stretched too far, in a sense Pediatrics in Review (PIR) is like that marvelous soup in that the journal, while maintaining its basic character, evolves over time to meet the needs of our readers and our ultimate consumers, children around the world.The basic “stock” in our soup pot is the body of content specifications of the American Board of Pediatrics (ABP), which provides a core of knowledge objectives encompassing the fundamentals of today’s pediatric medicine. Using this material to guide us, and teaming with the PREP Self-Assessment, we are able to meet our major objectives of keeping readers current in pediatric knowledge and preparing them for the cognitive portion of the ABP’s Maintenance of Certification program. The PREP Curriculum is a learning system that covers the spectrum of pediatric medicine every 5 years.The meat and potatoes are the review articles and shorter “In Brief” pieces, augmented by the different flavors of “Index of Suspicion,” “Back to Basics,” “Visual Diagnosis,” and other special sections.Some newer ingredients have been added. In 2006, we expanded our capability by offering some articles in an online-only format. This additional publishing space has allowed presentation of important and interesting topics outside of the core content, such as assessing the potential for violence in adolescents, a practical approach to quality improvement in the office, and telemedicine. The telemedicine article also demonstrated the capability of online articles for providing striking audiovisual enhancement of the text.Another new flavor in 2006 was a section that informs readers of therapies outside of the mainstream that may be affecting their patients. Our colleagues at the University of Alberta have created this series in conjunction with the Provisional Section on Complementary, Holistic, and Integrative Medicine of the American Academy of Pediatrics (AAP). Topics already covered include probiotics, Echinacea, peppermint oil, and garlic.Beginning with this issue, we highlight successful programs for children resulting from outreach of pediatric residents into the community. In collaboration with the Community Pediatric Training Initiative of the AAP and with support from the Anne E. Dyson Foundation, this series may inspire others to further the cause of community pediatrics. Our first report features a unique program that uses bicycles to make children more active physically while teaching them skills and self-reliance.PIR’s link with residents continues, as they write the “Focus on Diagnosis” articles and submit many of our “Index of Suspicion” cases, including the case that results from their annual case-writing contest. A grant from Ross allows distribution of PIR to all residents in the United States.Our international perspective is maintained by contributions from authors in many countries and through our international editions. We published a commentary by an Italian pediatrician on Italy’s intensive program of preparticipation screening of athletes (November 2006), and we are exploring other such observations by our colleagues worldwide.I would like to extend my thanks to the many individuals who have made this PIR soup so nourishing and tasty, including our Associate Editors Drs Tina Cheng and Joseph Zenel; section editors Drs Henry Adam, Janet Serwint, and Laura Ibsen; editorial board members; editorial assistant Sydney Sutherland; Luann Zanzola and Kerry O’Rourke at the AAP; Medical Copy Editor Deborah Kuhlman; the people at Cadmus and Highwire publishers; and our Consulting and Founding Editor Robert J. Haggerty.

PREP as a Teaching Tool

1. Mary Ellen Rimsza, MD 1. Editor, PREP Self Assessment American Academy of Pediatrics PREP the Curriculum was developed more than 25 years ago to assist physicians in practice with their continuing medical education needs. In most cases, individual clinicians read Pediatrics in Review ( PIR ) and take PREP Self-Assessment ( PREP SA ) to stay up-to-date, prepare for maintenance of certification, and determine areas in which they need more education, but innovative ways of using PREP the Curriculum have gone beyond the conventional uses. Although not developed specifically for pediatric residents, PREP the Curriculum is being used by many residents, a fact we discovered during focus groups held annually at the National Conference and Exposition of the American Academy of Pediatrics (AAP). In …

Improving the Health of Children Through You

1. Lawrence F. Nazarian, MD, Editor-in-Chief In 2005, Pediatrics in Review ( PIR ) concentrated on its dual missions of keeping clinicians current across the broad spectrum of pediatric medicine while preparing those who will be maintaining their certification. We consider PIR not just a journal but also a critical component of a systematic program of lifelong learning. Basing our coverage on the content specifications of the American Board of Pediatrics, the foundation for their cognitive recertification examination, has been a key factor in achieving those goals. The PREP Self-Assessment, our sibling in continuing medical education, shares coverage of the content specifications and allows those seeking maintenance of certification to fulfill the requirement for self-evaluation. At the same time, we recognize the need to present material that goes beyond those content specifications, and we want …

Improving the Health of Children Through You

In 2005, Pediatrics in Review (PIR) concentrated on its dual missions of keeping clinicians current across the broad spectrum of pediatric medicine while preparing those who will be maintaining their certification. We consider PIR not just a journal but also a critical component of a systematic program of lifelong learning.Basing our coverage on the content specifications of the American Board of Pediatrics, the foundation for their cognitive recertification examination, has been a key factor in achieving those goals. The PREP Self-Assessment, our sibling in continuing medical education, shares coverage of the content specifications and allows those seeking maintenance of certification to fulfill the requirement for self-evaluation.At the same time, we recognize the need to present material that goes beyond those content specifications, and we want to broaden our scope. This expansion of our horizons has presented challenges, particularly that of fitting all the material into the available pages. Solutions have included a modest lengthening of the journal and a tighter rein on the length of articles. Starting with this issue, we are taking advantage of the flexibility of our electronic edition by adding extra material in an online-only format. These extra articles are abstracted in the print edition and for this year, will not have quiz questions. Although we realize that some readers might have to make adjustments to access the bonus material, we feel that this expanded capability will allow us to give you even better coverage of pediatrics.Although review articles and “In Brief” pieces constitute the core of the journal, different formats allow the learning process to be more varied and interesting. “Focus on Diagnosis” made its debut last year as an approach to highlight diagnostic procedures as well as allow residents to serve as authors. Residents submit cases to an annual contest, from which we pick one case to publish in “Index of Suspicion.” The third annual winner was announced at the National Conference and Exposition and will be published later this year. An editorial writing contest produced some excellent commentaries by our readers, the best of which make their way into print.Following the philosophy of the American Academy of Pediatrics, we attempt to maintain a global perspective, both by including the work of international authors and through our international editions. Over the years, “Index of Suspicion” has included cases submitted from all over the United States, but also from Bangladesh, Canada, England, Germany, Greece, Guam, India, Iran, Israel, Norway, Saudi Arabia, Taiwan, and Turkey, with review articles coming from other countries as well. Our international editions currently serve readers in Hungary, Latin America, Poland, and Spain. The very first Chinese edition was distributed in October, and an Italian edition begins with this issue. Our electronic edition is available free of charge to clinicians in developing countries who might otherwise not have access to the journal.The emphasis on evidence-based medicine has led us to include more references in our articles. Traditionally, PIR has employed the textbook format of avoiding heavy referencing and putting suggested readings at the end of the article, feeling that our function is closer to that of a textbook than a new science journal. In the future, you will notice more references, and you will be seeing articles that end with a summary that includes the strength of the evidence behind the main points.One of the factors that helps us serve you is reader feedback. We receive your comments by way of the Rapid Response feature online, the yearly answer sheets, and direct communications. We read everything that comes in and respond appropriately. Many changes that have improved the journal have come from your suggestions. The comments are varied and sometimes contradictory, but we pay attention to all of them. Our reason for being is to improve the health of all children through you.

PREP Self-Assessment Example

Article| January 01 2004 PREP Self-Assessment Example Pediatr Rev (2004) 25 (1): 27–28. https://doi.org/10.1542/pir.25.1.27 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation PREP Self-Assessment Example. Pediatr Rev January 2004; 25 (1): 27–28. https://doi.org/10.1542/pir.25.1.27 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsPediatrics In ReviewPediatricsHospital PediatricsNeoReviewsAAP Grand RoundsAAP NewsAll AAP Sites Search Advanced Search Topics: self assessment, nicotine, smoking cessation, nicotine withdrawal, cigarettes, tobacco You do not currently have access to this content.

Entering our 25th year.

In this issue of Pediatrics in Review (PIR), we emphasize several aspects of prevention. The article by Belay and colleagues on pediatric precursors of adult diseases emphasizes a new and challenging part of pediatric practice: Identifying children who have no evidence of disease but who are at risk for developing certain diseases as adults and initiating interventions to prevent such problems. The article on smoking prevention, with the linkage to a PREP self-assessment question and critique on the same topic, deals with the single most important modifiable factor in adult health. However, smoking also can be considered a pediatric disease because nearly all who become addicted to tobacco do so before age 18 years, even though the consequences do not appear until later adult life.Our Index of suspicion (IOS) section continues to be valued highly by our readers. However, we receive many more good cases for IOS than we can publish. Unfortunately, from this point onward, we will be accepting fewer cases because of space limitations.We continue to believe that the future of medicine is evidence-based, with systematic evaluation of the evidence relating to the efficacy of medical services. We have published two articles on the method and will continue to recruit review articles that employ this process of evaluation.From its inception, PIR has been linked with The American Board of Pediatrics (ABP) Maintenance of Certification program. Committees of both practicing and academic pediatricians appointed jointly by the American Academy of Pediatrics (AAP) and the ABP have developed “content specifications” that cover the field of general pediatrics. There are more than 4,000 of these, and they are updated annually. A portion of these are used each year as the basis for the maintenance of certification examination. Each year, these content specifications are divided between the PREP Self-assessment program (SA) and PIR; over a 5-year period, almost all are covered by one or both of these vehicles. The 5-year cumulative index published each year in PIR lists all PIR articles, NeoReviews articles, SA exercises, and Update topics for the current plus the previous 4 years. Candidates taking the cognitive examination for maintenance of certification should use the 5-year index and contents of these publications to prepare for the examination. (For a good explanation of the links between the AAP’s educational program and the ABP’s Maintenance of Certification, see PIR. 2003;24:243–244.)Educational vehicles have been added by the AAP over the years; these now include PREP The Course, NeoReviews, and AAP Grand Rounds, as well as PIR, SA, and the Update tapes. This array of offerings allows pediatricians a variety of CME methods for attaining maintenance of clinical competence. We also strive to enhance the linkage between these vehicles by publishing occasional SA exercises in PIR (see pg 26 in this issue) and adding recent publication citations from AAP Grand Rounds and the Update tapes to the Suggested Reading lists at the ends of PIR articles. We believe that the AAP, through these different vehicles, offers the most comprehensive CME program of any clinical specialty, and these different venues provide different styles of learning from which the clinician can choose.Today, PIR has more than 35,000 subscribers in the United States as well as a circulation of nearly 40,000 in six different international editions (Italian, Hungarian, Portuguese, Polish, Spanish, and an English Indian edition), which speaks to the usefulness of the journal for pediatricians worldwide. The electronic version of PIR provides additional multimedia material and often includes peripheral material not covered in the journal’s print version, such as expanded lists of references. The electronic version’s rapid response online allows readers to ask questions and comment on PIR articles, many of which we answer online and often publish in the print version. We get comments from readers throughout the world via this excellent communication tool.I am very pleased to announce that the AAP has appointed Dr. Larry Nazarian to be the new editor of PIR beginning with the January 2005 issue. Larry’s superb role as associate editor of PIR since 1989; his role in developing several of our journal’s new features (especially the “jewel in the crown” IOS); and his long experience as a clinician, teacher, office-based researcher, and editor will ensure the ongoing high standard of quality for PIR. I have no doubt that PIR will continue to improve and provide the cognitive base for the optimum health care of children.

The program for maintenance of certification in pediatrics® (PMCP)™

The American Board of Pediatrics (ABP) has initiated a new process of recertification called Maintenance of Certification. Maintenance of certification embraces a different philosophical premise than that of traditional recertification. The traditional recertification process focused only on one physician competence—knowledge of the specialty—and assessed that knowledge only periodically (eg, once every 7 or 10 years). Maintenance of certification recognizes that there are several essential competencies involved in delivering quality care that extend beyond medical knowledge, and that these competencies should be developed and maintained throughout one’s career. The new maintenance of certification process is designed to evaluate, on a continual basis, the essential competencies deemed necessary for general pediatricians and pediatric subspecialists to deliver quality care with an emphasis on continual learning and practice improvement.

Welcoming the new year.

With the December 2002 issue of Pediatrics in Review (PIR), I have completed 23 years as editor. From its inception, the purpose has been to offer pediatric clinicians up-to-date information to help them provide optimal care to children and prepare pediatricians for the maintenance of competence examinations of the American Board of Pediatrics (ABP). The close collaboration between the American Academy of Pediatrics (AAP) and the ABP in developing nearly 5,000 content specifications, covering most of pediatric knowledge, has been the envy of other medical specialties. The content specifications form the basis for almost all of the material in PIR. In 2002, PIR covered nearly 300 of the more than 4,000 content specifications. Together with the PREP Self-Assessment program, we cover almost all of the nearly 5,000 content specifications over a 5-year period. In the December 2002 Index, the material covered from 1998 through 2002 in both vehicles is listed as well as that from Update Tapes, another AAP continuing education vehicle. For pediatricians planning to take the examinations in 2003, this index should serve as a guide to almost all of the material to be covered in the cognitive examinations.During the past 2 years, we have added two special sections to PIR: newly approved drugs (under the topic What’s New) and Questions from the Clinician. Both seem to have been well received.During the coming year, all educational vehicles of the AAP are urged to present material on cultural sensitivity. This is difficult to do in written form. We did publish such an article in 1996, and in 2003 we will publish a special article on how families from different cultures deal with the common cold. We also hope to have multimedia material in our electronic edition that will illustrate in video format how clinicians can deal effectively with different cultures. The other focus for AAP educational activity in 2003 is international health. We do not publish articles directly related to issues of clinical international health, but our large international journal circulation of more than 40,000 in seven foreign language editions indicates that we meet a need in many countries for pediatric continuing education.For many years, PIR has had several international editions. Currently, there are editions in Spanish for South America and Spain, Italian, Polish, Hungarian, English for India, and Portuguese for Brazil. In the past year, we have arranged for a limited distribution of the English edition to the European Union Pediatric Society (CESP) and have the president of that organization, Professor Robert Holl, on our editorial board. The AAP is working to develop closer ties to our European pediatric colleagues to share with them the many excellent continuing education programs developed for AAP members.Evidence-based medicine (EBM) is clearly what we all desire for our continuing medical education. EBM is a systematic approach to determining the strength of the evidence for any given diagnostic or therapeutic activity. We have initiated a series of articles that will help explain EBM and give the clinician examples of how this systematic approach can improve patient care.We’d appreciate your feedback on any topic of PIR. A happy and peaceful 2003 to us all!

PREP self-assessment

PREP self-assessment

PIR and the new millenium

1. RJ H Everyone seems to be celebrating the millenium. Not to be outdone, so is Pediatrics in Reveiw . During the year 2000 we will celebrate our 20th anniversary as part of the millenial event. For this entire 20 years, PIR has been tied to the American Board of Pediatrics’ recertification program. Each year, committees of clinicians and academicians develop content specifications (now nearly 5,000) from which about 900 are selected annually to be the basis of the time-limited certification test 2 years hence. PIR , together with the PREP Self-Assessment Program, divides these specifications and cover nearly all of them in the year preceding the recertification examination. Thus, in 2000, PIR will publish material that will be the basis for the examination in 2001. Over a 4-year period, these two parts of PREP cover almost all of the 5,000 content specifications, and the index of PIR each December lists the current material plus that of the previous 3 years. PIR continues to change to remain as useful as possible as a review vehicle. The ever-popular Index of Suspicion now is featured monthly, and this January issue offers six cases instead of the usual three. …

PREP CME Credits — Your Comments Pay Off

Many readers who fill out their Pediatrics In Review and Self-Assessment Quiz forms religiously also add comments about these educational vehicles. As editors, we take these very seriously. One repeated comment over the past years has been the relatively low number of CME credits awarded for reading PIR and completing the quizzes and doing the PREP Self-Assessment program. As a result, the Academy has increased the number of CME credits for PIR to 3 hours per issue (a total of 36 per year). The PREP Self-Assessment exercise will increase to 20 hours per year. Thus, if you do both parts, the total number of hours available for PREP will be 56 hours per year, effective 1994.

Pickles, Pizza, and PREP

The Department of Education of the American Academy of Pediatrics has provided residency training program directors with a complimentary copy of CompuPREP, the computerized version of the PREP Self-Assessment, each year since the computer version became available. Formatted for IBM and Macintosh personal computers, CompuPREP was developed in response to numerous requests from Academy members for computerized educational materials. Currently, it is sent to more than 3,000 subscribers annually. Although the questions, critiques, and references are identical to those contained in the printed version (which is distributed to all pediatric residents through a grant from Ross Laboratories), the computer version has several features that make it a particularly good learning tool: access to immediate feedback about answers without moving from booklet to booklet; an option to review questions by subject area to enhance concentrated learning; and an automatic scoring system that produces a personal performance chart.

Pickles, Pizza, and PREP

The Department of Education of the American Academy of Pediatrics has provided residency training program directors with a complimentary copy of CompuPREP, the computerized version of the PREP Self-Assessment, each year since the computer version became available. Formatted for IBM and Macintosh personal computers, CompuPREP was developed in response to numerous requests from Academy members for computerized educational materials. Currently, it is sent to more than 3,000 subscribers annually. Although the questions, critiques, and references are identical to those contained in the printed version (which is distributed to all pediatric residents through a grant from Ross Laboratories), the computer version has several features that make it a particularly good learning tool: access to immediate feedback about answers without moving from booklet to booklet; an option to review questions by subject area to enhance concentrated learning; and an automatic scoring system that produces a personal performance chart.