Is it all about knowledge? A survey of attitudes toward ADHD among German pediatricians.

Aim: Sometimes treatment is not necessarily according to guidelines, which is partly due to attitudes rather than lack of knowledge. In Germany, regional differences concerning prevalence rates of ADHD exist without valid explanation. We contribute with our data to the question of attitudes toward ADHD among pediatricians in Germany. Method: A specially designed questionnaire based on the Knowledge of Attention Deficit Disorders Scale and previous surveys was sent to pediatricians. In addition to descriptive statistics, we performed factor analysis and multiple linear regression analysis. Results: The vast majority (85.5%) of 581 respondents have a positive attitude toward ADHD, i.e., ADHD exists and should be treated appropriately. Physicians with positive attitudes were older and more often had a neuropediatric specialization. Conclusion: Most of the pediatricians surveyed in Germany assess ADHD and treatment in line with medical guidelines and treat as part of multimodal therapy. Supplementary Information: The online version contains supplementary material available at 10.1007/s10389-022-01758-4.

The impact of the COVID-19 pandemic on pediatric developmental services: a cross-sectional study on overall burden and mental health status.

BACKGROUND: The COVID-19 outbreak has taken a heavy toll on the mental well-being of healthcare workers, even those who have not been directly involved in the care of acutely ill patients. The aims of this study were to identify the overall burden and mental health status of healthcare workers in pediatric developmental services under the influence of the COVID-19 pandemic, and to identify the risk and protective factors associated with mental health. METHODS: This cross-sectional web-based study was part of a large multicenter VOICE study conducted among employees ((neuro-)pediatricians, psychologists, speech therapists, occupational therapists, etc.) from various pediatric developmental services between June and July 2020. A total of 1291 questionnaires regarding overall burden, mental health status (depression, generalized anxiety disorder and emotional exhaustion) and risk and protective factors for mental health (working conditions, potential problems during the COVID-19 pandemic and psychological resources) were analyzed. Descriptive statistics and multiple linear regression were used for data analysis. RESULTS: A total of 44.5% (574/1291) participants felt a high or very high overall burden during the COVID-19 pandemic. Of all the participants, 14.6% (171/1173) reported clinically significant levels of depressive symptoms, 17.0% (199/1173) reported generalized anxiety disorder symptoms and 44.6% (532/1192) reported emotional exhaustion. Multiple linear regression analyses identified several common risk and protective factors for mental health status variables. The burden of an increase in the quantity of work, fear of work and fear of becoming infected showed the strongest negative associations, whereas psychological resources and sufficient relaxation in leisure time exhibited the strongest positive associations. CONCLUSION: Employees who were not directly involved in the care of acutely ill patients were also exposed to considerable stress, some of which was not different from that experienced by professionals who were directly affected. These employees should not be lost sight of and must be offered appropriate support.

[Communicating test results in a comprehensible manner: A randomized controlled trial of word usage in doctor-patient communication]. / Befundergebnisse verständlich vermitteln ­ Eine randomisiert-kontrollierte Studie zur Wortwahl in der Ärzt*innen-Patient*innen-Kommunikation.

INTRODUCTION: Doctor-patient communication is one of the hallmarks of good medical treatment. Mutual understanding is of foremost importance, in particular when communicating non-numerical test results. METHODS: Using a two-step approach, this study analyses the influence of wording on the correct understanding of medical test results by people without a medical background. In a first step, a qualitative analysis of physicians' letters helped to identify adjectives that are frequently used to communicate test results. In a second step, a parallel randomised study was conducted to test the comprehensibility of particularly relevant adjectives, combining the written communication of test results with a subsequent survey. 1,131 participants, representing the population of Germany with regard to age, gender, and educational level, were recruited via an online platform. The participants read a scenario involving the communication of the results of a breath test, whereby non-numerical test results were described as being either "positive" vs. "negative" (n=566) or "abnormal" vs. "normal" (n=565). Participant assignment to one of these groups took place in a randomised way. The outcomes measured included the subjective and objective understanding of test results as well as the participants' subjective comprehension of the physician communicating with them. RESULTS: People without a medical background can understand medical test results more readily when neutral, descriptive adjectives are used rather than adjectives considered as being judgmental in everyday language. 54 % of the participants who read test results using the adjectives "positive" vs. "negative" and 65 % of the participants who read test results using the adjectives "abnormal" vs. "normal", respectively, understood the results correctly. This relative difference of 20.4 % in the number of participants with a correct understanding is statistically significant (Chi square=13.061; p=0.001). There was also a considerable difference in the subjective understanding (means of 5.04 of "positive" vs. "negative" and 5.47 for "abnormal" vs. "normal" on a 7-point Likert scale; absolute mean difference 0.42 [95 % CI: 0.20; 0.64]) as well as in the subjective comprehension of the communicating physician (means of 4.49 for "positive" vs. "negative" and 4.95 for "abnormal" vs. "normal" on a 7-point Likert scale; absolute mean difference 0.45 [95% CI: 0.23; 0.67]). A higher level of comprehension for the words "abnormal" vs. "normal" was consistent across the overall sample. It is mainly people with no school-leaving certificate and a lower educational level who benefit from the changed wording. CONCLUSIONS: In the process of communicating non-numerical medical test results, people without a medical background understand neutral, descriptive adjectives better than adjectives that are considered judgmental in everyday usage. A corresponding change of written and oral communication can easily be implemented by medical experts in their everyday practice and particularly supports a population group that already suffers disadvantages in the medical system.

[Internet-based Information on Genetic Testing in Children with Intellectual Disability and Epilepsies: a Systematic Survey]. / Informationen im Internet zu humangenetischen Untersuchungen (bei Kindern) zur Ursachenklärung von Intelligenzminderung oder Epilepsien.

BACKGROUND: Genetic testing is of increasing diagnostic relevance in the evaluation of children with developmental disorders, intellectual disability and epilepsies. The complexity of genetic analyses constitutes a challenge with respect to obtaining informed consent. Internet-based information might facilitate this process. METHOD: We systematically screened and evaluated the available internet-based information of the German pediatric societies and human genetic institutes using standardized methods (e. g. DISCERN Genetics, LIDA, LIX). RESULTS: We found information on 111 homepages. Appearance and navigation could be classified as satisfactory. However, the content was often incomplete and difficult to understand. Forms for informed consent sometimes lacked adequate options for individual decisions. Complexity of informational texts was rated "high" to "very high". Information using plain language was not at all available. There was a limited number of homepages containing information in a language other than German. CONCLUSION: Internet-based information might be helpful for achieving adequately informed consent in complex medical situations. In terms of genetic testing, this information might facilitate the preparation for the pre-diagnostic discussion. Information should be easily accessible including options like plain language, audio versions and foreign language material.

[Genetic Investigations in Children with Developmental Disorders, Intellectual Disability and/or Epilepsy - The Parents' Perspective]. / Genetische Untersuchungen bei Kindern und Jugendlichen mit Entwicklungsstörung, Behinderung und Epilepsien ­ was erwarten Eltern von der Aufklärung.

BACKGROUND: Shared decision-making is indispensable when it comes to molecular genetic investigations, but data on the expectations of the parents is scarce. METHODS: Using a step-by-step approach we initially performed free in-depth-interviews with five parents on which base we developed a half standardized questionnaire. This questionnaire was then applied in interviews with 30 parents of children with intellectual disability, autism or epilepsy subject to genetic examination. RESULTS: Pre-diagnostic discussions are challenging for the parents in an intellectual as well as emotional way. The most important general aspects are diagnosis and therapy. Self-assessment of prior knowledge is very variable and many parents expressed problems in understanding. During the conversation parents rate the following specific aspects as "very important" or "important": findings of unclear relevance, incidental findings, psychic consequences, prognostic aspects, possible therapeutic interventions. 10 Parents did not have any school-degree and 20 parents were not native speakers. DISCUSSION: All parents express a high need for information covering almost all aspects of the investigation. Communicational hurdles pose additional challenges leaving a large room for improvement. Trustworthy internet-based information systems in different languages including plain language could be a first step.

Automated extraction of quality indicators for treatment of children with complex developmental disorders: A feasibility study using the example of attention-deficit/hyperactivity disorder.

QUALITY ISSUE: Quality assessment is challenging in children with developmental disorders. Previously, a set of quality indicators (QIs) was developed and analyzed in terms of feasibility of use with patients with attention-deficit/hyperactivity disorder (ADHD). QI assessment turned out to be possible but highly complex. Thus, we compared different technologies for automated extraction of data for assessment of QIs. CHOICE OF SOLUTION: Four automated extraction technologies (regular expressions, Apache Solr, Apache Mahout, Apache OpenNLP) were compared with respect to their properties regarding the complexity of implementing the QI, the complexity of implementing a check module, the reliability and quality of results, the complexity of preparation of interdisciplinary medical reports, and the complexity of deployment and installation. IMPLEMENTATION: Twenty medical reports from different institutions were reviewed for compliance with three QIs by these technologies and compared with expert opinions. EVALUATION: Among the four technologies, Apache Solr had the best overall performance. For manual extraction of the three QIs, at least 77 s were necessary per medical report, whereas the prototype evaluated and extracted the QIs automatically in 8 s on average. Unexpectedly, different assessments of the degree of compliance by the experts turned out to be one of the stumbling blocks. An in-depth evaluation compared results on a semantic level. LESSONS LEARNED: It is possible to extract QIs by post-processing automated technologies. This approach can also be applied to other developmental disorders. However, a more uniform documentation throughout institutions involved will be necessary in order to implement this method in daily practice.

Quality Assessment of Treatment of Children and Adolescents with Developmental Disorders - A Feasibility Study Using the Example of Attention Deficit Hyperactivity Disorder.

The question of a possible presence of attention deficit/hyperactivity disorder (ADHD) is raised with increasing frequency in pediatric practice. There are guidelines and expert recommendations for diagnostic approaches. But there are no instruments available to evaluate the structural, process and outcome quality. In this pilot study, a set of quality indicators on the treatment quality of ADHD was analyzed in terms of their feasibility in tertiary referral centers.A set of 39 quality indicators (QI) on ADHD developed in advance in a multistage procedure was assessed at 9 tertiary referral centers, with a focus on process verifiability and feasibility. QI values were calculated as ratios for individual centers as well as across centers, followed by an explorative analysis to assess feasibility under due consideration of possible influencing factors.QI assessment is possible but highly complex and expensive in practice. Calculated QI values showed a high degree of heterogeneity between facilities as well as between institutions, which was mainly due to a lack of standardization in the documentation of required data.Basically, it is possible to assess the quality of ADHD treatment via QIs. The approach described here in assessing QIs may be also applied to other types of developmental disorders.

A longitudinal, randomized, and prospective study of nocturnal monitoring in children and adolescents with epilepsy: Effects on quality of life and sleep.

OBJECTIVE: Most studies on seizure detection systems focus more on the effectiveness of devices than on their practicability in and impact on everyday life. Our study investigated the impact of a technical monitoring system on subjective quality of sleep and the lives of affected families. Furthermore, we evaluated the impact of anxiety levels on seizure monitoring and vice versa. METHODS: Forty-three patients with newly diagnosed epilepsy were included. Initially, the families decided whether they did (group 1, n=27) or did not (group 2, n=16) want to use a monitoring device. In group 1, patients were randomly assigned to using Epi-Care® (group 1A, n=14) or an audio baby monitor (group 1B, n=13). Quality of life was assessed at two points (t1, at the start of the study and t2, at 5-7months of follow-up) using the SF-12, Kindl-R, and "Familien-Belastungs-Fragebogen" (German version of the "Impact on Family Scale"). In addition, parental anxiety was measured using the State-Trait Anxiety-Inventory, and subjective quality of sleep was measured using the Pittsburgh Sleep Quality Index. Statistical analysis focused on the possible differences between groups 1 and 2 that may influence parents' decisions and the effects of the presence and types of technical monitoring over time. RESULTS: Anxiety levels were not significantly different between the groups with and without monitoring (group 1 vs. group 2). We also found no statistically significant, substantial baseline differences between the Epi-Care® and audio baby monitor groups, with at least medium effect sizes (group 1A vs. group 1B). Parents' health-related mental quality of life measured via the SF-12 increased significantly over time in all groups. By tendency, the fear of further seizures as well as the frequency of cosleeping arrangements in the monitoring group decreased during the study and approached the stable values of the control group. SIGNIFICANCE: Individual parental anxiety levels are not crucial in the decision regarding the use of a monitoring device. A monitoring system may help some families in certain aspects of daily life. During the first months following a diagnosis of epilepsy, quality of life increases independently of the use of a monitoring system.

Autoantibodies to neuronal antigens in children with focal epilepsy and no prima facie signs of encephalitis.

OBJECTIVE: There is increasing awareness of neuronal autoantibodies and their impact on the pathogenesis of epilepsy. We investigated children with focal epilepsy in order to provide an estimate of autoantibody frequency within a pediatric population without prima facie evidence of encephalitis using a broad panel of autoantibodies. This was done to assess the specificity of antibodies and to see whether antibodies might be of modifying influence on the course of focal epilepsies. METHOD: We searched for autoantibodies in 124 patients with focal epilepsy (1-18 years; mean 10; 6 years). Sera were tested using a broad panel of surface and intracellular antigens. RESULTS: We found autoantibodies in 5/124 patients (4%): high-positive GAD65 antibodies (n = 1), low-positive GAD65 antibodies (N = 1), VGKC complex antibodies not reactive with LGI1 or CASPR2 (n = 3). We did not find any distinctive features distinguishing antibody positive patients from those without antibodies. CONCLUSIONS: The antibodies found in this cohort are probably neither disease-specific nor pathogenic. This has been suggested before for these antigenic targets. Moreover, they do not seem to modify disease severity in the antibody-positive epilepsy patients.

Effectiveness of antiepileptic therapy in patients with PCDH19 mutations.

PURPOSE: PCDH19 mutations cause epilepsy and mental retardation limited to females (EFMR) or Dravet-like syndromes. Especially in the first years of life, epilepsy is known to be highly pharmacoresistant. The aim of our study was to evaluate the effectiveness of antiepileptic therapy in patients with PCDH19 mutations. METHODS: We report a retrospective multicenter study of antiepileptic therapy in 58 female patients with PCDH19 mutations and epilepsy aged 2-27 years (mean age 10.6 years). RESULTS: The most effective drugs after 3 months were clobazam and bromide, with a responder rate of 68% and 67%, respectively, where response was defined as seizure reduction of at least 50%. Defining long-term response as the proportion of responders after 12 months of treatment with a given drug in relation to the number of patients treated for at least 3 months, the most effective drugs after 12 months were again bromide and clobazam, with a long-term response of 50% and 43%, respectively. Seventy-four percent of the patients became seizure-free for at least 3 months, 47% for at least one year. SIGNIFICANCE: The most effective drugs in patients with PCDH19 mutations were bromide and clobazam. Although epilepsy in PCDH19 mutations is often pharmacoresistant, three quarters of the patients became seizure-free for at least for 3 months and half of them for at least one year. However, assessing the effectiveness of the drugs is difficult because a possible age-dependent spontaneous seizure remission must be considered.

Prevalence of Epileptiform Discharges in Healthy Infants.

Most studies on epileptiform discharges in young children were performed using analog electroencephalographic (EEG) recording systems and a limited numbers of electrodes that might have a lower detection rate for epileptiform discharges than modern digital recording systems. Knowing the prevalence of epileptiform discharges in healthy children is critical for a valid interpretation of findings in patients with a suspected epileptic disorder. We reviewed EEG recordings of 393 otherwise healthy children aged 12 to 60 months using digital EEG recording with respect to epileptiform discharges. We found epileptiform discharges in 3 children aged 12, 34 and 55 months resulting in a prevalence of epileptiform discharges in our cohort of 0.76% (95% confidence interval 0.0% to 1.62%). The prevalence of epileptiform discharges in children younger than 5 years is by far lower than in older children, and the digital findings are in accordance with previous data of conventional EEG.

Antiepileptic drugs and bone metabolism in children: data from 128 patients.

There are conflicting results concerning bone metabolism in children receiving antiepileptic medication, with data concentrating on neurologically impaired patients. We performed a multicenter cross-sectional study in otherwise healthy children who received monotherapy with valproic acid, oxcarbazepine, lamotrigine, sulthiame, levetiracetam, or topiramate for at least 6 months. Data on calcium, phosphorus, alkaline phosphatase, 25-OH vitamin D, and parathormone were collected. Among 128 patients, 24.4% had hypocalcemia, 25.4% hypophosphatemia, and 13.3% (n = 17) 25-OH vitamin D levels <10 ng/mL. All patients were clinically asymptomatic. Mean calcium concentrations were found to be significantly lower among the study population (2.41 mmol/L) compared with healthy controls (2.53 mmol/L). Lowest mean concentration was observed in patients treated with sulthiame followed by oxcarbazepine and valproic acid. No influence of calcium intake or therapy on bone metabolism was noted. Effects on bone metabolism of anticonvulsive monotherapy are not restricted to neurologically impaired children but also affect otherwise healthy children.

Magnetic resonance imaging of the brain in children with headache: the clinical relevance with modern acquisition techniques.

The aim of this study was to evaluate the frequency of abnormal findings in magnetic resonance imaging (MRI) in children with headache, the clinical relevance of these findings, and whether more sophisticated technologies also result in more relevant abnormal findings. The MRIs of 1004 children with age ranging from 1 to 17 years were retrospectively analyzed. Children who were investigated with established sequences (n = 419) were compared with those examined with state-of-the-art MRI acquisition technology (n = 585). In 216/1004 investigations, MRI was performed because of headache (74/216 with established sequences, 142/216 with state-of-the-art acquisition technology). In 114/216 (52.8%) patients with headache, the MRI was abnormal with relevant findings in 23/114 patients and findings without clinical relevance in 91/114 children. A higher incidence of abnormal findings than in previous reports was found but there was only limited clinical gain of information using modern sequences in children with headache.

Alice-in-Wonderland syndrome--a case-based update and long-term outcome in nine children.

PURPOSE: There are some reports of so-called Alice-in-Wonderland syndrome mostly concerning differential diagnosis, association with a variety of infectious diseases and even some case reports on functional imaging. Long-term data are rare. METHODS: Nine boys aged 6 to 11 years that had been diagnosed with Alice-in-Wonderland syndrome between 2003 and 2008 were contacted for a long-term follow-up study in summer, 2009, with a mean follow-up of 4.6 years. RESULTS: At the time of the follow-up study, all children were in good general and mental health. Symptoms of Alice-in-Wonderland syndrome had ceased within weeks or months. In two patients, episodes of metamorphopsia returned after a symptom-free latency of 3 years and 1 year, respectively. Five children had a family history of migraine or epilepsy. In one case, the father was reported to have experienced similar symptoms when he was a child. CONCLUSION: Our follow-up study shows that Alice-in-Wonderland is most likely a benign, self-terminating childhood condition, although occasional recurrences of symptoms are possible.

Facial palsy: etiology, outcome and management in children.

BACKGROUND: Currently there is much controversy whether to treat idiopathic facial palsy with corticosteroids with sparse data on the natural course of the disease in children. METHODS: We performed a prospective study on all children <15 years of age who were admitted to our unit for facial palsy between 1st July 1998 to 30th June 2008. All patients received a standardized work-up and follow-up. Therapy consisted of symptomatic treatment either with (in case of neuroborreliosis) or without a 14 day course of intravenous antibiotics. FINDINGS: 106 patients were included in our study. The calculated incidence for facial palsy was 21.1/100000/year for children <15 years. The incidence for neuroborreliosis (NB) in this age group was calculated to be 4.9/100000/year. The overall rate of complete recovery was 97.6% with significantly faster recovery in younger children and in patients with NB as compared to idiopathic facial palsy. Both patients with incomplete recovery were at least 14 years old and presented late in the course of the disease. CONCLUSION: Based on the rate of 97.6% spontaneous complete recovery we believe that the routine use of corticosteroids in children with facial palsy is not justified, unless there is new data from controlled trials in children.

Lack of efficacy of manual therapy in children and adolescents with suspected cervicogenic headache: results of a prospective, randomized, placebo-controlled, and blinded trial.

OBJECTIVE: Clinical trials concerning cervical spine manipulation and mobilization in children and adolescents with cervicogenic headache are lacking. METHODS: We performed a multicenter, prospective, randomized, placebo-controlled, and blinded trial in 52 children and adolescents (21 boys, 31 girls) aged 7-15. After prospective baseline documentation for 2 months patients were either assigned to placebo or true manipulation with another 2-month follow-up. Main outcome measures were defined as: percentage of days with headache, total duration of headache, days with school absence due to headache, consume of analgesics, intensity of headache. RESULTS: We did not find a significant difference comparing the groups with placebo and true manipulation with respect to the defined main outcome measures. CONCLUSIONS: We were not able to show an efficacy of cervical spine manipulation in 52 children and adolescents.

Prevalence of epileptiform discharges in healthy children--new data from a prospective study using digital EEG.

PURPOSE: Data on epileptiform electroencephalography (EEG) discharges in healthy children are limited, with published studies dating back more than 20 years. Moreover, analyses have been performed exclusively using paper-recorded EEG, and reported prevalences differ significantly. With recent reports using these data as reference suggesting an increased prevalence of epileptiform EEG discharges in children with behavioral disturbances, acquisition of exact prevalence data has become even more critical. The aim of our study was to analyze the frequency of epileptiform EEG discharges in healthy children using digitally recorded EEG (DEEG) and to compare these data to those of previously published studies. METHODS: Prospective analysis of DEEG was performed in 382 healthy children (226 male, 156 female) ages 6-13 years admitted to our hospital for minor head trauma. Recording was carried out for a minimum of 20 min including hyperventilation and photic stimulation. Analysis was carried out by two board-certified clinical neurophysiologists. RESULTS: Epileptiform EEG discharges were detected in 25 of 382 children (11 of 226 male, 14 of 156 female) corresponding to an overall prevalence of 6.5%. Of these 25 children, 4 had either generalized or bifrontal spikes, 12 showed constant localized focal discharges, and 9 showed multifocal discharges. Compared to previous studies using non-DEEG recording, the prevalence of epileptiform EEG discharges in our population was significantly higher. No significant difference was found when comparing our data to prevalences recently reported in children with behavioral disturbances using DEEG. CONCLUSIONS: Our study further highlights the urgent need to reevaluate the prevalence of epileptiform EEG discharges in healthy children using DEEG recordings in a large cohort.

Electroencephalographic evolution of hypsarrhythmia: toward an early treatment option.

PURPOSE: A retrospective study for a classification of prehypsarrhythmic elecroencephalographies (EEGs) was carried out to enable an early treatment option for West syndrome. METHODS: Out of 39 infants with symptomatic West syndrome, 18 infants (age 3-14 months) with 61 serial non-REM sleep EEG records of the prehypsarrhythmic phase were identified. The prehypsarrhythmic phase encompassed 2 to 13 months (mean 4.5 months) after an initial insult. A classification system of three EEG types corresponding to the clinical states prior to West syndrome occurrence was developed. In addition, follow-up of all patients presenting with type 2 EEGs (n = 22) was evaluated. RESULTS: Three clinical states and corresponding EEG types were classified. Clinical state 1 (weeks to months, silent phase) presented with (multi-)focal epileptic discharges <50% of the non-REM EEG recording time (type 1 EEG). Clinical state 2 (several weeks, beginning mental deterioration) was accompanied by type 2 EEG with bihemispheric epileptic discharges >50% of the non-REM EEG recording time within abnormal background activity (imminent hypsarrhythmia). Clinical state 3 (mental deterioration) was characterized by hypsarryhthmia. Interrater reliability of seven blinded raters was good (median weighted kappa 0.67). Out of 22 patients presenting with type 2 EEGs, two were lost for follow-up, and 16 developed West syndrome, whereas four were treated early with anti-epileptic drugs and remained stable. CONCLUSIONS: Infants with West syndrome could be reliably identified several weeks before the occurrence of hypsarrhythmia by a typical EEG pattern (type 2), thereby opening the way for early intervention studies.

Cardiovascular effects in adolescents while they are playing video games: a potential health risk factor?

We analyzed heart rate (HR), systolic and diastolic blood pressure (SBP, DBP), oxygen consumption, and carbon dioxide production in 17 male adolescents during a racing simulation video game (VG) and compared to resting state (RS) and exercise testing (ET) measures. We were able to demonstrate a significant (p<.005) increase from RS to VG concerning HR (+13.1 bpm), SBP (+20.8 mmHg), and DBP (+12.1 mmHg) with SBP and DBP elevations exceeding 2 SD in all children and 14/17 children, respectively. The energy consumption during VG (max 1.71 kcal/min) was unaltered compared to RS and significantly lower compared to ET even at the starting strain of 25 W (1.94 kcal/min). Hemodynamic parameters tested demonstrated lower HR, unchanged SBP, and higher DBP during the VG compared with ET. Comparing all measured parameters it can be said that the relation of blood pressure and energy consumption during VG might not be favorable.