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2021

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Full-Text Articles in Clinical and Medical Social Work

Ketamine As A Treatment Modality For Treatment-Resistant Depression, Tracy Wulff, Shen Cao Dec 2021

Ketamine As A Treatment Modality For Treatment-Resistant Depression, Tracy Wulff, Shen Cao

Physician Assistant Capstones, 2020-current

Many recent studies have demonstrated the ability of ketamine, an NMDA receptor antagonist, to produce antidepressant effects that may be effective in helping reduce treatment-resistant major depression. In particular, three double-blinded randomized control trials have been conducted to assess the viability and effectiveness of this medication for treatment. This systematic literature review will analyze these studies and determine if the overall research indicates that ketamine is useful in improving depression as measured by the Montgomery–Asberg Depression Rating Scale (MADRS)1.

Objective: Assess the effectiveness of IV Ketamine in reducing treatment-resistant major depressive disorder as measured by the Montgomery–Asberg …


Appreciation Day For Clinical Staff At Vna Hospice, Melody Nguyen Dec 2021

Appreciation Day For Clinical Staff At Vna Hospice, Melody Nguyen

Capstone Projects and Master's Theses

VNA Hospice of the Central Coast is a nonprofit that was created back in 1951. The staff at VNA are visiting about 75,000 homes per year. Throughout the years the staff have been seeing patients who reached the requirement of having 6 months or less to live. Working with Hospice patients can be hard for everyone but, the staff at VNA are seeing the patients from good days and bad days. Depression is known to negatively impact the clinical staff at VNA Hospice. Staff are working long hours which leads to sleep disturbance and chronic stress. Some staff are also …


Expanding The Conceptualization Of Support In Low-Wage Carework: The Case Of Home Care Aides And Client Death, Emma K. Tsui, Marita Lamonica, Maryam Hyder, Paul Landsbergis, Jennifer Zelnick, Sherry Baron Dec 2021

Expanding The Conceptualization Of Support In Low-Wage Carework: The Case Of Home Care Aides And Client Death, Emma K. Tsui, Marita Lamonica, Maryam Hyder, Paul Landsbergis, Jennifer Zelnick, Sherry Baron

Publications and Research

Home care aides are a rapidly growing, non-standard workforce who face numerous health risks and stressors on the job. While research shows that aides receive limited support from their agency employers, few studies have explored the wider range of support that aides use when navigating work stress and considered the implications of these arrangements. To investigate this question, we conducted 47 in-depth interviews with 29 home care aides in New York City, focused specifically on aides’ use of support after client death. Theories of work stress, the social ecological framework, and feminist theories of care informed our research. Our analysis …


The Erasure Of Monosexism: An Exploration Of Identity Development In Bisexual Women, Emma M. Leonard Dec 2021

The Erasure Of Monosexism: An Exploration Of Identity Development In Bisexual Women, Emma M. Leonard

MSU Graduate Theses

Research has shown that bisexual individuals experience poorer mental health outcomes, resulting in depression, anxiety, substance use, and suicidal ideation, than their gay or straight counterparts (Calzo, Antonucci, Mays, & Cochran, 2011; Ross, Dobinson, & Eady, 2010; Taylor, Power, & Smith, 2020). These poor mental health outcomes suggest bisexual individuals may be experiencing hardships these other groups are not. This qualitative study sought to gain an understanding of the lived experiences of bisexual women aged 18-25. The researcher sought to gain an understanding of self-identified resiliency factors by the women as it pertains to their sexual/affectional orientation. Detailed interviews were …


Relative Effectiveness Of Online Cognitive Behavioural Therapy With Anxious Or Depressed Young People: Rapid Review And Meta-Analysis, Shikara T. Howes, Kevin M. Gorey, Carly M. Charron Nov 2021

Relative Effectiveness Of Online Cognitive Behavioural Therapy With Anxious Or Depressed Young People: Rapid Review And Meta-Analysis, Shikara T. Howes, Kevin M. Gorey, Carly M. Charron

Social Work Publications

Global estimates suggest that 25% and 20% of youth have reported elevated symptoms of depression and anxiety, respectively, since the beginning of the COVID-19 pandemic compared to baseline functioning (Racine et al., 2021). Cognitive behavioural therapy (CBT) has been found to significantly benefit young people experiencing anxiety and depression (Christ et al., 2020). Pandemic-related protocols have led many mental health services to shift to online platforms. We wondered about the comparative efficacy of online versus offline CBT for young people between the ages of 10-25. We responded with a rapid review and meta-analysis of eight randomized controlled trial outcomes. The …


Fidelity Monitoring In The Solution Focused Wellness For Hiv (Sfwh) Intervention For Women, Helen Taylor Yates, Spencer Elise Lee Nov 2021

Fidelity Monitoring In The Solution Focused Wellness For Hiv (Sfwh) Intervention For Women, Helen Taylor Yates, Spencer Elise Lee

Journal of Solution Focused Practices

Solution Focused methods are often interpreted by different practitioners with a degree of flexibility and adaptation to specific practice settings (Lehmann & Patton, 2012). This flexibility is one of the features that makes SFBT a very client-centered approach and has been highlighted as one of the key aspects of successful co-construction of desired outcomes with clients (Franklin et al., 2017). This collaborative approach is possible due to SFBT’s utilization of social constructionist principals in the solution-building process (Blundo & Simon, 2015). While encouraging flexibility of implementation of SFBT, identifying the main tenets of the therapy, including specific techniques and mindsets …


Effect Of Presence And Absence Of Parents On The Emotional Maturity And Perceived Loneliness In Adolescents, Sana Fatima, Momal Bashir, Kainat Khan, Sheeza Farooq, Sidra Shoaib, Sheeba Farhan Oct 2021

Effect Of Presence And Absence Of Parents On The Emotional Maturity And Perceived Loneliness In Adolescents, Sana Fatima, Momal Bashir, Kainat Khan, Sheeza Farooq, Sidra Shoaib, Sheeba Farhan

Journal of Mind and Medical Sciences

The present study was conducted to examine the Emotional Maturity and Perceived Loneliness of adolescents with respect to the presence and absence of parents. It was hypothesized that the absence or presence of parents of adolescents would affect the level of emotional maturity and perceived loneliness among adolescents. The adolescent participants N=250 (males n=125 and females n=125; age range= 13-18; M=16.63; SD=0.87) were approached through purposive convenient sampling technique. Measures included the Emotional Maturity Scale and the UCLA loneliness scale V-III. Results indicated that adolescent who lived with their guardians had greater perceived loneliness than those who lived with their …


Teachers’ Views On Preparation For Employment Of Young Autistic People, Biranavan Thavapalan, Emanuele Maria Merlo Oct 2021

Teachers’ Views On Preparation For Employment Of Young Autistic People, Biranavan Thavapalan, Emanuele Maria Merlo

Journal of Mind and Medical Sciences

Background. Contemporary literature indicates that there is significant support and assistance provided by schools for young autistic people, which has had a positive impact on the accessibility of jobs. Nevertheless, the employment rate of autistic people is unacceptably low in the UK. The current study investigated teachers’ views on the preparation for employment of young autistic people in the UK. Methods. Interviews were conducted with individuals from the educational field and thematic analysis was used to explore the teachers’ views regarding the factors that have an impact on the preparation for employment of young autistic people. Results. …


Decreasing Unintentional Pregnancies For Tennesseans, Paula M. Todd Oct 2021

Decreasing Unintentional Pregnancies For Tennesseans, Paula M. Todd

Electronic Theses and Dissertations

In 2018, 49% of all pregnancies in the United States were unintended, with women with a lower- income status being five times more likely to experience an unplanned pregnancy. Tennessee has a high rate of unintended pregnancies, particularly among the uninsured, low-income, and rural teen populations; some 22% of these unintended pregnancies end in abortion. Oral or transdermal contraceptives that are affordable and accessible for women of childbearing age can reduce unintentional pregnancies. The addressed gap in clinical practice was that contraceptives are not currently available over the counter in Tennessee pharmacies without a prescription, which necessitates a costly medical …


Scoping Review: The Empowerment Of Alzheimer’S Disease Caregivers With Mhealth Applications, Eunhee Kim, Andrius Baskys, Anandi V. Law, Moom R. Roosan, Yan Li, Don Roosan Sep 2021

Scoping Review: The Empowerment Of Alzheimer’S Disease Caregivers With Mhealth Applications, Eunhee Kim, Andrius Baskys, Anandi V. Law, Moom R. Roosan, Yan Li, Don Roosan

Pharmacy Faculty Articles and Research

Alzheimer’s Disease (AD) is one of the most prevalent neurodegenerative chronic diseases. As it progresses, patients become increasingly dependent, and their caregivers are burdened with the increasing demand for managing their care. Mobile health (mHealth) technology, such as smartphone applications, can support the need of these caregivers. This paper examines the published academic literature of mHealth applications that support the caregivers of AD patients. Following the PRISMA for scoping reviews, we searched published literature in five electronic databases between January 2014 and January 2021. Twelve articles were included in the final review. Six themes emerged based on the functionalities provided …


Mindfulness-Based Cognitive Therapy Staff Training Program To Tackle Postpartum Depression, Helen Xumin Chen Aug 2021

Mindfulness-Based Cognitive Therapy Staff Training Program To Tackle Postpartum Depression, Helen Xumin Chen

Doctor of Nursing Practice (DNP) Projects

Abstract

Background: Women in the process of childbirth go through significant physical and psychological changes. The internal changes along with other external factors can be overwhelming. There is a high rate of new mothers suffering from postpartum depression (PPD) as a result. Problem: High prevalence of PPD is a public health crisis. The condition has a negative impact on the mother-baby unit and the wellbeing of the whole family. Aside from the implications on the health of new mothers and babies, PPD is also costly to the economy. Methods: Mindfulness-Based Cognitive Therapy (MBCT) is a common and effective intervention for …


An Exploratory Study Of Individuals’ Transition To Adoptive Parenthood, Emily Brandt, Karen Park, Susan Macdermott, Becki Cohill Aug 2021

An Exploratory Study Of Individuals’ Transition To Adoptive Parenthood, Emily Brandt, Karen Park, Susan Macdermott, Becki Cohill

Summer 2021 Virtual OTD Capstone Symposium

The purpose of this study was to explore individuals’ transition to adoptive parenthood through an occupational therapy lens. More specifically, this study aimed to investigate how individuals’ performance patterns and daily occupations change through this transition. Ultimately, the purpose of this study was to gain insight into this population’s lived experience to inform occupational therapy services in order to meet the specific needs of the adoptive parent population.

A mix-method study was created using both surveys and semi-structured interviews. The survey contained both open and closed ended questions, as well as Likert Scale questions. There were forty survey participants and …


"When They See Someone Who Is Poor, They Step On Them": The Social Determinants Of Health Among Survivors Of Sex Trafficking In Cambodia, James P. Havey, Glenn M. Miles, Lim Vanntheary, Nhanh Channtha, Hanni Stoklosa Aug 2021

"When They See Someone Who Is Poor, They Step On Them": The Social Determinants Of Health Among Survivors Of Sex Trafficking In Cambodia, James P. Havey, Glenn M. Miles, Lim Vanntheary, Nhanh Channtha, Hanni Stoklosa

Dignity: A Journal of Analysis of Exploitation and Violence

Social determinants of health (SDH) are defined as the non-medical yet health-affecting conditions of a person’s life. They include such considerations as working conditions, discrimination, and access to health services. The aim of this study was to explore the SDH impacting those who have survived sex trafficking in Cambodia. This study employed a mixed methods, secondary analysis, focusing on 52 survivors of sex trafficking in the Butterfly Longitudinal Research Project from 2010 through 2019. Participants described myriad social determinants of health, including: gender, age, relationship status (marriage), ethnicity, national identification documentation (statelessness), social class, formal education, vocational training, occupation, and …


The Biopsychosocial Model And Clinical Decision Science In The Age Of Black Lives Matter: A Clinical Reflection, Abdul-Rahman M. Suleiman, Samer Ilayan May 2021

The Biopsychosocial Model And Clinical Decision Science In The Age Of Black Lives Matter: A Clinical Reflection, Abdul-Rahman M. Suleiman, Samer Ilayan

Clinical Research in Practice: The Journal of Team Hippocrates

The author reflects on the biopsychosocial considerations of elevated blood pressure in teenage African American youth during the era of Black Lives Matter (BLM). Parallels are drawn between Dr. Engel’s biopsychosocial model and clinical decision science.


Treatment Access For Dual Diagnosis Substance Use And Mental Health Disorders, Pedro Banuelos May 2021

Treatment Access For Dual Diagnosis Substance Use And Mental Health Disorders, Pedro Banuelos

Electronic Theses, Projects, and Dissertations

In 2018, of 1.3 million Latinx adults in the United States facing concurrent issues with substance use disorders (SUD) and mental health disorders (MHD) 93% remained untreated for either diagnosis. This is concerning since Substance Abuse and Mental Health Services Administration (SAMHSA) data reveals that this population is at greater risk for suicidal thoughts, plans, and attempts. They also face structural barriers such as employment, housing, legal involvement, and insurability that further impede access to treatment.

This study’s purpose was to examine barriers to accessing treatment for Latinx populations confronting co-occurring SUDs and MHDs. This study used a qualitative design …


The Value Of Community Psychiatric Services For The Elderly’S Dementia Caregiver Group: Exploring The Perspectives Of Participants, Elise Greto Apr 2021

The Value Of Community Psychiatric Services For The Elderly’S Dementia Caregiver Group: Exploring The Perspectives Of Participants, Elise Greto

Patient Experience Journal

Community Psychiatric Services for the Elderly (CPSE) at a large teaching hospital in Toronto has offered a monthly support group for caregivers of persons with dementia for over 30 years. Participants were surveyed in January 2018 about group attendance, benefits of attending the group, and areas for improvement. Results are shared in this case study. A total of 8 participants responded to the survey with a response rate of 47%. The feedback was predominantly positive. The most prevailing theme that emerged from the survey responses was group members’ appreciation for the opportunity to meet with one another to discuss relevant …


Clinical Intern, Funmibi Yusuff Apr 2021

Clinical Intern, Funmibi Yusuff

Professional Impact Project: Implementation of Evidence Based Practices by Clinical Mental Health Counseling Graduate Students

In this work, I describe the client that I worked with and their background information necessary to participating and understanding the therapeutic work conducted. I describe their symptoms, diagnoses, and case conceptualization. The clinical intervention used to examine change is described as well as the measure used to track any changes.


Building Community-Engaged Multidisciplinary Partnerships To Improve Medication Management In Elderly Patients With Multiple Chronic Conditions, Ivy O. Poon, Felicia Skelton, Lena R. Bean, Dominique Guinn, Terica L. Jemerson, Ngozi D. Mbue, Creaque V. Charles, Uche Anadu Ndefo Apr 2021

Building Community-Engaged Multidisciplinary Partnerships To Improve Medication Management In Elderly Patients With Multiple Chronic Conditions, Ivy O. Poon, Felicia Skelton, Lena R. Bean, Dominique Guinn, Terica L. Jemerson, Ngozi D. Mbue, Creaque V. Charles, Uche Anadu Ndefo

Journal of Patient-Centered Research and Reviews

Purpose: Many studies in preventing adverse drug events have been researcher-driven, yet few have engaged patients in the development of a project. This project aims to engage minority elderly patients with multiple chronic conditions in the development of research questions and strategies to improve medication safety.

Methods: Elderly patients (≥ 65 years old) who were prescribed 7 or more chronic medications were recruited through a university-based aging resource network in a historically African American community in Houston, Texas. Patients and a caregiver participated in a multidisciplinary workgroup comprised of a physician, pharmacists, a nurse, health educators, and a social worker. …


The Relationship Between Spiritual Health And Social Trust Among Students, Farzin Rezaei, Hero Khwrshid Hassan, Arezoo Fallahi, Reza Ghanei Gheshlagh, Shahram Sadeghi, Parisa Fallahi, Babak Nemat Apr 2021

The Relationship Between Spiritual Health And Social Trust Among Students, Farzin Rezaei, Hero Khwrshid Hassan, Arezoo Fallahi, Reza Ghanei Gheshlagh, Shahram Sadeghi, Parisa Fallahi, Babak Nemat

Journal of Mind and Medical Sciences

Social trust and spiritual health play an important role in social communication. The aim of this study was to determine the relationship between spiritual health and social trust among Iranian students. This cross-sectional study was conducted in the city of Sanandaj, in the West of Iran, in 2018. 686 students from 5 universities were included in the study through simple random sampling. The data were collected using established, reliable instruments for the assessment of social trust and spiritual health. Logistic regression models were applied to assess the association between social trust and spiritual health. We reported estimated logits and Odds …


Psychosocial Effects Of Infertility, Elizabeth Kulikov Apr 2021

Psychosocial Effects Of Infertility, Elizabeth Kulikov

Showcase of Osprey Advancements in Research and Scholarship (SOARS)

Infertility, or the inability to conceive a child, is a symbolic loss that affects up to 20% of couples in the United States. A symbolic loss is a loss due to something other than death. Infertility has been described as a disenfranchised and anticipatory loss that can lead to complicated grief reactions. Disenfranchised losses are those wherein the grief often goes unrecognized, unacknowledged and misunderstood. Despite its prevalence and the severity of the grief and loss associated with infertility, academic literature examining the psychosocial effects of infertility is scarce. The purpose of this project was to investigate the existing literature …


Front End Justice: Diverting People Affected By Mental Illness From The Criminal Justice System, Ariel Esqueda, Kelliann Kutschke, Matthew Miller, Kayleigh Wendland Apr 2021

Front End Justice: Diverting People Affected By Mental Illness From The Criminal Justice System, Ariel Esqueda, Kelliann Kutschke, Matthew Miller, Kayleigh Wendland

Master of Social Work Student Policy Advocacy Briefs

Many of the people caught up in the criminal justice system are non-violent offenders struggling with mental illness, which cannot and should not be addressed through incarceration. Our jails and prisons are ill-equipped to provide effective mental health services. Incarceration compounds the problem by contributing to increased psychological distress. We are relying on the criminal justice system to respond to mental illness, rather than investing fully in the spectrum of mental health care from prevention to recovery. Minnesota must invest in diverting people affected by mental illness away from the criminal justice system and into community-based treatment, services, and supports …


Investing In A Culturally Diverse Mental Health Workforce In Minnesota, Emma Fuhrman, Teia Kopari, Cody Reinke, Josie Schultz Apr 2021

Investing In A Culturally Diverse Mental Health Workforce In Minnesota, Emma Fuhrman, Teia Kopari, Cody Reinke, Josie Schultz

Master of Social Work Student Policy Advocacy Briefs

Minnesota’s mental health workforce lacks in both cultural diversity and cultural responsiveness. Each is critical for providing equitable mental health care to Minnesota's increasingly diverse population. Without ensuring that Minnesota’s mental health workforce is culturally diverse, culturally responsive mental health care for Black, Indigenous and People of Color (BIPOC) will not be attainable. Minnesota must broaden, strengthen, and create structures to support a racially and ethnically diverse mental health workforce.


Changing Needs Of Individuals With Disabilities In The Time Of Covid-19 As Observed By A Family Navigation Program In Miami, Fl, Gabriella Llano, Allison Kumnick, Jean-Paul Bryant Ms, Nancy Torres Ms, Jeffrey Brosco Md, Phd, Maite Schenker Phd Mar 2021

Changing Needs Of Individuals With Disabilities In The Time Of Covid-19 As Observed By A Family Navigation Program In Miami, Fl, Gabriella Llano, Allison Kumnick, Jean-Paul Bryant Ms, Nancy Torres Ms, Jeffrey Brosco Md, Phd, Maite Schenker Phd

Developmental Disabilities Network Journal

The Family Navigator Program (FNP) is designed to help families navigate the complex system of services available to people with intellectual and developmental disabilities (I/DD), chronic health conditions, mental health issues, and other special health care needs. Based at the Mailman Center for Child Development at the University of Miami, the FNP is free and available to all families in South Florida. Most families enrolled in the FNP are receiving medical services from a university clinic; however, the program also accepts referrals from outside agencies and self-referrals. The aim of this study was to investigate the needs of families enrolled …


Cooper Neurological Institute, Kayla Cupano Mar 2021

Cooper Neurological Institute, Kayla Cupano

Department of Occupational Therapy Entry-Level Capstone Projects

No abstract provided.


Communication And Self-Care In Times Of Stress, Elizabeth Marston, Sam Marion Mar 2021

Communication And Self-Care In Times Of Stress, Elizabeth Marston, Sam Marion

National Youth Advocacy and Resilience Conference

The global pandemic of Covid-19 placed protecting physical health at the forefront of all of our minds. However, the mental and emotional impact of stress, quarantine, social distance, political and social turmoil, and virtual learning is enormous. This presentation will outline strategies for effectively managing stress while also understanding how to effectively communicate with students and parents who are struggling.


Assisted Reproductive Technologies And Health-Related Issues Among Women And Children: A Research Review, Laura Maria Corradi Mar 2021

Assisted Reproductive Technologies And Health-Related Issues Among Women And Children: A Research Review, Laura Maria Corradi

Dignity: A Journal of Analysis of Exploitation and Violence

From their first use in the late 1970s until the mid-1990s, Assisted Reproductive Technologies (ART) gave rise to serious concerns by feminists internationally. Their questions ranged from asking about health risks to ethical and political problems inherent in these technologies. However, over the last 25 years, interest in women’s health which used to be central to feminist theory and politics, progressively decreased and with it concerns about ART. Today, while the medical literature about health risks in ART is increasing, the topic of women’s health in relation to reproductive technologies remains marginal in feminist discourse, social sciences, and the mainstream …


Dnp Final Report: Breaking The Cycle: Care Coordination Interventions And Sickle Cell Readmissions, Naphtali Edge Feb 2021

Dnp Final Report: Breaking The Cycle: Care Coordination Interventions And Sickle Cell Readmissions, Naphtali Edge

DNP Final Reports

Background

Approximately 100,000 people in the United States are affected by Sickle Cell Disease (SCD). Sickle Cell Disease represents the second highest readmitting diagnosis at Houston Methodist Hospital. The purpose of this study is to determine the impact of implementing care coordination interventions to reduce hospital readmissions of patients with SCD.

PICOT

In adult patients with SCD in the acute care hospital setting, how does care coordination intervention compared to no care coordination intervention affect the readmission rate for patients with SCD over a 3 – 6-month period?

Body of Evidence

Eleven studies were critical appraised and included in the …


The Rise In Use Of Emotional Support Animals By College Students: The Impact Of Parenting Styles, Misty G. Smith, Samantha Ballard, Jill Willis Jan 2021

The Rise In Use Of Emotional Support Animals By College Students: The Impact Of Parenting Styles, Misty G. Smith, Samantha Ballard, Jill Willis

Georgia Journal of College Student Affairs

As the generational context of higher education shifts, a rise of Emotional Support Animals (ESA) and mental health concerns are present for students on college campuses. While previous studies have aimed to address the relevancy and controversy of ESAs in higher education as well as their effectiveness in supporting individuals, less research has explored underlying factors that contribute to the use of an ESA. The purpose of this study was to explore the parenting behaviors of parents/caregivers of students with ESAs in comparison to parents/caregivers of students without ESAs. An embedded mixed methods design was used. Participants completed the Parenting …


Opioid Use Disorder: The Timeline For Medication Assisted Therapy, Alexander Cristofori Jan 2021

Opioid Use Disorder: The Timeline For Medication Assisted Therapy, Alexander Cristofori

Capstone Showcase

Opioid Use Disorder is patterns of opioid use leading to withdrawal, giving up important life events in order to use opioids, and excessive time spent using opioids, to name a few diagnostic criteria. The clinical progression of the disorder involves periods of acute exacerbation and remission that are cyclic in nature. Treatment is most effective when it includes both pharmacological and psychosocial modalities, referred to as medication assisted therapy (MAT). Three drugs used commonly in MAT-based treatment for OUD from oldest to newest include Methadone, Buprenorphine-naloxone, and Naltrexone. Treatment program models that prioritize total abstinence from the addictive substance attached …


The Experiences Of Women Who Have A Child Diagnosed With An Eating Disorder: A Narrative Inquiry, Jennifer Scarborough Jan 2021

The Experiences Of Women Who Have A Child Diagnosed With An Eating Disorder: A Narrative Inquiry, Jennifer Scarborough

Theses and Dissertations (Comprehensive)

Eating disorders (EDs) are serious, life-threatening illnesses that typically occur in adolescence. Immediate intervention is necessary in order to interrupt the associated behaviours. Typically, adolescents struggling with EDs minimize the severity the illness has on their psychological and physiological wellbeing. For this reason, family involvement in the intervention is strongly recommended. Additionally, family involvement has shown to increase the likelihood of better outcomes. Parents are typically tasked with the responsibility of making and monitoring meals and/or interrupting compensatory behaviours. These tasks often lead to high conflict. Despite the importance of parental involvement, predominantly, it is mothers who fulfill the intensive …