UK Albert B. Chandler Hospital

KNI Stroke Center awarded for high-quality patient care

UK HealthCare’s Kentucky Neuroscience Institute (KNI) has received the Get With The Guidelines – Stroke Gold-Plus Quality Achievement Award by the American Heart Association/American Stroke Association for maintaining nationally recognized standards for the treatment of stroke patients.

KNI also received the association’s Target: Stroke Honor Roll Elite for meeting stroke quality measures that reduce the time between hospital arrival and treatment with the clot-buster tPA, the only drug approved by the U.S. Food and Drug Administration to treat ischemic stroke.

Over 12 months, at least 75 percent of the hospital’s ischemic stroke patients received tPA within 60 minutes of arriving at the hospital (known as door-to-needle time). Stroke patients who receive tPA within three hours of the onset of symptoms may recover more quickly and are less likely to suffer severe disability.

This year marks the sixth year that KNI has received Gold Plus designation. KNI has been named to the Target: Stroke Honor Roll the past three years and repeats for the ‘elite’ level that was introduced last year.

Kentucky patients aren’t the only ones benefiting from this achievement.

“By participating in the Get With The Guidelines-Stroke program, we are able to share our expertise with other member hospitals around the country, including access to the most up-to-date research, clinical tools and resources, and patient education resources,” said Dr. Jessica Lee, medical director of the KNI Comprehensive Stroke Center.

Dr. Larry Goldstein, chair of the UK Department of Neurology and co-director of KNI, said that “Comprehensive Stroke Center status reflects our capability to provide the most advanced care for patients with stroke. These awards further underscore the hard work of our multidisciplinary team of neurologists, neurosurgeons, emergency physicians, nurses, therapists and others to optimize care delivery for stroke patients right here in Lexington.”

According to the American Heart Association/American Stroke Association, stroke is the number five cause of death and a leading cause of adult disability in the United States. In Kentucky, cardiovascular disease (which includes stroke) is the leading cause of death.  On average, someone suffers a stroke every 40 seconds; someone dies of a stroke every four minutes; and 785,000 people suffer a new or recurrent stroke each year.

The KNI Stroke Center is also also certified as a “Comprehensive Stroke Center” by The Joint Commission – its highest honor.

New installation showcases artwork of UK alumna

For 25 years, Ellen Skidmore has found solace in art. As a stutterer, Skidmore discovered the non-verbal communication experienced in painting to be liberating and grounding. During her time as a student at a small liberal arts college in Kentucky, she began painting seriously. It was then she began to realize how this visual communication would allow her to interact more openly with herself and those around her.

While working on a children’s book to teach the alphabet, Skidmore began to share her story of living with a stutter and ultimately the book evolved and became, “Ellen the Little Girl Who Found her Voice.” This story serves as somewhat of an autobiography to illustrate how, like many children, Ellen was able to adapt and overcome. Skidmore hopes viewers will respond to the overall message that it’s okay to be different and we don’t need to try to be perfect.

After writing the story, Skidmore, who received her Bachelor of Fine Arts from the University of Kentucky College of Fine Arts, created the illustrations that would accompany the words. These larger pieces were put on display and, last summer, Skidmore celebrated the works completion with an art exhibit and book launch at Forre & Co. Art Gallery in Aspen, Colorado.

Skidmore feels a clinical setting is perfect for this piece; she hopes patients, staff and visitors will see her work. “Find your passion; if you find something in your life that is grounding you should stick to it no matter what,” she said.

The exhibit is currently on display in the North Gallery, located on the third floor of the Kentucky Clinic, in the hallway leading to the Limestone pedestrian bridge connecting the clinic to the Biomedical Biological Sciences Research Building. It is brought to you by the UK Arts in HealthCare program.


Studies show that integrating the arts into health care settings cultivates a healing environment; supports the physical, mental and emotional recovery of patients; and communicates health and recovery information. It also helps reduce stress and improves workplace satisfaction for caregivers. The mission of the UK Arts in HealthCare Program is to create a healing environment of care and to focus on the spiritual and emotional well-being of our patients, families, caregivers and staff.

The UK Arts in HealthCare Program, supported by the generosity of private donors, brings together visual and performing arts, incorporating the unique aspects of Kentucky landscape, art and music. The program highlights local, national and international artists, art in multiple forms, and various initiatives to enhance the healing environment. You will find art throughout our facilities, and the public is always welcome to visit and view exhibits.


 

Prevent Zika virus in Kentucky with repellent.

What you should know about Zika virus this summer

Talk of the Zika virus is everywhere these days, and it has many people understandably worried. On Tuesday, UK HealthCare experts held a news conference to answer questions about Zika. The bottom line? If you’re here in Kentucky and aren’t planning to travel this summer, your risk of catching Zika is very low. But there are things you can do to be prepared in case that risk increases this summer.

“At the present time, the risk for infection is low for Kentuckians not traveling to areas with active Zika,” said Dr. Phillip Chang, UK HealthCare chief medical officer. “However, the Centers for Disease Control and Prevention (CDC) continue to provide updates and if locally transmitted cases are found in the U.S., the risk could increase.”

What is Zika virus?

The Zika virus is spread through mosquito bites or through sexual contact with an infected person. Currently, virus transmission is happening in many Caribbean and Central and South American countries. Although many people who become infected have mild or no symptoms, pregnant women who contract the disease are at high risk for complications. Zika has been linked to microcephaly, a potentially fatal neurological disorder characterized by an abnormally small head.

Currently, the only cases in the U.S. have been travel-associated. But concern is growing about the possibility of travelers spreading it to mosquitoes in the U.S., which can then infect people who have not traveled to countries with the active virus. The Aedes aegypti mosquito, which is the main carrier of the virus, can be found in the U.S. during the summer months, including Kentucky. This means that the Zika virus in Kentucky could be a real possibility.

“Currently, there is no anti-viral treatment and no vaccine for the Zika virus, so we are focusing on prevention and risk reduction and, if necessary, proper screening for our patients if Zika becomes a concern in the region,” said Dr. Derek Forster, UK HealthCare medical director for infection prevention and control.

Pregnant women and Zika

Since February, UK HealthCare’s obstetrics and gynecology clinics have been educating patients on the risks of Zika, particularly for pregnant patients or pregnant patients with partners who travel to these areas, said Dr. Wendy Hansen,chair of UK Obstetrics and Gynecology.

“We have been telling pregnant patients to postpone travel to areas with outbreaks of Zika virus, which currently is nearly all of Central America and much of the Caribbean and South America,” Hansen said. “We also are counseling and advising patients on what to do if they have partners that plan to or have traveled to these areas.”

According to current CDC guidelines, the following special precautions are recommended for pregnant women:

  • Pregnant women should not travel to any area with Zika.
  • If you must travel to one of these areas, talk to your doctor or other health care provider first and strictly follow steps to prevent mosquito bites during your trip.
  • Until more is known, pregnant women with male sex partners who have lived in or traveled to an area with Zika virus should either use a condom every time they have sex or abstain from sex throughout the pregnancy.

Precautions for everyone

While the Zika virus is most dangerous for pregnant women who risk complications, everyone is urged to take precautions to prevent mosquito bites during the summer months to prevent possible spread of the disease.

Precautions include:

  • Wearing protective clothes, including long-sleeved shirts and long pants. For extra protection, treat clothing with permethrin, a chemical that repels insects and kills mosquitoes and ticks when sprayed on clothing, tents and other gear.
  • Using an EPA-registered insect repellent every day containing one or more of the following active ingredients: DEET, PICARIDIN or IR3535.
  • Using screens on windows and doors, and using air conditioning when available.
  • Keeping mosquitoes from laying eggs in and near standing water near your home.

“Although these precautions are especially important for pregnant women and women of childbearing age who want to become pregnant, we want everyone to educate themselves on how to protect their family members and friends,” Hansen said.

Watch UK HealthCare experts discuss Zika virus below.

 


Next steps:

  • The CDC recommends that testing for the Zika virus be done for pregnant women who have recently traveled somewhere with active Zika or anyone who has traveled and has symptoms.
  • For the most up-to-date information, visit the CDC’s website.

Appalachian Research Day shows community-based health care efforts

For many UK researchers who study health in Appalachia, the Center of Excellence in Rural Health (CERH) is an indispensable partner in conducting community-based research. The Center, located in Hazard, connects researchers with the local community and provides necessary infrastructure, from conference rooms to a team of community health workers, called Kentucky Homeplace, who engage participants and gather data.

This week, researchers shared the findings from these community-based studies at the second annual Appalachian Research Day.

“Today is an opportunity for people who do research with the Center to report back about their findings, and see what we can come up with together to better our lives here in Appalachia,” said Fran Feltner, director of the CERH.

Addressing Appalachian health issues

Rural Appalachian communities in Eastern Kentucky experience some of the nation’s most concerning health disparities, including elevated rates of obesity, diabetes, stroke, heart disease, depression, and cancer incidence and death. Residents of Appalachia might also face challenges in accessing health care, such as distance from providers, lack of insurance, or socioeconomic barriers.

Community-based research is essential in addressing disproportionate rates of poor health by collaboratively identifying problems and developing shared solutions that are a good fit for communities. For this type of research to succeed, it must begin at the local level, built upon the foundation of relationships with individuals, neighborhoods and groups who have common questions and concerns. In Eastern Kentucky, the CERH has enabled community-based studies since 1990, when it was founded to improve health through education, service, and research.

In 2015, the CERH launched Appalachian Research Day as an opportunity to share and discuss research findings with the communities that were involved in the studies. Feltner describes the day as an invitation for everyone involved in community health research to “come sit on the porch” of the Center and talk about their work and ongoing needs. More than 100 researchers, coordinators, community health workers, community advisory board members, students, and staff participated this year, with four podium presentations and 13 poster presentations.

“These research findings drive new and exciting health initiatives that are transforming lives across our rural Appalachian region,” Feltner said.

Researching change

The presen­tations focused on community research related to healthy lifestyles, depression, lung cancer screening, drug use and risk behaviors in Appalachia.

Mark Dignan, professor in the UK College of Medicine and director of the UK Prevention Research Center, discussed his work with faith-based communities to study energy balance, obesity and cancer in Appalachia.  According to the CDC, the national obesity rate in adults is about 29 percent, while in Appalachian states the rate is 31-35 percent. Dignan was particularly interested in how to help people re-engineer their lives to include more physical activity.

“When you do research in the community, hopefully you’ll make change that will be lasting,” he said.

Rates of depression are also higher in Appalachia than the rest of the country. For Appalachian women, the rate of depression is four times higher than the national rate. They are also less likely to receive adequate treatment, according to Claire Snell-Rood, PhD, who shared her research on adapting treatment options for rural settings where the traditional mental health system is both inappropriate and inadequate.

“This research focuses on how to adapt evidence-based programs to address not only limited treatment options in rural areas, but the substantial social and health challenges that impede Appalachian women from obtaining the care they need,” she said.

Snell-Rood worked with Kentucky Homeplace community health workers to conduct interviews with women, and she is currently adopting a collaborative, peer-based practice to support rural individuals in developing their own processes for wellbeing.

Roberto Cardarelli, DO, MPH, professor and chief of community medicine in the UK College of Medicine, also presented his research project, the Terminate Lung Cancer study, which aims to understand the knowledge and attitudes of lung cancer screening among high-risk rural populations. Kentucky’s lung cancer mortality rate dramatically exceeds the national lung cancer mortality rate, with 73.2 deaths per 100,000 in Kentucky versus 49.5 nationally. Cardarelli and his team conducted focus groups in order to develop an effective campaign to promote lung cancer screening in the region.

“We like to focus on research that’s important to communities, and we couldn’t find a more important topic than tobacco cessation and lung cancer screening,” he said.

The final presentation of the day addressed drug use and prescription opioid use in Eastern Kentucky. Michele Staton-Tindall, PhD, associate professor in the UK College of Social Work, conducted research in jails to learn about drug use and health-related risk behaviors among rural women in Appalachia. She said that rates of drug use are “alarmingly high” in this area of Appalachia, with many users injecting.

“Injection is the preferred route of administration, which is coupled with increased public health risks including HCV and HIV,” she said.

Solving problems together

The event was supported in part by the UK Center for Clinical and Translational Science, which aims to accelerate discoveries that improve human health, with particular focus on the Appalachian region.

For Feltner, a nurse who has worked in rural health for 35 years, Appalachian Research Day represents the best qualities of the place she calls home.

“What I love most about Appalachia is the fellowship we have together, as neighbors and friends, working together to solve problems.”

Weekend of cycling events reflects doctor’s passion for Markey

For Dr. Jonathan Feddock, cycling isn’t just a hobby – it’s a way to save lives.

Dr. Jonathan Feddock

Dr. Jonathan Feddock

Feddock is a radiation oncologist at the UK Markey Cancer Center and also an avid triathlete and cyclist. Two years ago, Feddock combined his passions by competing in the Louisville Ironman competition while simultaneously raising more than $142,000 for patient care and research at Markey.

Ignited by the success of his personal fundraising efforts, Feddock wanted to do even more. Last year, he partnered with Markey to host the Healthiest Weekend in Lexington, a two-day event promoting healthy lifestyles that also raised money for cancer care at UK. The weekend event included the first-ever Survive the Night Triathlon, an overnight team relay covering 140.7 combined miles of swimming, biking and running.

“After seeing the success I had raising money racing in triathlons, a lot of people expressed an interest in helping raise money for Markey in a similar way,” Feddock said.

This year, the Survive the Night Triathlon is back, and Feddock is working with Markey and the Lexington Cancer Foundation to once again support patient care, research and outreach at UK through a weekend of cycling.

Survive the Night begins Friday, June 17, at 7:30 p.m. at Commonwealth Stadium on the UK campus. Registration is $500 per team.

Following Survive the Night, the Lexington Cancer Foundation hosts the Roll for the Cure bike event on June 18. Participants can choose the length of their ride: 10, 35, 50 or 95 miles through Kentucky horse farms, or a short Family Fun ride around Commonwealth Stadium. The longer rides will include rest breaks at Buffalo Trace and Woodford Reserve distilleries. Registration for the longer rides is $75 and the Family Fun ride is $10.

All proceeds from Survive the Night and Roll for the Cure will benefit cancer research and programs at the Markey and the pediatric oncology clinic at Kentucky Children’s Hospital. Feddock said participating in either event is an easy way to make a big difference.

“Every single dollar we raise helps,” he said. “By participating in our events, you’ll be making a huge impact on cancer care for women, men and children across Kentucky.”


Next steps:

Dr. Evers highlights Markey’s accomplishments in ‘State of the Cancer Center’ address

Dr. Mark Evers, director of the University of Kentucky Markey Cancer Center, gave his annual “State of the Cancer Center” address today at Markey Research Day, highlighting the center’s major accomplishments in patient care, recruitment, research and outreach from the past year.

“Markey is making great strides in both clinical care and research, and we plan to continue that trend moving forward,” Evers said. “Kentucky is still home to the worst cancer rates in the country, and we will continue to expand our reach and provide acute-level cancer care for not just Kentuckians, but patients from neighboring states and even across the country who are seeking services only we can provide.”

Patient care at Markey

Patient growth continued to increase in the past year, with more than 94,000 outpatient visits, a four percent increase over 2015 visits and a 42 percent increase since Evers’ arrival in 2009. In addition, the number of analytic cancer cases seen by Markey doctors has nearly doubled – 49 percent – since 2009.

Markey’s five-year survival rates for lung, brain, prostate, liver and ovarian cancers are higher than the SEER (Surveillance, Epidemiology and End Results) Program national average. In particular, Markey’s liver cancer survival rates are outstanding, with a 27 percent five-year-survival rate versus the SEER Program national average of 16 percent.

Cancer research

Cancer funding continues to increase, with Markey bringing in $43 million in funds from the National Cancer Institute, National Institutes of Health, and other peer-reviewed and non-peer reviewed sources – a $5 million increase in research funding over the previous year.

Under a new partnership with the NCI-designated cancer center at The Ohio State University, Markey will be a phase I and II trial site for OSU’s NCI-sponsored UM1 grant, providing access to new clinical trials for Markey patients. The goal is to develop the most effective dose and schedules for further therapeutic investigation of new anticancer agents that will be tested in late phase clinical trials by the National Clinical Trials Network

In early 2015, the cancer center launched the Markey Cancer Center Research Network (MCCRN), a new initiative conducting high priority cancer research through a network of collaborative centers with expertise in the delivery of cancer care and conduct of research studies. Medical centers participating in the MCCRN will have the opportunity to either conduct appropriate clinical trials for their population on-site or have a quick line of referral to Markey for trial participation.

Currently, the MCCRN has four sites on board, with several more to join over the next year:

  • King’s Daughters Medical Center, Ashland
  • Hardin Memorial Health, Elizabethtown
  • St. Claire Regional Medical Center, Morehead
  • St. Mary’s Regional Cancer Center, Huntington, W.Va

Markey’s reach across the state

Though based in Lexington, Markey also strives to provide access to top-notch cancer care across the state and beyond through the Markey Cancer Center Affiliate Network (MCCAN). The MCCAN is a group of healthcare facilities that provide high-quality cancer services and programs in their communities with the support and guidance of the UK Markey Cancer Center, allowing patients to receive their care closer to home.

Currently, the MCCAN comprises 16 medical centers across the state of Kentucky:

  • Clark Regional Medical Center, Winchester
  • Ephraim McDowell Regional Medical Center, Danville
  • Frankfort Regional Medical Center, Frankfort
  • Georgetown Community Hospital, Georgetown
  • Hardin Memorial Hospital, Elizabethtown
  • Harlan ARH Hospital, Harlan
  • Harrison Memorial Hospital, Cynthiana
  • Hazard ARH Regional Medical Center, Hazard
  • Methodist Hospital, Henderson
  • Norton Cancer Institute, Louisville
  • Our Lady of Bellefonte Hospital, Ashland
  • St. Claire Regional Medical Center, Morehead
  • Rockcastle Regional Hospital, Mt. Vernon
  • The Medical Center at Bowling Green
  • TJ Samson Community Hospital
  • Tug Valley ARH Regional Medical Center, South Williamson

Additionally, evaluations are under way for several other hospitals, further establishing Markey as the destination cancer center for the region.

The future of cancer care in Kentucky

The faculty and staff at Markey have a busy few years ahead of them, as the cancer center prepares to submit its application for an NCI designation as a comprehensive cancer center in 2017. Currently, 45 of the 69 total NCI-designated cancer centers in the country hold a comprehensive cancer center status.

To earn this top level of designation, cancer centers must show a depth and breadth of research in each of three major areas: laboratory, clinical, and population-based research, as well as substantial transdisciplinary research that bridges these scientific areas. Additionally, outreach is especially important, and comprehensive cancer centers must demonstrate professional and public education and outreach capabilities, including the dissemination of clinical and public health advances in the communities it serves.

“Earning a comprehensive cancer center designation from the NCI would be another giant leap forward for Markey,” Evers said. “We’ve already established ourselves as the destination cancer center for the state, and moving forward, we will continue to push to become a leader in cancer clinical care and research across the country.”

 

Clinician notes now available via our portal

We’re very excited to announce that, as an added benefit to our patients, UK HealthCare is now making clinician documentation from most outpatient and inpatient visits available via patients’ My UKHealthCare portal accounts.

Discharge summaries from inpatient hospital stays that ended after Feb. 15 and clinician notes from outpatient clinic visits after March 15 now can be viewed in patients’ portal accounts after they’ve been approved by the clinician.

To find your clinician notes, click on the Documents tab in the top right of your portal account’s home screen. Remember that if you have not had a recent appointment, no notes will be visible.

(Please note that it may take up to 30 days after a visit for notes to be available.)

Most clinics are included.

Like all other medical record information, documentation will not be released electronically for any patient age 12-18, due to federal and state privacy laws.

Only notes created after the Feb. 15 and March 15 start dates (respectively) will be available to patients electronically. Notes will not be released for earlier appointments.

As always, complete patient medical records for all dates of care, including clinician notes, are available in hard-copy form from our Health Information Management office. For information on how to request a hard copy of your medical record, visit ukhealthcare.uky.edu/med-records.

Clinician notes will only flow to active portal accounts. Patients who do not currently have an account can get more information and sign up at myukhealthcare.org. Once an account has been set up, notes from future inpatient and outpatient visits will be available.

Once you register for the My UKHealthCare patient portal, you can also:

  • Request prescription renewals when it’s convenient for you, not just when our offices are open.
  • Request, cancel or reschedule appointments.
  • View lab test results, radiology reports and office visit summaries.
  • Get health maintenance reminders.
  • View your immunization record and allergies.
  • View your hospital discharge instructions.

Patients are encouraged to review these notes and bring any questions to their next appointment.

Technical support for the My UKHealthCare patient portal is available weekdays 9 a.m. to 8 p.m. by calling 859-218-6221 or 844-820-7344 (toll free).

The decision to make providers’ notes available to patients electronically was made based on a 2010 study by the Robert Wood Johnson Foundation. The study, known as Open Notes, concluded that access to provider notes significantly increased patients’ engagement in their own health and treatment.

As a result of this study, 5 million patients (and growing) nationwide now have access to their clinicians’ notes. UK HealthCare is proud to be adding our patients to these ranks.

 

 

UK HealthCare leader honored as one of Most Powerful Women in Healthcare IT

One of UK HealthCare’s own is being recognized on a national level as one of the Most Powerful Women in Healthcare IT.

Dr. Carol Steltenkamp, professor of pediatrics at the UK College of Medicine and UK HealthCare’s first chief medical information officer, will be honored in May by Health Data Management  the information resource for medical and information technology professionals, executives and administrators  along with 74 other women from across the country.

As the chief medical information officer at UK HealthCare, Dr. Steltenkamp selected and led implementation of an electronic health record system across our clinical enterprise. She then became a leader for health information technology in Kentucky and was named chair of the Kentucky eHealth Board, where she successfully launched and maintains the Kentucky Health Information Exchange.

She also is the principal investigator for more than $10 million in health care information technology grant funding including the foundational grant establishing the Kentucky Regional Extension Center from the U.S. Department of Health & Human Services’ Office of the National Coordinator for Health Information Technology.

“Dr. Steltenkamp is a shining example of excellence within the UK HealthCare enterprise,” said Dr. Michael Karpf, UK executive vice president for health affairs.

Congratulations Dr. Steltenkamp!

UK HealthCare staff members take home Supervisor of the Year Award

The Supervisor of the Year Award recognizes employees at the University of Kentucky who make a difference in the lives of their employees. This year, the prestigious honor was given to two UK HealthCare staff members: Angela Dalton, practice manager in General Surgery, and Kristy McMillan, radiology technical manager in Imaging Services.

Nominated by their employees, both Dalton and McMillian were celebrated for creating a positive work environment that has led to improved patient care.

“(Angela) is a team player,” one nominating employee said of Dalton. “When my clinic is short-staffed, she is always one of the first managers to respond to send aid immediately so our patients’ care is not disrupted. The attention she dedicates to her providers, staff and patients is one to be model for UK excellence.”

McMillan, too, was lauded for her emphasis on improving the patient experience.

“(Kristy) is always thinking about her staff and patients and how to improve everything that surrounds them,” the nomination said. “She is a very strong believer in keeping a well-balanced work and home life for her staff as well has creating the best experience for our patients. … It shows because our patients love coming here for their exams.”

Angela and Kristy embody the compassionate, patient-first environment we strive to create every day here at UK HealthCare. Their employees love the work that they do and it shows in the excellent care our patients receive.

Congratulations to Angela and Kristy!

Check out a photo gallery below for pictures from this week’s award ceremony.

UK HealthCare celebrates 25 years of live-saving heart transplants.

Celebrating 25 years of heart transplants at UK HealthCare

On April 2, 1991, Dr. Michael Sekela performed the first heart transplant in the University of Kentucky’s history.

It’s been 25 years since that first operation, and we’ve been saving lives through heart transplantation ever since. In fact, we now do more than 40 heart transplants each year, and in 2015 we set a single-year record for the most heart transplants at one hospital in Kentucky.

While much has changed since Dr. Sekela’s first transplant, one thing has stayed the same: our commitment to providing the best care for patients with heart failure.

That commitment was on display earlier this week when patients gathered with staff and doctors from the UK Gill Heart Institute and the UK Transplant Center to celebrate 25 years of heart transplants at UK HealthCare.

“It’s so rewarding to see how our program has evolved,” Sekela said at the celebration. “We want to take care of our patients, and that’s always been the driving force of our program.”

Jim Holdiness, who received his new heart on Aug. 24, 1995, said UK HealthCare gave him a second chance at life.

“If hadn’t been for those people, in this hospital, I wouldn’t be here today,” he said.

Daniel Garcia received his new heart just earlier this year, but echoed Holdiness’ sentiment.

“I haven’t had this much energy in 25 years,” he said. “When I think of UK, I think of excellence and compassion. Everyone had my well-being in mind.”

Check out some photos from the event below and visit the UK HealthCare Facebook page for a full gallery.


Next steps: