Anatomy of Summertime Upslope Events in Northeastern Colorado: Ammonia (NH3) Transport to the Rocky Mountains.

The Transport and Transformation of Ammonia (TRANS2Am) airborne field campaign occurred over northeastern Colorado during the summers of 2021 and 2022. A subset of the TRANS2Am flights investigated easterly wind conditions capable of moving agricultural emissions of ammonia (NH3) through urban areas and into the Rocky Mountains. TRANS2Am captured 6 of these events, unveiling important commonalities. (1) NH3 enhancements are present over the mountains on summer afternoons when easterly winds are present in the foothills region. (2) The abundance of gas-phase NH3 is 1 and 2 orders of magnitude higher than particle-phase NH4+ over the mountains and major agricultural sources, respectively. (3) During thermally driven circulation periods, emissions from animal husbandry sources closer to the mountains likely contribute more to the NH3 observed over the mountains than sources located further east. (4) Transport of plumes from major animal husbandry sources in northeastern Colorado westward across the foothills requires ∼5 h. (5) Winds drive variability in the transport of NH3 into nearby mountain ecosystems, producing both direct plume transport and recirculation. A similar campaign in other seasons, including spring and autumn, when synoptic scale events can produce sustained upslope transport, would place these results in context.

Using qualitative exit interviews to explore schizophrenia burden and treatment experience in clinical trial patients.

Introduction: Qualitative research methods can be used to obtain a deeper understanding of patient experience by collecting information in the patients' own words about their encounters, perspectives, and feelings. In this study, patients with schizophrenia were interviewed to capture their voice and to complement the quantitative data typically obtained in clinical trials. Methods: Semi-structured exit interviews were conducted with 41 patients who completed or prematurely discontinued from a phase 3, open-label trial (NCT02873208). The interview guide included open-ended questions on current and prior disease burden, symptoms, quality of life, and treatment experiences. Steps taken to reduce interview stress and secure the validity of data included interviewer sensitivity training specific to mental health conditions and schizophrenia, use of in-person interviews whenever possible and use of videoconferencing for remote interviews to promote trust and comfort, and working closely with clinical site staff to identify patient eligibility and willingness to participate. Transcripts based on audio recordings were content coded and analyzed using thematic analysis; a post-hoc quantitative content analysis was conducted. Results: Patients reported that the symptoms of schizophrenia negatively impacted their work, relationships, self-esteem, emotional health, and daily activities. Most patients had positive experiences with medications that alleviated hallucinations, depression, and anxiety. However, side effects of medications were associated with negative impacts on physical, emotional, behavioral, and cognitive health. Lack of energy/drowsiness, weight gain, mood changes, and involuntary movements were the most common side effects reported with the use of antipsychotic medications. Patients reported unmet treatment needs related to better symptom control and to improved social and physical functioning. Conclusion: Collection of qualitative information within a schizophrenia clinical development process provides value and insights into patients' views on burden of illness, experiences with previous medications, and experiences following participation in a clinical trial and can inform design for future studies.

Characteristics and Habits of Psychiatrists and Neurologists With High Occupational Well-Being: A Mixed Methods Study.

Objective: To identify the characteristics that distinguish occupationally well outliers (OWO), a subset of academic psychiatrists and neurologists with consistently high professional fulfillment and low burnout, from their counterparts with lower levels of occupational well-being. Participants and Methods: Participants included faculty physicians practicing psychiatry and neurology in academic medical centers affiliated with the Professional Well-being Academic Consortium. In this prospective, longitudinal study, a mixed qualitative and quantitative approach was used. Quantitative measures were administered to physicians in a longitudinal occupational well-being survey sponsored by the academic organizations where they work. Four organizations participated in the qualitative study. Psychiatrists and neurologists at these organizations who competed survey measures at 2 consecutive time points between 2019 and 2021 were invited to participate in an interview. Results: Of 410 (213 psychiatrists and 197 neurologists) who completed professional fulfillment and burnout measures at 2 time points, 84 (20.5%) met OWO criteria. Occupationally well outliers psychiatrists and neurologists had more favorable scores on hypothesized determinants of well-being (values alignment, perceived gratitude, supportive leadership, peer support, and control of schedule). Ultimately, 31 psychiatrists (25% of 124 invited) and 33 neurologists (18.5% of 178 invited) agreed to participate in an interview. Qualitatively, OWO physicians differed from all others in 3 thematic domains: development of life grounded in priorities, ability to shape day-to-day work context, and professional relationships that provide joy and support. Conclusion: A multilevel approach is necessary to promote optimal occupational well-being, targeting individual-level factors, organizational-level factors, and broader system-level factors.

Health equity principles for oncology real world evidence studies.

BACKGROUND: Real-world research on cancer care in the community should address social determinants of health (SDOH) to advance health equity in cancer diagnosis, treatment, and survivorship. We sought patient and stakeholder perspectives to co-develop research principles to guide researchers when using patient record data to address health equity in their research protocols. MATERIALS AND METHODS: Key informant interviews with 13 individuals elicited perspectives and insights related to health equity and SDOH when conducting research using data from community-based oncology care. Interviews included a brief overview of a prior scoping review and related questions in the interview guide. Key informants included experts in health equity and SDOH, and patient and community advisory board members. Rapid qualitative analysis was used to identify key themes, patterns, and insights from the interview data. Principles were developed based on the results of the analysis. RESULTS: Three overarching categories for promoting health equity were (1) education; (2) community engagement; and (3) research design and implementation. Education principles highlight the necessity of training in relevant skills to address health equity. Community engagement principles highlight various actions that researchers can take to conduct research inclusive of community concerns regarding health equity. The research design and implementation category provides practical guidelines for researchers in planning, conducting, and disseminating community-based oncology research to address health equity. CONCLUSION: Our principles guide oncology real-world research protocols to address SDOH in community settings and promote health equity. These principles should be tailored to specific cancer topics and communities.

Regime shift in secondary inorganic aerosol formation and nitrogen deposition in the rural United States.

Secondary inorganic aerosols play an important role in air pollution and climate change, and their formation modulates the atmospheric deposition of reactive nitrogen (including oxidized and reduced nitrogen), thus impacting the nitrogen cycle. Large-scale and long-term analyses of secondary inorganic aerosol formation based on model simulations have substantial uncertainties. Here we improve constraints on secondary inorganic aerosol formation using decade-long in situ observations of aerosol composition and gaseous precursors from multiple monitoring networks across the United States. We reveal a shift in the secondary inorganic aerosol formation regime in the rural United States between 2011 and 2020, making rural areas less sensitive to changes in ammonia concentrations and shortening the effective atmospheric lifetime of reduced forms of reactive nitrogen. This leads to potential increases in reactive nitrogen deposition near ammonia emission hotspots, with ecosystem impacts warranting further investigation. Ammonia (NH3), a critical but not directly regulated precursor of fine particulate matter in the United States, has been increasingly scrutinized to improve air quality. Our findings, however, show that controlling NH3 became significantly less effective for mitigating fine particulate matter in the rural United States. We highlight the need for more collocated aerosol and precursor observations for better characterization of secondary inorganic aerosols formation in urban areas.

Challenges in Medicine, Magnified by the Pandemic: A Dual Battle for Female Physicians.

INTRODUCTION:  We aimed to understand how the pandemic impacted work hours and employment status of female physicians.  Methods: An anonymous survey of female physicians was distributed through social media and email lists from 12/2021 to 2/2022. Primary outcomes were changes in physicians' work schedules and employment status. Analyses included descriptive statistics of closed-ended items and qualitative content analysis of open-ended responses. RESULTS:  We restricted our analysis to four specialties: obstetrics and gynecology, internal medicine, anesthesia, and pediatrics (n=626). The majority (92%) of respondents had caretaking responsibilities; 43% changed work schedules to accommodate those responsibilities. Around 17% of physicians changed jobs. The most common reasons for job changes included: negative work environment, lack of work-life balance, burden of work, and lack of efforts to mitigate COVID-19.  Conclusion: The pandemic highlighted the need for flexibility, improvements in workplace culture, and financial incentives to increase retention.

Crystal structure and biophysical characterization of IspD from Burkholderia thailandensis and Mycobacterium paratuberculosis.

The methylerythritol phosphate (MEP) pathway is a metabolic pathway that produces the isoprenoids isopentyl pyrophosphate and dimethylallyl pyrophosphate. Notably, the MEP pathway is present in bacteria and not in mammals, which makes the enzymes of the MEP pathway attractive targets for discovering new anti-infective agents due to the reduced chances of off-target interactions leading to side effects. There are seven enzymes in the MEP pathway, the third of which is IspD. Two crystal structures of Burkholderia thailandensis IspD (BtIspD) were determined: an apo structure and that of a complex with cytidine triphosphate (CTP). Comparison of the CTP-bound BtIspD structure with the apo structure revealed that CTP binding stabilizes the loop composed of residues 13-19. The apo structure of Mycobacterium paratuberculosis IspD (MpIspD) is also reported. The melting temperatures of MpIspD and BtIspD were evaluated by circular dichroism. The moderate Tm values suggest that a thermal shift assay may be feasible for future inhibitor screening. Finally, the binding affinity of CTP for BtIspD was evaluated by isothermal titration calorimetry. These structural and biophysical data will aid in the discovery of IspD inhibitors.

Do we teach critical thinking? A mixed methods study of faculty and student perceptions of teaching and learning critical thinking at three professional schools.

INTRODUCTION: Critical thinking (CT) is an essential set of skills and dispositions for professionals. While viewed as an important part of professional education, approaches to teaching and assessing critical thinking have been siloed within disciplines and there are limited data on whether student perceptions of learning align with faculty perceptions of teaching. MATERIALS AND METHODS: The authors used a convergent mixed methods approach in required core courses in schools of education, government, and medicine at one university in the Northeast United States. Faculty surveys and student focus groups (FG) addressed definitions, strategies, and barriers to teaching CT. RESULTS AND CONCLUSIONS: Sixty-four (51.6%) faculty completed the survey, and 34 students participated in FGs. Among faculty, 54.0% (34/63) reported explicitly teaching CT; but students suggested teaching CT was predominantly implicit. Faculty-reported strategies differed among schools. Faculty defined CT in process terms such as 'analyzing'; students defined CT in terms of viewpoints and biases. Our results reveal a lack of explicit, shared CT mental models between faculty and students and across professional schools. Explicit teaching of CT may help develop a shared language and lead to better understanding and application of the skills and dispositions necessary to succeed in professional life.

Fostering Governance and Information Partnerships for Chronic Disease Surveillance: The Multi-State EHR-Based Network for Disease Surveillance.

CONTEXT: Electronic health records (EHRs) are an emerging chronic disease surveillance data source and facilitating this data sharing is complex. PROGRAM: Using the experience of the Multi-State EHR-Based Network for Disease Surveillance (MENDS), this article describes implementation of a governance framework that aligns technical, statutory, and organizational requirements to facilitate EHR data sharing for chronic disease surveillance. IMPLEMENTATION: MENDS governance was cocreated with data contributors and health departments representing Texas, New Orleans, Louisiana, Chicago, Washington, and Indiana through engagement from 2020 to 2022. MENDS convened a governance body, executed data-sharing agreements, and developed a master governance document to codify policies and procedures. RESULTS: The MENDS governance committee meets regularly to develop policies and procedures on data use and access, timeliness and quality, validation, representativeness, analytics, security, small cell suppression, software implementation and maintenance, and privacy. Resultant policies are codified in a master governance document. DISCUSSION: The MENDS governance approach resulted in a transparent governance framework that cultivates trust across the network. MENDS's experience highlights the time and resources needed by EHR-based public health surveillance networks to establish effective governance.

Finding the right combination for self-directed learning: A focus group study of residents' choice and use of digital resources to support their learning.

BACKGROUND: There has been a shift in postgraduate medical education towards digital educational resources-podcasts, videos, social media and other formats consumed asynchronously and apart from formal curricula. It is unclear what drives residents to select and use these resources. Understanding how and why residents choose digital resources can aid programme directors, faculty and residents in optimising residents' informal learning time. METHOD: This focus group study was conducted with residents at two US internal medicine residency programmes. The authors used the framework approach to content analysis using self-determination theory as guide for deductive coding and iteratively assessing connections among codes and identifying themes. Trustworthiness was addressed through use of analytic memos, reflexive practice and member checking. RESULTS: The authors conducted eight virtual focus groups (n = 23) from 5/27/20 to 6/11/20. Residents described that a feeling of 'should know' drove initial choices towards self-directed learning outside of work. Regular use of a resource was influenced by how the resource fit into a resident's lifestyle, the personal cognitive energy and the perceived 'activation energy' of using a particular resource. Familiarity, increased confidence and in-person social networks gained from digital resources served to reinforce and further guide resource choice. CONCLUSIONS: The selection of digital resources for self-directed learning is driven by multiple factors, suggesting an interdependent relationship between the learning environment and a residents' cognitive capacity. Understanding these interconnections can help residents and clinical educators explicitly choose resources that fit their lifestyle and learning needs.

Insights for Healthcare Providers on Shared Decision-Making in Multiple Sclerosis: A Narrative Review.

Shared decision-making (SDM) between the patient and their healthcare provider (HCP) in developing treatment plans is increasingly recognized as central to improving treatment adherence and, ultimately, patient outcomes. In multiple sclerosis (MS), SDM is particularly crucial for optimizing treatment in a landscape that has grown more complex with the availability of newer, high-efficacy MS therapies. However, little direct evidence on the effectiveness of SDM is available to guide practice. Multiple factors, including patient age, ethnic background, perceptions, invisible MS symptoms, and psychological comorbidities can influence a patient's willingness and ability to participate in SDM. HCPs need to appreciate these factors and ask the right questions to break down obstacles to SDM. The HCP has a responsibility to help patients feel adequately informed and comfortable in having an active role in their care. This review identifies potential barriers to SDM and provides a strategy for HCPs to overcome these obstacles through patient (and caregiver) discussions to ensure optimal patient satisfaction with treatment and thus the best possible outcomes for their patients.

"Should I Say Something?": A Simulation Curriculum on Addressing Lapses in Professionalism to Improve Patient Safety.

Introduction: Medical students may witness lapses in professionalism but lack tools to effectively address such episodes. Current professionalism curricula lack opportunities to practice communication skills in addressing professionalism lapses. Methods: We designed a simulation curriculum to introduce professionalism expectations, provide communication tools using elements of the Agency for Healthcare Research and Quality TeamSTEPPS program, and address observed professionalism lapses involving patient safety in hierarchical patient care teams. Students were surveyed on knowledge, skills, and attitude regarding professionalism before, immediately after, and 6 months after participation. Results: Of 253 students, 70 (28%) completed baseline and immediate postsurveys, and 39 (15%) completed all surveys. In immediate postsurveys, knowledge of communication tools (82% to 94%, p = .003) and empowerment to address residents (19% to 44%, p = .001) and attendings (15% to 39%, p < .001) increased. At 6 months, 96% of students reported witnessing a professionalism lapse. Discussion: The curriculum was successful in reported gains in knowledge of communication tools and empowerment to address professionalism lapses, but few students reported using the techniques to address witnessed lapses in real life.

"Two Years Later I'm Still Just as Angry": A Focus Group Study of Emergency and Internal Medicine Physicians on Disrespectful Communication.

Phenomenon: Disrespectful behavior between physicians across departments can contribute to burnout, poor learning environments, and adverse patient outcomes. Approach: In this focus group study, we aimed to describe the nature and context of perceived disrespectful communication between emergency and internal medicine physicians (residents and faculty) at patient handoff. We used a constructivist approach and framework method of content analysis to conduct and analyze focus group data from 24 residents and 11 faculty members from May to December 2019 at a large academic medical center. Findings: We organized focus group results into four overarching categories related to disrespectful communication: characteristics and context (including specific phrasing that members from each department interpreted as disrespectful, effects of listener engagement/disengagement, and the tendency for communication that is not in-person to result in misunderstanding and conflict); differences across training levels (with disrespectful communication more likely when participants were at different training levels); the individual correspondent's tendency toward perceived rudeness; and negative/long-term impacts of disrespectful communication on the individual and environment (including avoidance and effects on patient care). Insights: In the context of predominantly positive descriptions of interdepartmental communication, participants described episodes of perceived disrespectful behavior that often had long-lasting, negative impacts on the quality of the learning environment and clinical work. We created a conceptual model illustrating the process and outcomes of these interactions. We make several recommendations to reduce disrespectful communication that can be applied throughout the hospital to potentially improve patient care, interdepartmental collaboration, and trainee and faculty quality of life.

Predicting Atmospheric Water-Soluble Organic Mass Reversibly Partitioned to Aerosol Liquid Water in the Eastern United States.

Water-soluble organic matter (WSOM) formed through aqueous processes contributes substantially to total atmospheric aerosol, however, the impact of water evaporation on particle concentrations is highly uncertain. Herein, we present a novel approach to predict the amount of evaporated organic mass induced by sample drying using multivariate polynomial regression and random forest (RF) machine learning models. The impact of particle drying on fine WSOM was monitored during three consecutive summers in Baltimore, MD (2015, 2016, and 2017). The amount of evaporated organic mass was dependent on relative humidity (RH), WSOM concentrations, isoprene concentrations, and NOx/isoprene ratios. Different models corresponding to each class were fitted (trained and tested) to data from the summers of 2015 and 2016 while model validation was performed using summer 2017 data. Using the coefficient of determination (R2) and the root-mean-square error (RMSE), it was concluded that an RF model with 100 decision trees had the best performance (R2 of 0.81) and the lowest normalized mean error (NME < 1%) leading to low model uncertainties. The relative feature importance for the RF model was calculated to be 0.55, 0.2, 0.15, and 0.1 for WSOM concentrations, RH levels, isoprene concentrations, and NOx/isoprene ratios, respectively. The machine learning model was thus used to predict summertime concentrations of evaporated organics in Yorkville, Georgia, and Centerville, Alabama in 2016 and 2013, respectively. Results presented herein have implications for measurements that rely on sample drying using a machine learning approach for the analysis and interpretation of atmospheric data sets to elucidate their complex behavior.

Source characterization of volatile organic compounds at Carlsbad Caverns National Park.

Carlsbad Caverns National Park (CAVE), located in southeastern New Mexico, experiences elevated ground-level ozone (O3) exceeding the National Ambient Air Quality Standard (NAAQS) of 70 ppbv. It is situated adjacent to the Permian Basin, one of the largest oil and gas (O&G) producing regions in the US. In 2019, the Carlsbad Caverns Air Quality Study (CarCavAQS) was conducted to examine impacts of different sources on ozone precursors, including nitrogen oxides (NOx) and volatile organic compounds (VOCs). Here, we use positive matrix factorization (PMF) analysis of speciated VOCs to characterize VOC sources at CAVE during the study. Seven factors were identified. Three factors composed largely of alkanes and aromatics with different lifetimes were attributed to O&G development and production activities. VOCs in these factors were typical of those emitted by O&G operations. Associated residence time analyses (RTA) indicated their contributions increased in the park during periods of transport from the Permian Basin. These O&G factors were the largest contributor to VOC reactivity with hydroxyl radicals (62%). Two PMF factors were rich in photochemically generated secondary VOCs; one factor contained species with shorter atmospheric lifetimes and one with species with longer lifetimes. RTA of the secondary factors suggested impacts of O&G emissions from regions farther upwind, such as Eagle Ford Shale and Barnett Shale formations. The last two factors were attributed to alkenes likely emitted from vehicles or other combustion sources in the Permian Basin and regional background VOCs, respectively.Implications: Carlsbad Caverns National Park experiences ground-level ozone exceeding the National Ambient Air Quality Standard. Volatile organic compounds are critical precursors to ozone formation. Measurements in the Park identify oil and gas production and development activities as the major contributors to volatile organic compounds. Emissions from the adjacent Permian Basin contributed to increases in primary species that enhanced local ozone formation. Observations of photochemically generated compounds indicate that ozone was also transported from shale formations and basins farther upwind. Therefore, emission reductions of volatile organic compounds from oil and gas activities are important for mitigating elevated O3 in the region.

Observations of ozone, acyl peroxy nitrates, and their precursors during summer 2019 at Carlsbad Caverns National Park, New Mexico.

Carlsbad Caverns National Park (CAVE) is located in southeastern New Mexico and is adjacent to the Permian Basin, one of the most productive oil and natural gas (O&G) production regions in the United States. Since 2018, ozone (O3) at CAVE has frequently exceeded the 70 ppbv 8-hour National Ambient Air Quality Standard. We examine the influence of regional emissions on O3 formation using observations of O3, nitrogen oxides (NOx = NO + NO2), a suite of volatile organic compounds (VOCs), peroxyacetyl nitrate (PAN), and peroxypropionyl nitrate (PPN). Elevated O3 and its precursors are observed when the wind is from the southeast, the direction of the Permian Basin. We identify 13 days during the July 25 to September 5, 2019 study period when the maximum daily 8-hour average (MDA8) O3 exceeded 65 ppbv; MDA8 O3 exceeded 70 ppbv on 5 of these days. The results of a positive matrix factorization (PMF) analysis are used to identify and attribute source contributions of VOCs and NOx. On days when the winds are from the southeast, there are larger contributions from factors associated with primary O&G emissions; and, on high O3 days, there is more contribution from factors associated with secondary photochemical processing of O&G emissions. The observed ratio of VOCs to NOx is consistently high throughout the study period, consistent with NOx-limited O3 production. Finally, all high O3 days coincide with elevated acyl peroxy nitrate abundances with PPN to PAN ratios > 0.15 ppbv ppbv-1 indicating that anthropogenic VOC precursors, and often alkanes specifically, dominate the photochemistry.Implications: The results above strongly indicate NOx-sensitive photochemistry at Carlsbad Caverns National Park indicating that reductions in NOx emissions should drive reductions in O3. However, the NOx-sensitivity is largely driven by emissions of NOx into a VOC-rich environment, and a high PPN:PAN ratio and its relationship to O3 indicate substantial influence from alkanes in the regional photochemistry. Thus, simultaneous reductions in emissions of NOx and non-methane VOCs from the oil and gas sector should be considered for reducing O3 at Carlsbad Caverns National Park. Reductions in non-methane VOCs will have the added benefit of reducing formation of other secondary pollutants and air toxics.

Who Is Teaching Residents in the Intensive Care Unit? Perceptions of Interprofessional Teaching at an Academic Medical Center.

Background: Teamwork is essential for high-quality care in the intensive care unit (ICU). Interprofessional education has been widely endorsed as a way of promoting collaborative practice. Interprofessional providers (IPPs), including nurses, pharmacists, and respiratory therapists (RTs), routinely participate in multidisciplinary rounds in the ICU, but their role in teaching residents at academic medical centers has yet to be characterized. Objective: To characterize perceptions of interprofessional teaching during and outside of rounds in the ICU. Methods: The authors conducted a cross-sectional survey of critical care physicians, internal medicine residents, nurses, pharmacists, and RTs across three ICUs at a tertiary academic medical center from September 2019 to March 2020. The frequency of different types of rounds contributions was rated on a Likert scale. Means and medians were compared across groups. Results: A total of 221 of 285 participants completed the survey (78% response rate). All IPPs described that they report data, provide clinical observations, and make recommendations frequently during ICU rounds, but teaching occurred infrequently (mean values, nurses = 2.9; pharmacists = 3.5; RTs = 3.7; 1 = not at all; 5 = always). Nurses were least likely to report teaching (P = 0.0017). From residents' and attendings' perspectives, pharmacists taught most frequently (mean values, 3.7 and 3.4, respectively). RTs self-report of teaching was higher than physicians' reports of RT teaching (P < 0.0001). Outside of rounds, residents reported a low frequency of teaching by nurses and RTs (means, nurses = 3.1; RTs = 3.1), but they reported a high rate of teaching by pharmacists (mean, 4.4). Conclusion: Nonphysician IPPs routinely participate in ICU rounds but teach medical trainees infrequently. Physicians' perception of IPP teaching frequency was generally lower than self-reports by IPPs. Exploring modifiers of interprofessional teaching may enhance education and collaboration.

The Roles Between Gratitude, Perceived Stress, and Quality of Life Among Patients with Multiple Sclerosis.

Dispositional gratitude has been negatively associated with perceived stress (PS) and positively associated with higher well-being in both general and chronically ill people. Attempts to understand the relationship between gratitude and aspects of quality of life (QOL) have been documented; however, there is limited research on determining the potential mediating effect of PS on gratitude and QOL factors in individuals with Multiple Sclerosis (MS). In this cross-sectional study, participant demographics, dispositional gratitude, PS, and QOL factors were collected online via self-report measures from a sample of 68 participants diagnosed with MS. Results indicated that both dispositional gratitude and PS were associated with aspects of QOL and that PS was found to partially and indirectly account for the relationship between gratitude and improved QOL. Findings are consistent with existing research conducted with non-chronically ill samples. Clarifying relationships between PS and dispositional factors in MS is necessary to inform future interventions aimed at maintaining and enhancing an individual's QOL.