South Jordan Health Center

STUDY QUESTION: What is the feasibility of a prospective protocol to follow subfertile couples being treated with natural procreative technology for up to 3 years at multiple clinical sites? SUMMARY ANSWER: Overall, clinical sites had missing data for about one-third of participants, the proportion of participants responding to follow-up questionnaires during time periods when participant compensation was available (about two-thirds) was double that of time periods when participant compensation was not available (about one-third) and follow-up information was most complete for pregnancies and births (obtained from both clinics and participants). WHAT IS KNOWN ALREADY: Several retrospective single-clinic studies from Canada, Ireland and the USA, with subfertile couples receiving restorative reproductive medicine, mostly natural procreative technology, have reported adjusted cumulative live birth rates ranging from 29% to 66%, for treatment for up to 2 years, with a mean women's age of about 35 years. STUDY DESIGN SIZE DURATION: The international Natural Procreative Technology Evaluation and Surveillance of Treatment for Subfertility (iNEST) was designed as a multicenter, prospective cohort study, to enroll subfertile couples seeking treatment for live birth, assess baseline characteristics and follow them up for up to 3 years to report diagnoses, treatments and outcomes of pregnancy and live birth. In addition to obtaining data from medical record abstraction, we sent follow-up questionnaires to participants (both women and men) to obtain information about treatments and pregnancy outcomes, including whether they obtained treatment elsewhere. The study was conducted from 2006 to 2016, with a total of 10 clinics participating for at least some of the study period across four countries (Canada, Poland, UK and USA). PARTICIPANTS/MATERIALS SETTING METHODS: conception. MAIN RESULTS AND THE ROLE OF CHANCE: The mean age of women starting treatment was 34.0 years; among those with additional demographic data, 382/478 (80%) had 16 or more years of education, and 199/659 (30%) had a prior live birth. Across 10 clinical sites in four countries (mostly private clinical practices) with family physicians or obstetrician-gynecologists, data about clinic visits were submitted for 60% of participants, and diagnostic data for 77%. For data obtained directly from the couple, 59% of couples had at least one follow-up questionnaire, and the proportion of women and men responding to fill out the follow-up questionnaires was 69% and 67%, respectively, when participant financial compensation was available, compared to 38% and 33% when compensation was not available. Among all couples, 57% had at least one pregnancy and 44% at least one live birth during the follow-up time period, based on data obtained from clinic and/or participant questionnaires. All sites reported on female pelvic surgical procedures, and among all participants, 22% of females underwent a pelvic diagnostic and/or therapeutic procedure, predominantly laparoscopy and hysterosalpingography. Among the 643 (77%) of participants with diagnostic information, ovulation-related disorders were diagnosed in 87%, endometriosis in 31%, nutritional disorders in 47% and abnormalities of semen analysis in 24%. The mean number of diagnoses per couple was 4.7. LIMITATIONS REASONS FOR CAUTION: The level of missing data was higher than anticipated, which limits both generalizability and the ability to study different components of treatment and prognosis. Loss to follow-up may also be differential and introduce bias for outcomes. Most of the participating clinicians were not surgeons, which limits the opportunity to study the impact of surgical interventions. Participants were geographically dispersed but relatively homogeneous with regard to socioeconomic status, which may limit the generalizability of current and future findings. WIDER IMPLICATIONS OF THE FINDINGS: Multicenter studies are key to understanding the outcomes of subfertility treatments beyond IVF or IUI in broader populations, and the association of different prognostic factors with outcomes. We anticipate that the iNEST study will provide insight for clinical and treatment factors associated with outcomes of pregnancy and live birth, with appropriate attention to potential biases (including adjustment for potential confounders, multiple imputation for missing data, sensitivity analysis and inverse probability weighting for potential differential loss to follow-up, and assessments for clinical site heterogeneity). Future studies will need to either have: adequate funding to compensate clinics and participants for robust data collection, including targeted randomized trials; or a scaled-down, registry-based approach with targeted data points, similar to the multiple national and regional ART registries. STUDY FUNDING/COMPETING INTERESTS: Funding for the study came from the International Institute for Restorative Reproductive Medicine, the University of Utah, Department of Family and Preventive Medicine, Health Studies Fund, the Primary Children's Medical Foundation, the Mary Cross Tippmann Foundation, the Atlas Foundation, the St. Augustine Foundation and the Women's Reproductive Health Foundation. The authors declare no competing interests. TRIAL REGISTRATION NUMBER: The iNEST study is registered at clinicaltrials.gov, NCT01363596.

The US Environmental Protection Agency and several U.S. states and Canadian provinces are currently developing national water quality criteria for selenium that are based in part on toxicity tests performed by feeding freshwater fish a selenomethionine-spiked diet. Using only selenomethionine to examine the toxicity of selenium is based in part on the limitations of the analytical chemistry methods commonly used in the 1990s and 2000s to speciate selenium in freshwater biota. While these methods provided a good starting point, recent improvements in analytical chemistry methodology have demonstrated that selenium speciation in biota is far more complex than originally thought. Here, we review the recent literature that suggests that there are numerous additional selenium species present in freshwater food chains and that the toxicities of these other selenium species, both individually and in combination, have not been evaluated in freshwater fishes. Evidence from studies on birds and mammals suggests that the other selenium forms differ in their metabolic pathways and toxicity from selenomethionine. Therefore, we conclude that toxicity testing using selenomethionine-spiked feed is only partly addressing the question "what is the toxicity of selenium to freshwater fishes?" and that using the results of these experiments to derive freshwater quality criteria may lead to biased water quality criteria. We also discuss additional studies that are needed in order to derive a more ecologically relevant freshwater quality criterion for selenium.

OBJECTIVE: This study aims to increase the body of knowledge regarding osteoporosis in the Jordanian context by investigating the magnitude of osteoporosis amongst perimenopausal women, as well as the risk factors associated with the disease. METHODS: Two hundred and fifty one women between the ages of 40 to 60 years were randomly selected from the Orthopedics and Rheumatology out patient clinics at the Major Teaching Hospital in Amman, Jordan. A structured questionnaire, which focused upon risk factors and preventive measures for osteoporosis, was administered by a trained staff nurse to all women. Index women were then referred to a private hospital, also in Amman, for a dual energy x-ray absorptiometry of the lumbar spine (Lumbar 1-4) and hip. RESULTS: Results show the magnitude of osteoporosis was 13% according to the bone mineral density of the lumbar spine. Women with osteoporosis were older (p< 0.00) and smaller in build (p<0.00) than women with low or normal bone density. Osteoporotic women were also more likely to be menopausal (p<0.00) and to have taken corticosteroids for a prolonged period of time (p<0.00). Logistic regression showed being menopausal (p<0.00), taking corticosteroids (p<0.05), and having a relatively lower body mass index (p<0.00) were significantly related to being osteoporotic in this group of women. CONCLUSION: The authors conclude that this study was not only able to report upon the magnitude of osteoporosis among women sampled, and the risk factors for low bone density, but also raised issues related to inconsistencies in how the health care system deals with women who are at risk for osteoporosis. Study findings are discussed in their socio-cultural context, and implications of the study findings are presented.

The American Physical Therapy Association (APTA) provided funding for a series of meetings among a small group of leaders representing the research and clinical communities whose task was to plan a conference, the outcome of which would be a “road map” for the process of generating evidence that would be implemented by clinicians so that the provision of services might be enhanced. Two of these planning sessions were held and resulted in a decision to focus a conference on the identification of strategies to lessen perceived “gaps” between physical therapist clinicians and researchers and the development of strategies to bridge the “gaps” between the 2 groups. These meetings ultimately resulted in the Vitalizing Practice Through Research and Research Through Practice Conference hosted by APTA. A perceived gap between research and practice has been cited as a problem by others within and outside the profession as well. In a recent editorial in the Journal of Orthopaedic and Sports Physical Therapy, Bechtel et al stated, “We have a problem in manual therapy, and perhaps in the whole profession of physical therapy. Our problem is the growing chasm between researchers on the one hand, and clinicians on the other.”1(p451) A recent Institute of Medicine workshop titled “Transforming Clinical Research in the United States: Challenges and Opportunities” echoed this theme and identified bridging the divide between research and practice as one of the most critical needs facing clinical research.2 Discussion of the perceived gap between research and practice extends internationally, as Demers and Poissant3 lamented that research would be meaningless if it did not affect clinical practice. Furthermore, Demers and Poissant discussed the value of creating partnerships across the research process, from conception to dissemination of results.

Rosengart, Todd K MD, FACS; Chen, Jennifer H MD; Gantt, Nancy L MD, FACS; Angelos, Peter MD, FACS; Warshaw, Andrew L MD, FACS; Rosen, Jennifer E MD, FACS; Perrier, Nancy D MD, FACS; Kaups, Krista L MD, FACS; Doherty, Gerard M MD, FACS; Zoumpou, Theofano MD; Ashley, Stanley W MD, FACS; Doscher, William MD, FACS; Welsh, David MD, FACS; Savarise, Mark MD, MBA, FACS; Sutherland, Michael J MD, MBA, FACS; Sidawy, Anton N MD, MPH, FACS; Kopelan, Adam M MD, FACS Author Information

BACKGROUND: Virtual reality (VR) is increasingly being explored as a teaching tool in dental education. VR provides immersive training environments that aim to enhance procedural skills and anatomical understanding. OBJECTIVE: This systematic review aimed to examine the effectiveness of VR in undergraduate endodontic learning compared to traditional learning methods. MATERIALS AND METHODS: Online databases of Scopus, Embase, Medline, and Web of Science databases were electronically searched according to specific inclusion and exclusion criteria in August 2024. Studies that explored the use of VR among dental undergraduates for endodontic education were included. Articles in languages other than English were excluded. Study quality was assessed based on the ROB2 and ROBINS-I tools. GRADE was used to assess the certainty of evidence. RESULTS: Of 99 initial records, six studies met the inclusion criteria, comprising 255 participants. Four studies were RCTs, and two utilized non-randomized designs. The majority of the studies showed a high or serious risk of bias. Despite these limitations, the majority of studies demonstrated significant improvements in skill acquisition and performance with VR training, including reductions in task completion times and enhanced procedural accuracy. CONCLUSION: Based on the limited evidence available, there is low-level evidence that VR is as effective as traditional learning techniques in endodontic education, enhancing skill proficiency, reducing errors, and improving anatomical comprehension.

The rapid integration of artificial intelligence (AI) in medical imaging has transformed the healthcare landscape, enabling precision therapy for a range of diseases. This article explores the key roles of AI in medical imaging, particularly focusing on three vital areas: segmentation, laser-guided procedures, and protective shielding. AI-driven segmentation tools offer unprecedented accuracy in identifying pathological regions, improving diagnostic efficiency, and aiding in personalized treatment plans. Laser-guided procedures, powered by AI algorithms, provide enhanced precision in targeting affected tissues, minimizing damage to healthy tissues, and promoting faster recovery times. Additionally, AI has made significant strides in optimizing protective shielding techniques, ensuring patient safety while minimizing radiation exposure during imaging and therapy. The article discusses the technological advances, clinical applications, challenges, and future directions of AI in these domains. Through this synthesis, the potential of AI to revolutionize medical imaging and contribute to more effective, safer, and personalized therapies becomes evident.

Background: Cadmium is known to affect liver and kidney function due to its toxicity detrimentally. Vitamin D reportedly mitigates cadmium-induced damage in various organs, yet its specific role in liver and kidney protection requires validation. Method: 24 male rats received cadmium chloride (CD) and nutritional vitamin D via intramuscular administration for 6 weeks. Liver and kidney function were assessed through ALT, AST, ALP, CRE, UA levels, and total protein concentration. Result: Groups A and B exhibited significant elevation (P&lt;0.001) in ALT, AST, ALP, CRE, and UA levels compared to controls for 4 weeks, indicating cadmium-induced impairment. However, these markers significantly decreased after 6 weeks of vitamin D3 treatment, signifying improved liver and kidney function. Both groups showed increased TP levels compared to controls. Conclusion: Vitamin D mitigates liver and kidney damage induced by cadmium in adult male rats. The study highlights the protective effects of vitamin D against cadmium toxicity, potentially preserving organ function under toxin-induced stress.

= 0.05, 95 % CI: 0.41-0.99) significantly influenced exclusive breastfeeding rates. The findings revealed that breastfeeding practices do not align with WHO recommendations, emphasizing the crucial role of healthcare providers in supporting breastfeeding mothers during crises. It is essential to consider the unique circumstances and cultural backgrounds of refugees when evaluating their needs for developing breastfeeding programs. International health organizations, like the UNHCR, and host country policymakers should prioritize access to antenatal and postnatal counseling services and health insurance for mothers and children during crises.

One of the challenges in discussion facilitation is creating a climate that allows multiple voices to be heard. Although the practice of calling on students whose hands are not raised has been used to engage the entire class in discussions, many believe that cold calling sabotages the communication climate and makes students extremely uncomfortable. This study examines the impact of cold calling on student comfort and communication climate. The results suggest that when instructors choose to cold-call, they must create a supportive communication climate to ensure student comfort. This study challenges the assumption that cold calling makes students uncomfortable.

PURPOSE: Failure modes and effects analysis (FMEA) was used to identify ways in which community clinic practices related to suboptimal human papillomavirus (HPV) vaccination rates could be improved. METHOD: FMEA is a standardized safety method that helps determine where processes fail, the impact of failures, and needed process changes. In a quality improvement initiative conducted at an academic health center-based community clinic, a multidisciplinary team used FMEA to map HPV vaccination processes and identify areas for improvement of vaccination practices. Risk priority numbers (RPNs) were assigned to identified failure modes based on likelihood of occurrence, likelihood of detection, and ability to correct locally. Failure modes with the highest RPNs were targeted for process improvements. RESULTS: High RPN failure modes were related to clinic processes for follow-up, immunization status checks during well-child visits, and vaccination discussions during sick-child visits. New procedures included scheduling follow-up vaccinations and reminders during the initial vaccination appointment. HPV immunization rates improved following implementation of these procedures, indicating that clinic processes focused on patient follow-up can impact vaccination series completion. CONCLUSION: FMEA processes can help health systems identify workflow barriers and locally relevant opportunities for improvement. Team-based approaches to care process improvements can also benefit from standardized problem identification and solving.

Levothyroxine (LT) is the synthetic form of thyroxine (T4), a thyroid hormone analog used to treat hypothyroidism. LT overdose rarely results in severely poor outcomes. General guidelines for treating exogenous thyrotoxicosis depend on the severity of symptoms. There is no standardized protocol; however, drug discontinuation, beta-blockers (specifically propranolol), and cholestyramine effectively manage overdose when needed, with most cases resolving independently without medical intervention. Here, we present the case of a 26-year-old female with a history of supraventricular tachycardia, anxiety, depression, and Hashimoto thyroiditis who was accidentally overprescribed LT (300 mcg for one and a half months) that resulted in symptoms of lethargy, tremors, body temperature dysregulation, orthostatic hypotension, and diarrhea. This case, with limited evidence, suggests that excessive LT exacerbated the patient's underlying psychiatric symptoms, encouraging suicidal ideation.

ABSTRACT Background Pharmacologic and nutritional therapies are prescribed for men with idiopathic infertility, but their effectiveness by intervention class remains uncertain. Objectives To evaluate these interventions on semen parameters and clinical pregnancy in men with idiopathic infertility, stratified by mechanism of action. Materials and Methods We searched PubMed, Embase, Scopus, Cochrane CENTRAL, ClinicalTrials.gov, and Google Scholar (January 2010 to January 2026) for randomized controlled trials comparing pharmacologic or nutritional interventions with placebo or no treatment in men with idiopathic infertility. Semen parameters were the primary outcomes, analyzed by mechanism of action using three‐level random‐effects models with Knapp–Hartung adjustment. Certainty of evidence was assessed using GRADE. PROSPERO: CRD420261289976. Results Forty‐one RCTs (3615 men) were included. Antioxidants were associated with higher sperm concentration (SMD: 1.09, 95% CI: 0.10 to 2.08), progressive motility (SMD: 1.11, 95% CI: 0.32 to 1.90), total motility (SMD: 0.69, 95% CI: 0.26 to 1.13), and normal morphology (SMD: 0.43, 95% CI: 0.05 to 0.82); prediction intervals crossed the null for all. PDE inhibitors showed numerically higher point estimates for concentration (SMD: 1.96, 95% CI: −2.25 to 6.17) and morphology (SMD: 1.28, 95% CI: −0.47 to 3.02); methyl donors reduced DNA fragmentation (SMD: −1.17, 95% CI: −2.82 to 0.47). Confidence intervals for these included the null. Heterogeneity was substantial ( I 2 &gt; 80%). Hormonal agents and clinical pregnancy were synthesized narratively. Discussion Pooled estimates represent averages of diverse effects; individual patient responses remain uncertain given wide prediction intervals. Conclusion Antioxidants were associated with higher values for several semen parameters, though certainty was very low and prediction intervals were wide. PDE inhibitors and methyl donors showed numerically positive point estimates but with confidence intervals that included the null. Larger trials reporting live births are needed.

In this plain language podcast, highlights from the American Society of Clinical Oncology (ASCO) Annual Meeting 2025 are discussed, supplemented with additional reflections from the European Hematology Association (EHA) 2025 Congress. These insights come from the perspective of an expert patient and physician, both of whom have experience and expertise in the field of multiple myeloma (MM). This podcast is intended to broaden the reach of complex data on MM from these scientific meetings to a broader audience, including nonspecialists, helping enable better informed treatment decisions between patients and healthcare professionals. Four key topics are discussed, including emerging measurable residual disease (MRD)-driven strategies, novel immunotherapies, supportive care, and precision medicine approaches. MRD negativity is becoming a therapeutic goal and monitoring benchmark in the era of novel immunotherapies, helping patients with MM to achieve long-term disease control and remission. Supportive care, including access to patient organization information and support, is a critical component of modern MM care to maximize treatment benefit and quality of life for patients while limiting treatment toxicities. Finally, personalized treatment approaches and the use of artificial intelligence could re-shape outcomes for patients, including those with high-risk smoldering MM who would benefit from early intervention. As the treatment landscape continues to evolve in MM, so does the likelihood of long-term disease control and the potential for functional cure-a goal that was once a fantasy but is increasingly definable and measurable. A glossary of abbreviations and terms used in this podcast is provided in the appendix for reference.

Plain Language SummaryWhat is this summary about?This summary describes results from a study of preferences for treatment features among patients with a type of blood cancer called multiple myeloma. Treatment features are the characteristics of a treatment, such as how effective it is, how it is administered, and potential side effects.Why was the study done and how was it conducted?The aim of this research was to learn more about the most important features of treatment to patients with multiple myeloma. This information can help healthcare professionals, patients, and caregivers choose between different therapies.Patients with multiple myeloma that had either recurred (relapsed) or did not respond (refractory) to previous therapy completed an online survey. Using the survey results, researchers quantified patient preferences for different treatment features. Researchers made predictions about how patients may choose between different treatments based on their different features.What were the results and what do they mean? On average, patients rated the most important feature to be increasing the amount of time they could expect to live after starting the treatment.Other highly important features included reducing the risk of serious infection, avoiding long hospital stays at the start of treatment, and the increasing likelihood of their cancer responding to treatment (i.e., the treatment reduced the signs of cancer in the body, either partially or completely, to undetectable levels).Although patients were wary of serious infections, they were willing to trade a higher risk of serious infection to increase how long they could expect to live.When considering hypothetical treatment options, patients in general preferred a treatment that was immediately available versus one that would not be immediately available.

Plasma cell disorders (PCDs) are a spectrum of diseases characterized by abnormal proliferation of plasma cells, from precursor conditions, monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM), to malignant multiple myeloma (MM). Over the past decade, therapeutic advances have improved survival and outcomes for MM patients. As individuals live longer, there are opportunities to enhance long-term health and quality of life through diet and lifestyle interventions.

1 Key barriers to multiple myeloma clinical trial participation were identified, and country-specific recommendations are provided. 2 Findings will advance the field and can form the basis of a framework that informs the optimal implementation of recommendations. Therapies for multiple myeloma (MM) have advanced; however, disparity in healthcare outcomes remains. Barriers to clinical trial enrollment contribute to this disparity and result in recruiting unrepresentative groups of patients, depriving patients of opportunities to benefit from experimental treatments, and causing incompletion of some trials due to insufficient accrual rates. This study aimed to identify geographic inequalities in clinical trial participation and develop a comprehensive list of barriers (factors preventing participation) to and facilitators (factors enabling improvements) of patient enrollment in MM clinical trials. Geographic data were collected for MM trials registered between 2011 and 2021 to determine the number of trials and recruitment rates in different regions. Of the trials identified, 61% recruited patients from the US; 24%, 14%, and 13% recruited patients from Western Europe, Southern Europe, and Eastern Asia, respectively. Other geographic regions were less involved in MM clinical trials, highlighting global inequality in MM clinical research. Barriers to and facilitators of patient enrollment in MM trials were identified through a systematic literature review and broadly categorized into 4 domains: clinical (eg, eligibility criteria), patient specific (eg, socioeconomics), physician specific (eg, awareness of trials), and structural (eg, regulatory environment). These domains were presented to stakeholders, who were from various backgrounds and geographic regions, to ascertain which were most relevant to patients with MM globally. Recommendations were identified, with unanimous support from interviewees, and have the most potential for global application. The application of these findings will help overcome the many barriers to enrollment in MM clinical trials.

Background: The population of adults aged 65 and older is rapidly increasing, while the availability of caregivers is declining. Smart homes that provide unobtrusive, continuous monitoring and alerting on clinically relevant changes in daily activity patterns offer a potentially innovative solution for aging in place. Objective: This study aims to evaluate the barriers and facilitators to the adoption of a low-cost smart home embedded within a community-based approach to health monitoring for older adults with multiple chronic conditions and who are experiencing poverty. Methods: Using a prospective, mixed methods design and iterative community co-design, 46 older adults from 7 different language groups were continuously monitored for 6 months with ambient sensors installed in their homes. Two older adults were monitored for 4 and 5 months, respectively, resulting in a total sample of 48. The system generated alerts based on movement pattern changes and escalated notifications to participants, support persons, community health workers, and nurses. Sensor data were analyzed descriptively to quantify alert patterns and response rates, while written text-based data from in-the-moment surveys, community health workers' and registered nurses' notes, and semistructured interviews underwent qualitative descriptive analysis and reflexive thematic coding. Results: The system generated 37 million sensor readings condensed into 1.2 million high-level events and 4719 novel alerts. Qualitative data comprised 34,086 words of text. Participants responded to 1.57% (74) of the initial email alerts and 7.79% (368) of the follow-up SMS text message alerts sent when no email response was received. Community health workers and registered nurses responded to 78.36% (n=3698) of the escalated alerts, resulting in 1060 contacts with participants in response to alerts. Clinical contacts resulted in 72 interventions. Three major qualitative themes emerged: (1) Alone, (2) Trust, and (3) Human Connection. Subthemes included Safety, Personalization, and Digital Distress defined as stress associated with interacting with digital health-monitoring systems. Participants rated the system highly (mean likelihood-to-recommend rating 8.68/10, SD 1.68); however, they expressed a strong preference for phone calls over automated alerts. Cultural expectations influenced adoption, particularly in multigenerational households. Conclusions: Communities can effectively engage in technology-delivered health care. Future research is needed to improve technical aspects of smart home monitoring systems, including accurate alerting using machine learning, data visualizations for older adults and health care workers, and culturally sensitive features. Additional work should address how and when to communicate automated messaging, engage older adults with their own data, and integrate sensor-based monitoring into health care workflows. Research should also explore personalization through advanced computational approaches such as machine learning and strategies to reduce digital distress.

INTRODUCTION: Embryonal Rhabdomyosarcoma (ERMS) is a malignant soft tissue musculoskeletal tumor which constitutes about 0.06% of all malignancies affecting children. Biliary tract ERMS is still rare, though it is considered the most common cause of malignant obstructive jaundice in children. CASE PRESENTATION: A report of a 2-year-old boy, who was presented with recurrent episodes of scleral icterus of three months duration, is added to the related literature. His labs went with obstructive jaundice and the radiological investigations were consistent with a diagnosis of choledochal cyst. The found mass was suspected to be an ERMS of common bile duct and turned out to be so by the histopathology. He was managed totally by laparoscope, both excision and hepaticojejunostomy reconstruction, which is an extremely uncommon entity. CONCLUSION: Common Bile Duct Rhabdomyosarcoma is rare and diagnosis at this anatomical site is difficult. Our case highlights the feasibility of laparoscopic resection and hepaticojejunostomy reconstruction with very good results at 16-month follow up and parents' gratitude as well.

The only way to accomplish the goals discussed is for health plans to collaborate more constructively with the oncologist community. We have reached out to providers, but there is still plenty of room for improvement. It is critical for both our success and that of the oncology community, because no one benefits from an adversarial relationship. We have not really sat down as partners with care providers to talk about what both parties see as emerging issues and how to best address them. We are at a point in oncology where we have this opportunity.