Can the endometrioma be an obstacle to complete oocyte retrieval in IVF cycles? A retrospective study.

OBJECTIVE: The study aimed to evaluate the utility and safety of ancillary maneuvers during oocyte retrieval for patients with endometrioma that makes ovum pick-up hard due to poor ovarian surgical accessibility. PATIENTS AND METHODS: Cases of 251 women with ovarian endometriomas undergoing in vitro fertilization (IVF) in our infertility unit were retrospectively analyzed to evaluate the clinical IVF cycle outcomes after oocyte retrieval. Controls (n = 251) were age-matched women without endometriomas who underwent an uncomplicated oocyte retrieval. RESULTS: No statistically significant differences were observed between groups except for the number of oocytes retrieved, which was higher in the control group than in the group of women with endometrioma. On the contrary, there were no differences between the experimental groups in the fertilization rate and number of embryos, and neither were there in the pregnancy and live birth rate. Moreover, the surgical complications were infrequent and similar between the two analyzed groups. Accidental or voluntary endometrioma punctures were not accompanied by increases in the risk of a pelvic infection. CONCLUSIONS: In conclusion, patients with endometrioma can undergo high-performance oocyte recovery procedures thanks to safe accessory maneuvers during the ovum pick-up.

Obesity does not increase the risk of side effects and complications of egg retrieval: delaying oocyte retrieval in obese patients is not a good strategy.

OBJECTIVE: Obesity is one of the main concerns for public health and is becoming an increasingly widespread problem worldwide. Women are more likely to require a cesarean section and have a longer hospital stay after delivery. Excess body weight can interfere with ovulation and make it more difficult for embryos to implant in the uterus. A high body mass index (BMI) has controversial effects on the outcomes of medically assisted reproduction treatments (IVF) and, if careful counseling is not performed, medical-legal risks may be incurred. While some researchers argue that obesity does not particularly affect ART outcomes, other studies claim that a high BMI does not interfere with embryonic development. Both the American Society for Reproductive Medicine (ASRM) and the European Society of Human Reproduction and Embryology (ESHRE) has stated that there is no clear evidence supporting a BMI limit for IVF treatment and that each patient should be evaluated on an individual basis. The purpose of our study was to evaluate whether performing in vitro fertilization on these patients increases the risk of medical, surgical, and anesthetic complications of oocyte retrieval. PATIENTS AND METHODS: From January 2011 to December 2022, all patients with BMI higher than 25 were enrolled in the study (n=766). Complications and risks related to oocyte retrieval were evaluated, and patients were divided according to BMI groups. RESULTS: With the one-way ANOVA test, all groups were compared with the control group, and none showed statistically significant differences, only the number of produced embryos in the BMI group between 30-34.9 was lower and statistically significant. CONCLUSIONS: Only one study has analyzed these aspects, mainly focusing on the need for anesthesia drugs and any related complications, and the same author reported greater difficulty in performing oocyte retrieval. The same study recorded an increase in incomplete oocyte retrievals. Our work does not confirm any of these impressions.

Evaluation of the ideal vaginal Progesterone effectiveness doses for luteal support in embryo thawing cycles after endometrial preparation without using the GnRh analogue.

OBJECTIVE: Frozen-thawed embryo transfer (FET) cycles require the use of luteal phase support (LPS) for supporting implantation, endometrial and embryo maturity. Individualized LPS should be chosen according to the used endometrial preparation protocol. The aim of the study was to analyze the effectiveness of two different vaginal Progesterone doses for women who underwent FET cycle and the same endometrial preparation without using the GnRh analogue. PATIENTS AND METHODS: 607 women who underwent FET cycle were included in the study. 305 patients received luteal support with 600 mg/day vaginal Progesterone and 302 patients were treated with 800 mg/day of vaginal Progesterone. RESULTS: In the 800 mg/day group, the mean serum Progesterone concentration on the day of embryo transfer was higher than in the 600 mg group (14.00±6.18 ng/mL and 12.22±5.39, respectively, p < 0.001). Moreover, human chorionic gonadotrophin (hCG) positive and ongoing pregnancy rates were higher in the group of patients who received LPS with 800 mg/day of Progesterone than in the group of patients treated with 600 mg/day of Progesterone.  CONCLUSIONS: In patients undergoing FET cycles following endometrial preparation made without previously using the GnRh analogue, 800 mg doses of vaginal Progesterone as LPS improve reproductive outcomes.

Influence of COVID-19 Pandemic on Colorectal Cancer Presentation, Management and Outcome during the COVID-19 Pandemic.

The aim of the study was to investigate whether the COVID-19 pandemic and related measures had an influence on colorectal cancer (CRC) presentation, management, and outcomes; it was a retrospective monocentric study. CRC patients undergoing surgery during the COVID-19 pandemic (1 March 2020-28 February 2022) (group B) were compared with patients operated on in the previous two years (1 March 2018-29 February 2020) in the same unit (group A). The primary outcome was to investigate whether there were differences in concern regarding the stage at presentation, as a whole and after dividing groups based on cancer location (right colon cancer, left colon cancer, rectal cancer). Secondary outcomes included differences in the number of patients admitted from emergency departments and emergency surgeries between periods, and differences in the postoperative outcomes. A subanalysis within the pandemic group was conducted on the same outcomes, dividing the aforementioned group based on pandemic trends. Two hundred and eighty (280) were operated on during the study period: 147 in group A and 133 in group B. Stage at presentation was similar between groups; however, the subgroups analysis showed that in the pandemic group, the number of early-stage left colon cancer occurrences almost halves, yet not significantly. Emergency department referral was more common in group B (p-value: 0.003); in group B, they also had longer operations and there was a more frequent use of ostomy. No differences in the number of postoperative complications nor in the postoperative outcomes were found. Patients with CRC were more frequently referred through the emergency department during the COVID-19 pandemic and left-sided cancers appear to be generally diagnosed at a more advanced stage. Postoperative outcomes showed that high specialized colorectal units can deliver standard high-level treatment under high-pressure external conditions.

Using a generative adversarial network to generate synthetic MRI images for multi-class automatic segmentation of brain tumors.

Challenging tasks such as lesion segmentation, classification, and analysis for the assessment of disease progression can be automatically achieved using deep learning (DL)-based algorithms. DL techniques such as 3D convolutional neural networks are trained using heterogeneous volumetric imaging data such as MRI, CT, and PET, among others. However, DL-based methods are usually only applicable in the presence of the desired number of inputs. In the absence of one of the required inputs, the method cannot be used. By implementing a generative adversarial network (GAN), we aim to apply multi-label automatic segmentation of brain tumors to synthetic images when not all inputs are present. The implemented GAN is based on the Pix2Pix architecture and has been extended to a 3D framework named Pix2PixNIfTI. For this study, 1,251 patients of the BraTS2021 dataset comprising sequences such as T1w, T2w, T1CE, and FLAIR images equipped with respective multi-label segmentation were used. This dataset was used for training the Pix2PixNIfTI model for generating synthetic MRI images of all the image contrasts. The segmentation model, namely DeepMedic, was trained in a five-fold cross-validation manner for brain tumor segmentation and tested using the original inputs as the gold standard. The inference of trained segmentation models was later applied to synthetic images replacing missing input, in combination with other original images to identify the efficacy of generated images in achieving multi-class segmentation. For the multi-class segmentation using synthetic data or lesser inputs, the dice scores were observed to be significantly reduced but remained similar in range for the whole tumor when compared with evaluated original image segmentation (e.g. mean dice of synthetic T2w prediction NC, 0.74 ± 0.30; ED, 0.81 ± 0.15; CET, 0.84 ± 0.21; WT, 0.90 ± 0.08). A standard paired t-tests with multiple comparison correction were performed to assess the difference between all regions (p < 0.05). The study concludes that the use of Pix2PixNIfTI allows us to segment brain tumors when one input image is missing.

In patients with isthmocele undergoing IVF, the risk of ectopic pregnancy on the cesarean scar is reduced only if the ultrasound-guided transfer is performed on day 5 - A retrospective case-control study.

OBJECTIVE: The study aimed to demonstrate that the risk of Cesarean Scar Pregnancy (CSP) for patients with isthmocele decreases when the embryo transfer is performed on day 5 at the blastocyst stage. PATIENTS AND METHODS: From January 2014 to December 2021, 167 patients who previously had an IVF treatment and delivered by cesarean section, were selected. The isthmocele was found in 98 of them. Firstly, we evaluated whether the isthmocele increases the risk of CSP. Subsequently, we investigated the possible correlation between the risk of the CSP with the day of the embryo transfer. Hence, the selected patients were divided into two groups: Group A where the embryo transfer was performed at the cleavage stage on day 3 and Group B where the embryo was transferred at the blastocyst stage on day 5. RESULTS: The outcomes show that the isthmocele does not seem to increase the risk of CSP, while the embryo transfer on day 3 increases its rate. CONCLUSIONS: When the isthmocele is diagnosed, according to our results, an embryo transfer on day 5 at the blastocyst stage seems to minimize the risk of the CSP.

The abortion rate in trans-myometrial eggs retrieval is the same as in classical transvaginal retrieval.

OBJECTIVE: This study compares the miscarriage rate of pregnancies after trans-myometrial eggs retrieval to transvaginal eggs retrieval. PATIENTS AND METHODS: In the period between January 2004 and December 2020, 13,323 egg retrievals were carried out. In 699 cases, the ovaries were unreachable. Alternative maneuvers were performed to solve this problem, but despite this, in 132 patients the technique of trans-myometrial sampling had to be used. 26 patients were excluded from the study, because of the inclusion criteria, and therefore two groups of 106 patients were selected, Group A and Group B (control). RESULTS: In the comparison between the two groups, there were no statistically significant differences in abortion rates, pregnancy rates and complications after the technique. CONCLUSIONS: This study shows that the abortion rate in trans-myometrial oocyte retrieval does not change when compared to classic retrieval, despite the sampling needle completely crossing the myometrium. Furthermore, the pregnancy rate and the complication rate do not appear to have worsened with this technique.

Increased bioavailability of Vitamin D improved pregnancy outcomes in in vitro fertilization cycles, only in patients over 36 years: a cross-sectional study.

OBJECTIVE: Vitamin D (VitD) is a secosteroid hormone showing both antiproliferative and immunomodulatory effects. Its involvement in placental steroidogenesis and endometrial decidualization even plays a role in other gynecological functions, including assisted reproductive technology (ART). However, controversial data have been reported on its implication in pregnancy outcomes during In Vitro Fertilization (IVF) programs. In order to elucidate the VitD role in ART success, we evaluated serum and follicular fluid (FF) VitD levels in infertile women concerning the pregnancy rate. PATIENTS AND METHODS: In our IVF center, 446 patients, under the age of 42 years old,  were evaluated in the period between January 2018 and December 2019. It is here important to clarify that, in order to respect the exclusion criteria, only 103 of them were enrolled for the study concerning the VitD evaluation in serum and follicular fluid at the time of the egg retrieval. This took place both in 34 pregnant patients (Group 1) and 69 non-pregnant ones (Group 2). Furthermore, the collection of these data gave us the opportunity to assess a possible correlation between the VitD levels and the achievement of pregnancy in the performed IVF cycles. RESULTS: The studied group included 103 eligible women. The average age for Group 1 was 33.12 ± 3.72 yrs whereas 33.72+3.99 yrs (p=0.467) for Group 2. The main differences were observed concerning follicle numbers of 17-21 mm (p=0.0043), the number of retrieved oocytes (p=0.0207), as well as the number of mature oocytes (p=0.0233) among the different groups. Different reference ranges, established according to the pregnancy outcomes, revealed that pregnant women with >36 yrs showed significantly higher levels of VitD. CONCLUSIONS: Increased serum and FF-VitD levels in women undergoing IVF with age ≥36 yrs, were significantly associated with a favorable outcome to achieve and carry on with the pregnancy.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018.

BACKGROUND: This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS: A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS: All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS: The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Looking for Calcium Phosphate Composite Suitable to Study Osteoclast Endocytosis: Preliminary Observations.

One of the issues regarding in vitro study of bone resorption is the synthesis of a bone-like biomaterial forming a thin layer onto either glass or plastic. The synthesis of a bone-like material suitable for in vitro studies can be valuable both to investigate osteoclast differentiation, that in vivo proceeds within the local microenvironment of bone and to understand how its presence triggers activation of macrophages present in situ when bone is damaged (a scenario that can occur for example in case of bone fracture). Despite the intensive studies committed to recreate synthetic bone analogues, the most used substrates for in vitro studies on bone resorption are slices of bone or dentine. Therefore morphological investigations (i.e. fluorescence analysis and phase contrast) are strongly compromised due to the thickness of the bone analogue. In the present study, with the aim to guarantee a versatile (and easy to be made) substrate, that could be suitable to study cell adhesion and morphology by epifluorescence, phase contrast and TEM, we developed a biomaterial containing a calcium phosphate salt and type I collagen. This material (made specifically for in vitro studies) forms a very thin layer that allowed to merge the morphological information derived from phase-contrast and epifluorescence observation, making possible the observation of the interface between cell and matrix. Moreover the electron microscopy evaluation of the endocytosis performed on cell differentiated could be more suitable because sample does not need the process of demineralization.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice.

BACKGROUND: The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. METHODS: Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English-language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. RESULTS: This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. CONCLUSIONS: Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi-institutional prospective and adequately powered randomized trials.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations.

BACKGROUND: The present article has been written to convey concepts of anaesthetic care within the context of an Enhanced Recovery After Surgery (ERAS) programme, thus aligning the practice of anaesthesia with the care delivered by the surgical team before, during and after surgery. METHODS: The physiological principles supporting the implementation of the ERAS programmes in patients undergoing major abdominal procedures are reviewed using an updated literature search and discussed by a multidisciplinary group composed of anaesthesiologists and surgeons with the aim to improve perioperative care. RESULTS: The pathophysiology of some key perioperative elements disturbing the homoeostatic mechanisms such as insulin resistance, ileus and pain is here discussed. CONCLUSIONS: Evidence-based strategies aimed at controlling the disruption of homoeostasis need to be evaluated in the context of ERAS programmes. Anaesthesiologists could, therefore, play a crucial role in facilitating the recovery process.

Meta-analysis of the effect of goal-directed therapy on bowel function after abdominal surgery.

BACKGROUND: Intraoperative goal-directed therapy (GDT) was introduced to titrate intravenous fluids, with or without inotropic drugs, based on objective measures of hypovolaemia and cardiac output measurements to improve organ perfusion. This meta-analysis aimed to determine the effect of GDT on the recovery of bowel function after abdominal surgery. METHODS: MEDLINE, Embase, the Cochrane Library and PubMed databases were searched for randomized clinical trials and cohort studies, from January 1989 to June 2013, that compared patients who did, or did not, receive intraoperative GDT, and reported outcomes on the recovery of bowel function. Time to first flatus and first bowel motion, time to tolerate oral diet, postoperative nausea and vomiting, and primary postoperative ileus were included. RESULTS: Thirteen trials with 1399 patients were included in the analysis. GDT shortened the time to the first bowel motion (weighted mean difference (WMD -0·67, 95 per cent c.i. -1·23 to -0·11; P = 0·020) and time to tolerate oral intake (WMD -0·95, -1·81 to -0·10; P = 0·030), and reduced postoperative nausea and vomiting (risk difference -0·15, -0·26 to -0·03; P = 0·010). When only high-quality studies were included, GDT reduced only the time to tolerate oral intake (WMD -1·18, -2·03 to -0·33; P = 0·006). GDT was more effective outside enhanced recovery programmes and in patients undergoing colorectal surgery. CONCLUSION: GDT facilitated the recovery of bowel function, particularly in patients not treated within enhanced recovery programmes and in those undergoing colorectal operations.

Impact of a bladder scan protocol on discharge efficiency within a care pathway for ambulatory inguinal herniorraphy.

BACKGROUND: Postoperative urinary retention (POUR) is a common complication of ambulatory inguinal herniorraphy, with an incidence reaching 38%, and many surgeons require patients to void before discharge. This study aimed to assess whether the implementation of a bladder scan-based voiding protocol reduces the time until discharge after ambulatory inguinal herniorraphy without increasing the rate of POUR. METHODS: As part of a perioperative care pathway, a protocol was implemented to standardize decision making after elective inguinal hernia repair (February 2012). Patients were assessed with a bladder scan, and those with <600 mL of urine were discharged home, whereas those with more than 600 mL of urine had an in-and-out catheterization before discharge. The patients received written information about urinary symptoms and instructions to present to the emergency department if they were unable to void at home. An audit of scheduled outpatient inguinal hernia repairs between October 2011 and July 2012 was performed. Comparisons were made using the t test, Fisher's exact test, and Wilcoxon rank sum test where appropriate. Statistical significance was defined a priori as a p value lower than 0.05. RESULTS: During the study period, 124 patients underwent hernia repair: 60 before and 64 after implementation of the protocol. The findings showed no significant differences in patient characteristics, laparoscopic approach (35 vs. 33%; p = 0.80), proportion receiving general anesthesia (70 vs. 73%; p = 0.67), or amount of intravenous fluids given (793 vs. 663 mL; p = 0.07). The proportion of patients voiding before discharge was higher after protocol implementation (73 vs. 89%; p = 0.02). The protocol had no impact on median time to discharge (190 vs. 205 min; p = 0.60). Only one patient in each group presented to the emergency department with POUR (2%). CONCLUSION: After ambulatory inguinal herniorraphy, implementation of a bladder scan-based voiding protocol did not result in earlier discharge. The incidence of POUR was lower than reported in the literature.

Human exposure to lead, cadmium and mercury through fish and seafood product consumption in Italy: a pilot evaluation.

The presence of selected toxic heavy metals, such as cadmium (Cd), lead (Pb) and mercury (Hg), was investigated in fish and seafood products, namely, blue mussel, carpet shell clam, European squid, veined squid, deep-water rose shrimp, red mullet, European seabass, gilthead seabream, Atlantic cod, European hake, Atlantic bluefin tuna and swordfish so as to assess their human exposure through diet. Metals were detected by quadrupole inductively coupled plasma mass spectrometry (Q-ICP-MS) and hydride generation atomic absorption spectrometry (Hg-AAS). Measurements of Cd, Pb and Hg were performed by means of analytical methods validated in compliance with UNI CEI EN ISO/IEC 17025 [2005. General requirements for the competence of testing and calibration laboratories. Milano (Italy): UNI Ente Nazionale Italiano di Unificazione]. The exposure assessment was undertaken matching the levels of Cd, Pb and total Hg with consumption data related to fish and seafood products selected for this purpose. In order to establish human health implications, the estimated weekly intakes (EWIs) for Cd, Pb and Hg were compared with the standard tolerable weekly intakes (TWI) for Cd and provisional tolerable weekly intakes (PTWIs) for Pb and Hg stipulated by the European Food Safety Authority (EFSA) and the Food and Agriculture Organization/World Health Organization (FAO/WHO) Joint Expert Committee on Food Additives (JECFA). The found metal concentrations were largely below the maximum levels (MLs) established at the European Union level with the exception of Cd. This metal exceeded the MLs in squid, red mullet, European hake and Atlantic cod. Squid and blue mussel showed the highest Pb concentrations which accounted for 60% and 10% of the MLs, respectively. Highest Hg levels were found in predatory fish. The concentrations of Hg in swordfish, Atlantic bluefin tuna and red mullet accounted for 50%, 30% and 30% of the MLs, respectively. The EWIs for Cd, Pb and Hg related to the consumption of fish and seafood products by the median of the Italian total population accounted for 20%, 1.5% and 10% of the standard TWI for Cd as well as PTWIs for Pb and Hg, respectively. Furthermore, the EWIs estimated using consumption data concerning Italian consumers did not exceed the standard TWI and PTWIs, except for Cd at 95th percentile.

Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial.

BACKGROUND: This study was undertaken to determine the impact of an intrathecal mixture of bupivacaine and morphine, when compared with systemic morphine, on the quality of postoperative analgesia and other outcomes in the context of the enhanced recovery after surgery (ERAS) programme for laparoscopic colonic resection. METHODS: Fifty patients undergoing general anaesthesia were randomly allocated to receive either a spinal mixture of bupivacaine and morphine followed by oral oxycodone (spinal group) or patient-controlled analgesia (PCA group). The primary outcome was consumption of opioids during the first three postoperative days. Secondary outcomes were pain scores, return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay. RESULTS: Postoperative opioid consumption in the spinal group was significantly less over the first three postoperative days (P<0.001). The quality of analgesia at rest in the first 24 h was better in the spinal group (P<0.005). Excessive sedation and respiratory depression were reported in two elderly patients with spinal analgesia. There were no differences between the two groups in other outcomes (return of bowel function and dietary intake, readiness to hospital discharge, and length of hospital stay). CONCLUSIONS: When ERAS programme is used for laparoscopic colonic resection, an intrathecal mixture of bupivacaine and morphine was associated with less postoperative opioid consumption, but has no other advantages over systemic opioids.

Fast-track surgery: it is time for the anesthesiologist to get involved!

Fast-track methodology has been developed with the aim of improving postoperative recovery and reducing perioperative morbidity and mortality. A multidisciplinary approach involving surgeons, anesthesiologists, nurses and physiotherapists is necessary. While the surgical community has revised many of the standard principles used in clinical practice, anesthesiologists still need to contribute more to further optimize and facilitate recovery after surgery.

Anesthetic and adjunctive drugs for fast-track surgery.

With the changes in health care dictated by economic pressure, there has been a realization that hospital stay could be shortened without compromising quality of care. Advances in surgical technology and anesthetic drugs have made an impact in the way perioperative care is delivered with some emphasis on multidisciplinary approach. From the expansion of ambulatory care, lessons were learnt how to apply same concepts to major surgery with the understanding that interventions to attenuate the surgical stress would facilitate the return to "baseline". Beside minimal invasive approach to surgery, anesthesia interventions are arranged with the intent to decrease the negative effects of surgical stress and pain, to minimize the side effects of drugs and at the same time to facilitate the recuperation which follows after surgery. Fast-track or accelerated care encompasses many aspects of anesthesia care, not only preoperative preparation and prehabilitation, but intraoperative attenuation of surgical stress and postoperative rehabilitation. The anesthesiologist is part of this team with the specific mission to use medications and techniques which have the least side effects on organ functions, provide analgesia which in turn facilitates the intake of food and mobilization out of bed. This chapter has been conceived with the intention to direct the clinician towards procedure-specific protocols where the choice of medications and techniques is based on published evidence. The success of implementing fast-track depends more on dynamic harmony amongst the various participants (surgeons, anesthesiologists, nurses, nutrtionists, physiotherapists) than on reaching an optimum level of excellence at each separate organization level.