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Psychiatric and Mental Health Commons™
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Articles 181 - 210 of 281
Full-Text Articles in Psychiatric and Mental Health
Maltreatment And Resilience: Examining The Unique Roles Of Threat And Deprivation, Priscilla Herrera
Maltreatment And Resilience: Examining The Unique Roles Of Threat And Deprivation, Priscilla Herrera
Undergraduate Research Symposium Posters
Background and objectives: This study aimed to investigate the involvement that maltreatment type, specifically threat and deprivation, play in a child’s life. We examine how threat uniquely contributes to resilience and how deprivation impacts resilience. Literature has highlighted differences in the effects of deprivation and threat in recent research that shows the impact on various neurological systems.
Methods and approach: Participants included youth aged 11-17 years in the Department of Family Services (DFS) custody following removal from their home after substantiated child maltreatment and were assessed. 90 of the youth in the sample reported that they have experienced threat-based maltreatment, …
Burnout In Optometry.....How Do We Compare?, Jeffrey L. Weaver Od, Mba
Burnout In Optometry.....How Do We Compare?, Jeffrey L. Weaver Od, Mba
Optometric Clinical Practice
Letter to the Editor
Nursing Care Of Individuals Engaging In Non-Suicidal Self-Injury: Impact Of Dialectical Behavior Therapy Skills Reinforcement, Lucas Bridgens
Nursing Care Of Individuals Engaging In Non-Suicidal Self-Injury: Impact Of Dialectical Behavior Therapy Skills Reinforcement, Lucas Bridgens
MSN Capstone Projects
As explained by Linehan et al. (2006b), the seriousness of borderline personality disorder can be highlighted by the manifestations of emotional dysregulation, such as impulsive and suicidal and non-suicidal self-injurious (NSSI) behaviors. As the mental health field grows, so too does the knowledge base from which practitioners derive therapeutic interventions with hopes of effectively and safely treating patients while maintaining a culture of dignity and respect. One such treatment modality that has proven to reduce NSSI and improve interpersonal functioning, specifically in patients with borderline personality disorder, is Dialectical Behavior Therapy (DBT) which is a form of cognitive-behavioral therapy developed …
Predicting Hospitalization Risk Of Schizophrenia Patients In Missouri, Arun Kumar
Predicting Hospitalization Risk Of Schizophrenia Patients In Missouri, Arun Kumar
Theses
Understanding the factors that contribute to the risk of hospitalization among individuals with schizophrenia is crucial for optimizing treatment strategies and improving patient outcomes. In this study, we used recent Medicaid adminis trative claims data in Missouri (from 2016 to 2019) and predicted the risk of hospitalization of patients diagnosed with Schizophrenia (N=143446). We ana lyzed the association between previous hospitalizations and the likelihood of future hospitalizations. We developed machine learning techniques, including logistic re gression and decision tree classifiers, to predict the risk of hospitalization based on demographic factors, clinical variables, and historical hospitalization records. Our findings reveal that …
Implementing Universal Adult Depression Screening In A Rural Maine Free Medical Clinic, Karen Hussion
Implementing Universal Adult Depression Screening In A Rural Maine Free Medical Clinic, Karen Hussion
Doctor of Nursing Practice Scholarly Projects
Abstract
BACKGROUND: Depression in adults is a leading cause of disability, morbidity and mortality worldwide with an estimated prevalence of 20% in the US population. Despite estimates that one out of every five Americans suffers from depression, less than 50% of adult primary care patients with depression are identified, and less than 5% of all adult primary care patients are screened. To increase early detection and management of depression, the United States Protective Service Task Force (USPSTF) recommends routine depression screening for adults older than 18 years in primary care settings.
LOCAL PROBLEM: This project site was a rural, free, …
Nurse Anesthetists’ Perceptions And Experiences Of Managing Emergence Delirium: A Qualitative Study, Yi Xin, Fu-Cai Lin, Chen Huang, Bin He, Ya-Ling Yan, Shuo Wang, Guang-Ming Zhang, Rui Li
Nurse Anesthetists’ Perceptions And Experiences Of Managing Emergence Delirium: A Qualitative Study, Yi Xin, Fu-Cai Lin, Chen Huang, Bin He, Ya-Ling Yan, Shuo Wang, Guang-Ming Zhang, Rui Li
Faculty, Staff and Student Publications
BACKGROUND: This study employs a descriptive phenomenological approach to investigate the challenges anesthesia nurses face in managing emergence delirium (ED), a common and complex postoperative complication in the post-anesthesia care unit. The role of nurses in managing ED is critical, yet research on their understanding and management strategies for ED is lacking.
AIM: To investigate anesthetic nurses' cognition and management experiences of ED in hopes of developing a standardized management protocol.
METHODS: This study employed a descriptive phenomenological approach from qualitative research methodologies. Purposeful sampling was utilized to select 12 anesthetic nurses from a tertiary hospital in Shanghai as research …
Implementation Of Psychiatric Collaborative Care Management In Rural Primary Care Practices, Ryan Dean Kruis
Implementation Of Psychiatric Collaborative Care Management In Rural Primary Care Practices, Ryan Dean Kruis
MUSC Theses and Dissertations
Behavioral health (BH) disorders are highly prevalent in the United States and especially concerning in rural communities which disproportionately lack access to BH services. While models for integrating BH into primary care, such as psychiatric collaborative care management (CoCM), have shown promise in mitigating the BH crisis, implementation in rural communities has proved challenging.
This dissertation examines implementation of CoCM nationally and in rural settings through three distinct aims. First, a claims-based retrospective cohort study was used to determine whether commercially insured patients receiving CoCM had lower acute BH care utilization and cost as compared to similar patients not receiving …
Ot's Role With Survivors Of Sexual Assault, Myracle N. Carter, Cassandra M. Nelson
Ot's Role With Survivors Of Sexual Assault, Myracle N. Carter, Cassandra M. Nelson
Spring 2024 Virtual OTD Capstone Symposium
Sexual assault can lead to a multitude of symptoms that can negatively impact an individual’s occupational participation and quality of life. However, the literature and programming surrounding the use of occupational therapy (OT) with survivors of sexual assault is limited or outdated. Therefore, this program was created to be a resource and guide to increase the use of OT with survivors. This program included a total of five modules, which provided education and occupation-based activities to the participants to increase their occupational participation, specifically in work and education, and their overall quality of life. Following the conclusion of the implementation …
Preparatory Program For Women During Pregnancy/Postpartum And Transitioning Back To Work Or School, Bria Runnels, Rebecca King
Preparatory Program For Women During Pregnancy/Postpartum And Transitioning Back To Work Or School, Bria Runnels, Rebecca King
Spring 2024 Virtual OTD Capstone Symposium
Despite the importance of maternal health during the prenatal, postnatal, and parenting stages, there is a lack of research on the role of occupational therapists (OTs) in addressing the occupational challenges faced by women during this transitional phase. This dissertation aims to develop a program that raises awareness of the role of occupational therapy in maternal health and promotes occupational therapists as part of an interdisciplinary team within the scope of maternal health care. By adapting co-occupation for mothers, occupational therapists can play an important role in individualizing occupations for enhanced transitioning and overall quality of life. The study highlights …
Lai Antipsychotics Vs. Oral Antipsychotics: Treatment Adherence, Relapses, And Readmissions, Natalie N. Lewis Bsn, Rn, Mallory F. Johnson Bsn, Rn-Bc, Tyler N. Halle-Todd Bsn, Rn, Natalie N. Ragland Bsn, Rn, Sharon H. Little Dnp, Aprn, Fnp-Bc, Jacqueline Sharp Dnp, Aprn,Pmhnp-Bc
Lai Antipsychotics Vs. Oral Antipsychotics: Treatment Adherence, Relapses, And Readmissions, Natalie N. Lewis Bsn, Rn, Mallory F. Johnson Bsn, Rn-Bc, Tyler N. Halle-Todd Bsn, Rn, Natalie N. Ragland Bsn, Rn, Sharon H. Little Dnp, Aprn, Fnp-Bc, Jacqueline Sharp Dnp, Aprn,Pmhnp-Bc
Doctor of Nursing Practice Projects
Purpose/Background
Schizophrenia is a lifelong illness with recurrent and often debilitating symptoms that may impair daily functioning, cognition, behaviors, socialization, emotions, and expression. It is recognized as a global mental health burden that affects the individual, their family, and society. Medication nonadherence and resulting relapse detrimentally affect the patient’s physical and mental health and quality of life. They are associated with increased hospitalization and emergency room visits, substance use, suicide, and homelessness. Current guidelines endorse second-generation antipsychotics such as Risperidone and Aripiprazole as the first-line treatment for most cases of psychosis. However, long-acting injectable (LAIs) atypical antipsychotics are a promising …
Implementation Of A Standardized Suicide Screening Process In A University Student Health Clinic: A Quality Improvement Project, Addie Grace Strong, Kathryn Dambrino, R. David Phillippi, Linda Wofford
Implementation Of A Standardized Suicide Screening Process In A University Student Health Clinic: A Quality Improvement Project, Addie Grace Strong, Kathryn Dambrino, R. David Phillippi, Linda Wofford
DNP Projects
Background: Suicide is a leading cause of death among college age students, prompting the need for evidence-based screening tools like the Columbia Suicide Severity Rating Scale (C-SSRS) to enable early detection and timely intervention. Inconsistencies in suicide screening may pose a risk of missed intervention opportunities. This Doctor of Nursing Practice project specifically aimed to improve the quality and consistency of suicide screening in a university student health clinic by implementing the C-SSRS tool into the clinic workflow during mental health appointments. Methods: Employing a quality improvement framework, this scholarly project followed the Institute for Healthcare Improvement Model for Improvement …
Prevalence And Severity Of Adhd Among Children With Second-Hand Smoke Exposure – A Us Population-Based Study, Saral R. Desai, Edward Lin
Prevalence And Severity Of Adhd Among Children With Second-Hand Smoke Exposure – A Us Population-Based Study, Saral R. Desai, Edward Lin
Tower Health Research Day
No abstract provided.
Demographic, Socioeconomic And Clinical Determinants Of Recurrent Suicide Visits To The Emergency Department At A Community Hospital, Paul Scalzo, Nicole Villa, Kristina Shum, Ashini Patel, Madhulika Badri, Stacy Chou, Evan Woods, Charles Wen, Allison Atkinson, Amy Hsu, Eduardo Espiridion
Demographic, Socioeconomic And Clinical Determinants Of Recurrent Suicide Visits To The Emergency Department At A Community Hospital, Paul Scalzo, Nicole Villa, Kristina Shum, Ashini Patel, Madhulika Badri, Stacy Chou, Evan Woods, Charles Wen, Allison Atkinson, Amy Hsu, Eduardo Espiridion
Tower Health Research Day
No abstract provided.
Every Moment Counts (Emc): Understanding School Stakeholder Perceptions Of Positive Mental Health Promotion In The Elementary School Setting. A Preliminary Report., Madeline Malooly, Angela Blackwell, Lauren Thomas
Every Moment Counts (Emc): Understanding School Stakeholder Perceptions Of Positive Mental Health Promotion In The Elementary School Setting. A Preliminary Report., Madeline Malooly, Angela Blackwell, Lauren Thomas
Spring 2024 Virtual OTD Capstone Symposium
For children and adolescents, the prevalence of psychological disorders associated with mental illness continues to rise in North America and is now considered to be the leading cause of disability for this population (Bitsko et al., 2022). It was estimated that between 25 and 50% of adult mental illnesses could be prevented through early intervention and preventative measures in childhood (Kim-Cohen et al., 2003). In an effort to address mental health promotion in schools, Dr. Susan Bazyk founded and created EMC, which is a “multi-pronged mental health promotion initiative to help all children to be mentally healthy in order to …
An Ot Needs Assessment For Children And Families Residing In Shelters, Jessie Siono, Susan Macdermott
An Ot Needs Assessment For Children And Families Residing In Shelters, Jessie Siono, Susan Macdermott
Spring 2024 Virtual OTD Capstone Symposium
This study created a needs assessment is to determine the unique occupational deficits of children and their families in California experiencing homelessness within a shelter setting via recording their lived experiences. A local family shelter was analyzed via observation and interviews with staff and residents of the shelter. The results were compiled into a facility assessment to identify supports and barriers to occupation. Results were also utilized to complete an occupational needs assessment for families and children living in homeless shelters. The study determined the occupational needs and occurrences of occupational deficits that were experienced by residents of the family …
Mental Healthcare Differences Between The United States, Costa Rica, And Sweden, Michaela Diehm
Mental Healthcare Differences Between The United States, Costa Rica, And Sweden, Michaela Diehm
Honors Program: Senior Projects (Public)
Countries such as the United States, Costa Rica, and Sweden differ in the ways that they approach treatment of mental health disorders, which is due to the structure of their healthcare as well as the culture, affordability, accessibility, and type of treatment that is available to the people of that country. A literature review did not reveal a comparison of the three countries related to the topic of mental healthcare, nor use of the three selected countries to review their structures to determine the best approach to combating mental disorders before. Costa Rica and Sweden are both countries with universal …
Comparing Universal Versus Targeted School Screenings For Depression Among Teens, Reach Dissemination Committee, Maine, Usa
Comparing Universal Versus Targeted School Screenings For Depression Among Teens, Reach Dissemination Committee, Maine, Usa
REACH: Research Evidence-to-Action for Community Health
The US Preventive Services Task Force endorses universal adolescent major depressive disorder (MDD) screening in primary care; however, most adolescents lack preventive health care, resulting in worsening disparities in MDD screening and treatment.
Examining Effects Of State Policies To Monitor Mental Health Medicines For Children In Foster Care, Reach Dissemination Committee, Maine, Usa
Examining Effects Of State Policies To Monitor Mental Health Medicines For Children In Foster Care, Reach Dissemination Committee, Maine, Usa
REACH: Research Evidence-to-Action for Community Health
Antipsychotics can have long-term risks but help treat conditions like schizophrenia.
Prevalence Of Depression In Physical Therapy Environments For Young Adult Populations In The U.S.: A Systematic Literature Review, Audrey N. Baucom
Prevalence Of Depression In Physical Therapy Environments For Young Adult Populations In The U.S.: A Systematic Literature Review, Audrey N. Baucom
Honors College Theses
Objective: This systematic review aimed to examine interactions of depression symptoms and diagnoses and its prevalence in physical therapy settings among the young adult population ages 18-24 in the United States through current literature and to identify existing literature. Methods: This review followed the PRISMA guidelines to form a systematic review. Ten databases were extensively searched. Results were screened by one researcher and those that met the criteria were verified as inclusive by a second researcher. Results: The search yielded 3,017 results and included two studies. In each study, age was not identified as a prevalent variable in mental health …
Adolescent Marijuana Use And The Contribution To The Development Of Schizophrenia, Jocelyn Spandikow
Adolescent Marijuana Use And The Contribution To The Development Of Schizophrenia, Jocelyn Spandikow
Psychology Student Papers and Posters
Schizophrenia is an often debilitating mental condition that has become a popular topic of psychological research in recent years. Current research examines the correlation between drug use, genetics, and environment on the development of schizophrenia. Research looks at the structure of the brain in individuals with and without schizophrenia. However, research has failed to look at the specific correlation between marijuana use in adolescent youth and the developmental impact on the brain, including in the development of schizophrenia. The legalization of many recreational drugs, including marijuana, has come to fruition in recent years. This has raised concerns over adolescent access …
Sprint Performance Following Plyometric Conditioning Activity In Elite Sprinters, Kinga Huminska-Lisowska, Aleksandra Strońska-Pluta, Aleksandra Suchanecka, Myosotis Massidda, Grzegorz Trybek, Carla Maria Calò, Agata Rzeszutko-Bełzowska, Remigiusz Recław, Anna Grzywacz
Sprint Performance Following Plyometric Conditioning Activity In Elite Sprinters, Kinga Huminska-Lisowska, Aleksandra Strońska-Pluta, Aleksandra Suchanecka, Myosotis Massidda, Grzegorz Trybek, Carla Maria Calò, Agata Rzeszutko-Bełzowska, Remigiusz Recław, Anna Grzywacz
Baltic Journal of Health and Physical Activity
Introduction: This study investigates an association between the human dopamine receptor 2 gene DRD2 Taq1D rs1800498 polymorphism and personality traits among athletes, exploring the genetic underpinnings of sports performance and psychological characteristics. It aims to understand how genetic factors related to dopamine reception influence athletic predispositions and behaviors. Materials and Methods: An association study was conducted with 391 male participants, comparing 159 sports subjects with 232 non-trained controls. Personality traits were assessed using the NEO Five-Factor Inventory, while the DRD2 Taq1D rs1800498 polymorphism was genotyped through real-time PCR. Results: Significant differences in the DRD2 Taq1D rs1800498 genotype and allele frequencies …
Hubungan Tingkat Stres, Kecemasan, Dan Depresi Dengan Konstipasi Fungsional Pada Mahasiswa Kedokteran, Khafifah Z, Wilson Wilson, Agustina Arundina Triharja Tejoyuwono
Hubungan Tingkat Stres, Kecemasan, Dan Depresi Dengan Konstipasi Fungsional Pada Mahasiswa Kedokteran, Khafifah Z, Wilson Wilson, Agustina Arundina Triharja Tejoyuwono
Jurnal Penyakit Dalam Indonesia
Introduction. Stress, anxiety, and depression are factors associated with functional constipation that affect students’ quality of life. Stress, anxiety, and depression are often experienced by first-year medical students, but studies assessing these three variables with functional constipation are still limited.
Methods. This study used a cross-sectional analytical design. Study was carried out in July 2023 involving 88 first-year medical students from the Tanjungpura University Medical Study Program. Analysis of relationship tests was carried out using Kendall’s Tau-B tests.
Results. Most students were in the normal category of stress, anxiety and depression levels, however 21 students were in …
Effectiveness Of Contact-Based Strategies On Improving Mental Illness Stigma And Help-Seeking Behaviors Within Families, B. Michelle Wilks
Effectiveness Of Contact-Based Strategies On Improving Mental Illness Stigma And Help-Seeking Behaviors Within Families, B. Michelle Wilks
USF Tampa Graduate Theses and Dissertations
Adolescence is a developmental period that often involves extreme physical, psychological, and emotional changes and sometimes the experience of significant personal and social challenges. In addition to these challenges, youth are trying to find their place in the world and developing their identities, which depend heavily on their relationships with others. Adolescents who struggle with their mental health and also fail to develop meaningful connections with others, tend to have poor self-esteem, self-isolate, are ostracized by others, and have a poor social self-concept, all of which are associated with poor mental health and increased risk for suicidal ideation. The impact …
Emotional Support Animals And Mental Health, Kyla E. Barnett, Kaia Miller
Emotional Support Animals And Mental Health, Kyla E. Barnett, Kaia Miller
SACAD: Scholarly Activities
Depression and anxiety disorders are a significant problem in adults and teenagers. These disorders continue to increase in prevalence year by year. One way to combat this is the use of emotional support animals (ESA’s), which have become increasingly popular. This study investigates the relationship between the use of emotional support animals and mental well-being of students with mental health disorders. This study is designed to illustrate the increase in sense of well-being in patients with mental health disorders who utilize ESA’s. This study applies both a qualitative and quantitative study design, the qualitative design of this study is phenomenological. …
Implementation Of Mindfulness & Stress Reduction Training For Medical Students, Jill Berenato
Implementation Of Mindfulness & Stress Reduction Training For Medical Students, Jill Berenato
SACAD: Scholarly Activities
Abstract
This proposal advocates for implementing mandatory mindfulness and stress reduction training sessions for surgical students at Philadelphia College of Osteopathic Medicine (PCOM). It is well-documented that medical students, particularly those in surgical disciplines, experience high levels of stress, which can negatively impact their mental health, academic performance and overall well-being. Mindfulness-based interventions have shown promise in reducing stress and enhancing resilience among medical students. By integrating mindfulness training into the surgical curriculum, PCOM aims to equip students with essential coping skills to effectively manage stress, thereby promoting their mental health and academic success. This handout serves to accompany the …
Addressing Weight In Primary Care: Perspectives Of African American Young Adults With Serious Mental Illness, Sang Qin, Lindsay Sheehan, Janis Sayer, Kristin S. Williams, Julius Mercer, Ashley Scott, Tevin Anderson
Addressing Weight In Primary Care: Perspectives Of African American Young Adults With Serious Mental Illness, Sang Qin, Lindsay Sheehan, Janis Sayer, Kristin S. Williams, Julius Mercer, Ashley Scott, Tevin Anderson
Journal of Human Services Scholarship and Interprofessional Collaboration
Young adults with serious mental illness (SMI) experience disproportionate rates of physical illness. Morbidity and mortality are even worse for young African Americans with SMI, especially those who are overweight. Primary care physicians (PCPs) have an important role in addressing weight management. Current research explored these young patient’s perceptions of weight management and how PCPs can best address their weight concerns. Using community-based participatory research, we interviewed 25 African American aged 18-30 who were overweight and had a SMI. Results revealed 1) patient perceptions around weight and 2) patient preferences. Participants identified both positive and negative aspects of being overweight, …
Gamma-Aminobutyric Acid (Gaba) Neurons And Perineuronal Nets (Pnn) In The Monodelphis Domestica And Relevance To Psychiatric Disorders, Jatziry Z. Luna Escobedo, Mariela Garcia, John L. Vandeberg, Mario Gil
Gamma-Aminobutyric Acid (Gaba) Neurons And Perineuronal Nets (Pnn) In The Monodelphis Domestica And Relevance To Psychiatric Disorders, Jatziry Z. Luna Escobedo, Mariela Garcia, John L. Vandeberg, Mario Gil
Research Symposium
Background/ Purpose: Gamma-aminobutyric acid (GABA) is an amino acid that serves as the central nervous system’s (CNS) main inhibitory neurotransmitter. By inhibiting nerve transmission, it works to lower neuronal excitability. Altered GABA levels have been associated with a variety of psychiatric disorders, for example Epilepsies, Parkinson’s Disease, and Schizophrenia. Perineuronal nets (PNN) are extracellular molecules that are released by neurons and glial cells that modulate many neuronal and glial functions by encapsulating the inhibitory cells and neurites. Altered PNN levels serve as a potential trigger to synaptic imbalance. The purpose of this study is to quantify and analyze the presence, …
Reliability And Validity Of The Patient Health Questionnaire-4 Scale And Its Subscales Of Depression And Anxiety Among Us Adults Based On Nativity, David Adzrago, Timothy J Walker, Faustine Williams
Reliability And Validity Of The Patient Health Questionnaire-4 Scale And Its Subscales Of Depression And Anxiety Among Us Adults Based On Nativity, David Adzrago, Timothy J Walker, Faustine Williams
Faculty, Staff and Student Publications
BACKGROUND: The burdens of anxiety and depression symptoms have significantly increased in the general US population, especially during this COVID-19 epidemiological crisis. The first step in an effective treatment for anxiety and depression disorders is screening. The Patient Health Questionnaire-4 (PHQ-4, a 4-item measure of anxiety/depression) and its subscales (PHQ-2 [a 2-item measure of depression] and Generalized Anxiety Disorder [GAD-2, a 2-item measure of anxiety]) are brief but effective mass screening instruments for anxiety and depression symptoms in general populations. However, little to no study examined the psychometric properties (i.e., reliability and validity) of the PHQ-4 and its subscales (PHQ-2 …
An Evidence-Based Approach For Decreasing Burnout In Health Care Workers, Leonor T. Salalila
An Evidence-Based Approach For Decreasing Burnout In Health Care Workers, Leonor T. Salalila
Student Scholarly Projects
Practice Problem: Health care worker (HCW) burnout is a pervasive phenomenon within the healthcare industry, affecting professionals across various disciplines. Emotional exhaustion is a prominent feature, leading to feelings of being emotionally drained, overwhelmed, and unable to cope effectively with the demands of the job. Additionally, burnout often results in a significant lack of motivation among HCWs, who may struggle to find meaning and purpose in their work, exacerbating feelings of frustration and disillusionment. Consequences extend beyond individual well-being, impacting healthcare organizations with reduced work efficacy, low productivity, increased absenteeism, and high turnover rates. Addressing burnout requires a multifaceted approach, …
Risk Assessment Of Blood-Borne Pathogen Exposure For Emergency Responders, Jill A. Ireland
Risk Assessment Of Blood-Borne Pathogen Exposure For Emergency Responders, Jill A. Ireland
USF Tampa Graduate Theses and Dissertations
Emergency responders face a significant risk of exposure to blood-borne pathogens (BBPs), such as HIV and hepatitis, due to the nature of their work environment. This study investigates this issue utilizing a dual approach of data analysis and online surveys to assess exposure rates, risk perceptions, factors that contribute to risk and prevention practices. In addressing issues ranging from personal protective equipment (PPE) usage to levels of concern surrounding blood and bodily fluid contact, the findings underscore the need for tailored safety measures, comprehensive education, and improved prevention strategies.
The examination of 346 worker's compensation exposure claims highlighted a significant …