Bleeding Control Protections Within US Good Samaritan Laws.

INTRODUCTION: In the United States, all 50 states and the District of Columbia have Good Samaritan Laws (GSLs). Designed to encourage bystanders to aid at the scene of an emergency, GSLs generally limit the risk of civil tort liability if the care is rendered in good faith. Nation-wide, a leading cause of preventable death is uncontrolled external hemorrhage. Public bleeding control initiatives aim to train the public to recognize life-threatening external bleeding, perform life-sustaining interventions (including direct pressure, tourniquet application, and wound packing), and to promote access to bleeding control equipment to ensure a rapid response from bystanders. METHODS: This study sought to identify the GSLs in each state and the District of Columbia to identify what type of responder is covered by the law (eg, all laypersons, only trained individuals, or only licensed health care providers) and if bleeding control is explicitly included or excluded in their Good Samaritan coverage. RESULTS: Good Samaritan Laws providing civil liability qualified immunity were identified in all 50 states and the District of Columbia. One state, Oklahoma, specifically includes bleeding control in its GSLs. Six states - Connecticut, Illinois, Kansas, Kentucky, Michigan, and Missouri - have laws that define those covered under Good Samaritan immunity, generally limiting protection to individuals trained in a standard first aid or resuscitation course or health care clinicians. No state explicitly excludes bleeding control from their GSLs, and one state expressly includes it. CONCLUSION: Nation-wide across the United States, most states have broad bystander coverage within GSLs for emergency medical conditions of all types, including bleeding emergencies, and no state explicitly excludes bleeding control interventions. Some states restrict coverage to those health care personnel or bystanders who have completed a specific training program. Opportunity exists for additional research into those states whose GSLs may not be inclusive of bleeding control interventions.

Descriptive Analysis of Clinical Encounters by Emergency Medical Services Physicians Using the RE-AIM Framework.

CONTEXT: Emergency medical services (EMS) medicine continues to expand and mature as a recognized subspeciality within emergency medicine. In the United States, EMS physicians historically supported training, protocol development, and EMS clinician credentialing. In the past, only limited programs existed in which prehospital physicians were engaged in the direct and routine care of prehospital patients; however, a growing number of EMS programs are recognizing the value and impact of direct EMS physician involvement in prehospital patient care. PROGRAM: A large suburban, volunteer-based EMS agency implemented a volunteer prehospital physician program where providers routinely responded to emergency calls for service. IMPLEMENTATION: Beginning in November 2019, a cadre of board-certified physicians completed a field preceptorship and local protocol orientation. Once complete, the physicians were released to function and respond independently to high acuity emergency calls or any call at their discretion. Prehospital physicians were authorized to utilize their full scope of practice and expected to provide field mentorship to traditional prehospital clinicians. EVALUATION: This study systematically evaluated a prehospital physician program for public health relevance, sustainability, and population health impact using the RE-AIM framework. A retrospective descriptive analysis was performed on the role and responses by a cohort of prehospital physicians using dispatch data and electronic medical records. DISCUSSION: Over the 17-month study period, 9 prehospital physicians responded to 482 calls, predominately cardiac arrests, traumatic injuries, and cardiac/chest pain. The physicians performed 99 procedures and administered 113 medications. Ultimately, the program added physician-level care to the prehospital setting in an ongoing and sustainable way. The routine placement of physicians in the prehospital environment can help benefit patients by enhancing access to advanced clinical knowledge and skills, while also benefiting EMS clinicians through opportunities for enhanced patient-side training, education, and medical control.

Enhancing Artificial Intelligence for Twitter-based Public Discourse on Food Security During the COVID-19 Pandemic.

OBJECTIVE: Food security during public health emergencies relies on situational awareness of needs and resources. Artificial intelligence (AI) has revolutionized situational awareness during crises, allowing the allocation of resources to needs through machine learning algorithms. Limited research exists monitoring Twitter for changes in the food security-related public discourse during the COVID-19 pandemic. We aim to address that gap with AI by classifying food security topics on Twitter and showing topic frequency per day. METHODS: Tweets were scraped from Twitter from January 2020 through December 2021 using food security keywords. Latent Dirichlet Allocation (LDA) topic modeling was performed, followed by time-series analyses on topic frequency per day. RESULTS: 237,107 tweets were scraped and classified into topics, including food needs and resources, emergency preparedness and response, and mental/physical health. After the WHO's pandemic declaration, there were relative increases in topic density per day regarding food pantries, food banks, economic and food security crises, essential services, and emergency preparedness advice. Threats to food security in Tigray emerged in 2021. CONCLUSIONS: AI is a powerful yet underused tool to monitor food insecurity on social media. Machine learning tools to improve emergency response should be prioritized, along with measurement of impact. Further food insecurity word patterns testing, as generated by this research, with supervised machine learning models can accelerate the uptake of these tools by policymakers and aid organizations.

Reexamining Health-Care Coalitions in Light of COVID-19.

The national response to the coronavirus disease 2019 (COVID-19) pandemic has highlighted critical weaknesses in domestic health care and public health emergency preparedness, despite nearly 2 decades of federal funding for multiple programs designed to encourage cross-cutting collaboration in emergency response. Health-care coalitions (HCCs), which are funded through the Hospital Preparedness Program, were first piloted in 2007 and have been continuously funded nationwide since 2012 to support broad collaborations across public health, emergency management, emergency medical services, and the emergency response arms of the health-care system within a geographical area. This commentary provides a SWOT (strengths, weaknesses, opportunities, and threats) analysis to summarize the strengths, weaknesses, opportunities, and threats related to the current HCC model against the backdrop of COVID-19. We close with concrete recommendations for better leveraging the HCC model for improved health-care system readiness. These include better evaluating the role of HCCs and their members (including the responsibility of the HCC to better communicate and align with other sectors), reconsidering the existing framework for HCC administration, increasing incentives for meaningful community participation in HCC preparedness, and supporting next-generation development of health-care preparedness systems for future pandemics.

Insomnia predicts treatment engagement and symptom change: a secondary analysis of a web-based CBT intervention for veterans with PTSD symptoms and hazardous alcohol use.

Posttraumatic Stress Disorder (PTSD) and hazardous drinking are highly comorbid, and often more severe than PTSD or hazardous drinking alone. Integrated, web-based interventions for PTSD/hazardous drinking may increase access to care, but have demonstrated equivocal results in reducing PTSD and hazardous drinking. One factor that may explain treatment engagement and symptom change is the presence of insomnia symptoms. The current study conducted secondary data analysis of a randomized controlled trial of an integrated web-based intervention for PTSD symptoms and hazardous drinking to examine insomnia symptoms as predictors of PTSD symptoms, alcohol use, and treatment engagement. In the parent study, 162 veterans in primary care reporting PTSD symptoms and hazardous drinking were randomized to receive either the intervention or treatment as usual. The current study examined insomnia among veterans who received the intervention (n = 81). Regression models tested baseline insomnia symptoms as predictors of treatment engagement, follow-up PTSD symptoms, and alcohol use. Hierarchical regression models tested change in insomnia during treatment as a predictor of follow-up PTSD symptoms and alcohol use. Results showed baseline insomnia predicted treatment engagement and follow-up drinking days, but not PTSD symptoms or heavy drinking days. Although overall change in insomnia was small, it predicted follow-up PTSD and heavy drinking days, but not drinking days. Results are consistent with previous research highlighting the importance of identifying and treating insomnia in the course of integrated treatment for PTSD/hazardous drinking. Future research should investigate how to best integrate insomnia, PTSD, and/or hazardous drinking interventions to maximize treatment engagement.

Factors Associated With Emergency Medical Services Providers' Acceptance of the Seasonal Influenza Vaccine.

OBJECTIVE: Influenza vaccination remains the most effective primary prevention strategy for seasonal influenza. This research explores the percentage of emergency medical services (EMS) clinicians who received the seasonal flu vaccine in a given year, along with their reasons for vaccine acceptance and potential barriers. METHODS: A survey was distributed to all EMS clinicians in Virginia during the 2018-2019 influenza season. The primary outcome was vaccination status. Secondary outcomes were attitudes and perceptions toward influenza vaccination, along with patient care behaviors when treating an influenza patient. RESULTS: Ultimately, 2796 EMS clinicians throughout Virginia completed the survey sufficiently for analysis. Participants were mean 43.5 y old, 60.7% male, and included the full range of certifications. Overall, 79.4% of surveyed EMS clinicians received a seasonal flu vaccine, 74% had previously had the flu, and 18% subjectively reported previous side effects from the flu vaccine. Overall, 54% of respondents believed their agency has influenza or respiratory specific plans or procedures. CONCLUSIONS: In a large, state-wide survey of EMS clinicians, overall influenza vaccination coverage was 79.4%. Understanding the underlying beliefs of EMS clinicians remains a critical priority for protecting these frontline clinicians. Agencies should consider practical policies, such as on-duty vaccination, to increase uptake.

Use of Big Data in Disaster Recovery: An Integrative Literature Review.

OBJECTIVE: Disasters of all varieties have been steadily increasing in frequency. Simultaneously, "big data" has seen explosive growth as a tool in business and private industries while opportunities for robust implementation in disaster management remain nascent. To more explicitly ascertain the current status of big data as applied to disaster recovery, we conducted an integrative literature review. METHODS: Eleven databases were searched using iteratively developed keywords to target big data in a disaster recovery context. All studies were dual-screened by title and abstract followed by dual full-text review to determine if they met inclusion criteria. Articles were included if they focused on big data in a disaster recovery setting and were published in the English-language peer-reviewed literature. RESULTS: After removing duplicates, 25,417 articles were originally identified. Following dual title/abstract review and full-text review, 18 studies were included in the final analysis. Among those, 44% were United States-based and 39% focused on hurricane recovery. Qualitative themes emerged surrounding geographic information systems (GIS), social media, and mental health. CONCLUSIONS: Big data is an evolving tool for recovery from disasters. More research, particularly in real-time applied disaster recovery settings, is needed to further expand the knowledge base for future applications.

Haddon matrix analysis of medical preparedness for mass gathering music festivals.

Beginning in the 1960s as a tool to disaggregate complicated auto injuries, the Haddon matrix has evolved into a modern method of analyzing complex public health challenges. Throughout the United States and internationally, music festivals have become a rapidly growing and increasingly complex area of mass gathering medicine. Given the austere environment and inherent challenges of providing medical care during a music festival, we utilized a modified Haddon matrix. The objective is to assess the relevant human, physical, and sociocultural factors that impact these festivals throughout the pre-event, event, and post-event time periods. This will ensure an all-hazards preparedness approach to the historically high incidence of traumatic injuries and polysubstance abuse, coupled with modern challenges such as infectious diseases and acts of intentional violence.

The impact of COVID-19 on opioid treatment programs in the United States.

BACKGROUND: The COVID-19 pandemic had the potential to severely disrupt the delivery of methadone and buprenorphine, as social distancing and other public health regulations made in-person services difficult to maintain. Federal and state regulators changed requirements regarding the dispensing of medication and in-person counseling at opioid treatment programs. Understanding staff and patient reactions to these changes can help determine whether they should be maintained. METHODS: We interviewed 25 directors of OTP programs located throughout the United States. Note takers wrote summaries of each interview which were coded for topics and themes covered in the interview guide, including changes to clinic practices, take-home medications, telehealth, patient and staff reactions to new COVID-related protocols, and financial concerns for programs. RESULTS: Most programs rapidly incorporated new regulatory requirements, and directors were generally positive about the impact of increased take-home doses of medication and increased reliance on telehealth. Some directors voiced concerns about these changes, and some reported that patients missed the daily clinical contact with staff. Directors also suggested that more time was needed to assess the full impact of these changes. Financial impacts varied, although many directors were quick to point out that the ongoing opioid epidemic has delivered a steady stream of new patients, thus offsetting potential financial losses. CONCLUSIONS: Overall, this study demonstrated the generally positive view of OTP directors to the regulatory changes necessitated by the COVID-19 pandemic. More time is needed to fully evaluate the impact of these changes on clinical outcomes.

Digital Strategies to Improve Food Assistance in Disasters: A Scoping Review.

OBJECTIVE: Modern digital strategies, including Internet of Things, machine learning, and mobile applications, have revolutionized situational awareness during disaster management. Despite their importance, no review of digital strategies to support emergency food security efforts has been conducted. This scoping review fills that gap. METHODS: Keywords were defined within the concepts of food assistance, digital technology, and disasters. After the database searches, PRISMA guidelines were followed to perform a partnered, 2-round scoping literature review. RESULTS: The search identified 3201 articles, and 26 articles met criteria and were included in the analysis. The data types used to describe the tools were text/opinion (42.3%), qualitative (23.1%), system architecture (19.2%), quantitative and qualitative (11.5 %), and quantitative (3.8%). The tools' main functions were Resource Allocation (41.7%), Data Collection and Management (33%), Interagency Communications (15.4 %), Beneficiary Communications (11.5%), and Fundraising (7.7%). The platforms used to achieve these goals were Mobile Application (36%), Internet of Things (20%), Website (20%), and Mobile Survey (8%); 92% covered the disaster response phase. CONCLUSIONS: Digital tools for planning, situational awareness, client choice, and recovery are needed to support emergency food assistance, but there is a lack of these tools and research on their effectiveness across all disaster phases.

Online Medication Assisted Treatment Education for Court Professionals: Need, Opportunities and Challenges.

INTRODUCTION: Although medication-assisted treatment (MAT) effectively treats opioid use disorders (OUD), MAT access is restricted in criminal justice (CJ) settings. Previous studies have documented that stigma and limited knowledge about MAT are prevalent among CJ court personnel. We describe development and pilot testing of an eLearning intervention to improve MAT knowledge and increase MAT referrals in Ohio courts. Methods: Building upon a nationwide survey conducted in 2011 of drug courts and informed by MAT opinions from judges who supervised OUD clients, we developed two eLearning MAT modules. Judges completed a brief online MAT knowledge-attitude scale (K-A) before, after, and at 3 months. Judges were asked about MAT referrals pretest and 3 months later. Results: Sixty-three judges expressed interest in the study, 25 completed the pretest and viewed the modules, 11 completed a 3 month posttest. At pretest, K-A scores were significantly (p<.05) lower for agonist medications than for extended-release naltrexone (XR-NTX; Vivitrol). K-A scores improved at posttest for agonist medications (p<.05) but declined to pretest levels three months later. Three months after the pretest, buprenorphine referrals increased from 2.6% to 9.7% (p<.05). There was no significant difference on K-A scores for agonist medication between the Ohio sample (at pretest) and the 2011 sample. Conclusion: Although there is some indication that eLearning may have strengthened knowledge gains and increased buprenorphine referrals, a more robust eLearning intervention will likely be required to increase court personnel participation and sustain eLearning knowledge gains. Recruiting and sustaining judges' participation in the study represented a significant study limitation.

Web-based cognitive behavior therapy for chronic pain patients with aberrant drug-related behavior: How did it work and for whom?

This study explored mediating pathways, moderating factors, and moderated mediation effects of a web-based, cognitive behavioral therapy (CBT) intervention for chronic pain patients with aberrant drug-related behavior (ADRB). In a 2-arm RCT, patients with chronic pain who screened positive for ADRB received treatment-as-usual (TAU, n = 55) or TAU plus a 12-week, web-based CBT intervention (n = 55). Assessments were conducted at weeks 4, 8, and 12, and at 1- and 3-months post intervention. Web-CBT significantly reduced pain catastrophizing, which, in turn, reduced pain interference and pain severity via a pathway of pain catastrophizing. Web-CBT also significantly reduced ADRB both directly and indirectly by reducing pain catastrophizing. For pain interference and pain severity, web-CBT was more effective than TAU for younger patients (≤ age 50). For pain severity, web-CBT was more effective for both younger patients (≤ age 50), and those with a lifetime substance use disorder. Findings suggest that web-CBT's positive impact on pain outcomes and ADRB are mediated by its effect on pain catastrophizing, and its treatment effects may be most robust for younger patients and those with histories of substance dependence.

An Analysis of After Action Reports From Texas Hurricanes in 2005 and 2017.

OBJECTIVE: To review and analyze After Action Reports from jurisdictions in Texas following Hurricanes Katrina and Rita in 2005 and Hurricane Harvey in 2017 in order to assess the utility of AARs as a quality improvement measurement tool. METHODS: The authors searched the Homeland Security Digital Library, the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange, and Google Scholar for any AARs that covered the response phase of at least one of the 3 hurricanes, mentioned the state of Texas, and suggested solutions to problems. The authors applied public health emergency management (PHEM) domains, as outlined by Rose et al, to frame the AAR analysis. AARs were coded by 2 reviewers independently, with a third acting as adjudicator. As an example, the problem statements in 2005 and 2017 AARs from 1 statewide agency were compared. RESULTS: Sixteen AARs met the inclusion criteria. There were 500 identified problem-solution sets mapped to a PHEM domain. The content was unevenly distributed, with most issues coming under PHEM 2: Policies, Plans, Procedures, and Partnerships at 45.2% in the 2005 hurricanes and 39.9% in 2017. AARs lacked consistent format and were often prepared by the response agencies themselves. Five consistent issues were raised in 2005 and again in 2017. These were volunteer management and credential verification, donations management, information sharing, appropriately identifying those requiring a medical needs shelter, and inadequate transportation to support evacuation. CONCLUSION: Because of the lack of objective data, inconsistent format, unevenly distributed content, and lack of adherence to any framework, AARs are fraught with shortcomings as a tool for PHEM. Inclusion of more objective reporting measures is urgently needed.

Applying the Haddon Matrix to Hospital Earthquake Preparedness and Response.

Since its 1960s origins, the Haddon matrix has served as a tool to understand and prevent diverse mechanisms of injuries and promote safety. Potential remains for broadened application and innovation of the matrix for disaster preparedness. Hospital functionality and efficiency are particularly important components of community vulnerability in developed and developing nations alike. Given the Haddon matrix's user-friendly approach to integrating current engineering concepts, behavioral sciences, and policy dimensions, we seek to apply it in the context of hospital earthquake preparedness and response. The matrix's framework lends itself to interdisciplinary planning and collaboration between social and physical sciences, paving the way for a systems-oriented reduction in vulnerabilities. Here, using an associative approach to integrate seemingly disparate social and physical science disciplines yields innovative insights about hospital disaster preparedness for earthquakes. We illustrate detailed examples of pre-event, event, and post-event engineering, behavioral science, and policy factors that hospital planners should evaluate given the complex nature, rapid onset, and broad variation in impact and outcomes of earthquakes. This novel contextual examination of the Haddon matrix can enhance critical infrastructure disaster preparedness across the epidemiologic triad, by integrating essential principles of behavioral sciences, policy, law, and engineering to earthquake preparedness.

Between- and within-person associations between opioid overdose risk and depression, suicidal ideation, pain severity, and pain interference.

BACKGROUND: To better understand overdose (OD) risk and develop tailored overdose risk interventions, we surveyed 234 opioid-using veterans residing in New York City, 2014-2017. Our aim was to better understand how predictors of OD may be associated with physical and mental health challenges, including pain severity and interference, depression and suicidal ideation over time. METHODS: Veterans completed monthly assessments of the Overdose Risk Behavior Scale (ORBS), pain severity and interference, suicidal ideation, and depression for up to two years and were assessed an average of 14 times over 611 days. To estimate between-person and within-person associations between time-varying covariates and opioid risk behavior, mixed-effects regression was used on the 145-person subsample of veterans completing the baseline and at least three follow-up assessments. RESULTS: The level of each time-varying covariate at the average of study time (between-person effect) was positively related to ORBS for pain severity and interference, suicidal ideation, and depression. Deviations from individuals' personal trajectories (within-person effect) were positively related to ORBS for pain severity and interference, suicidal ideation, and depression. CONCLUSIONS: US military veterans endure physical and mental health challenges elevating risk for opioid-related overdose. When pain severity, pain interference, suicidal ideation and depression were higher than usual, opioid risk behavior was higher. Conversely, when these health issues were less of a problem than usual, opioid risk behavior was lower. Assessing the physical and mental health of opioid-using veterans over time may support the development and implementation of interventions to reduce behaviors that increase the likelihood of overdose.

The immediate and lasting impact of Hurricane Sandy on pregnancy complications in eight affected counties of New York State.

BACKGROUND: The frequency and intensity of hurricane have increased greatly. However, whether hurricane exposure is associated with an increased risk of pregnancy complications is less known. OBJECTIVE: To assess the immediate impact and lasting impact of Hurricane Sandy (Sandy) on pregnancy complications. METHODS: Using time-series study, we estimated the relative risks (RRs) of emergency department (ED) visits for pregnancy complications in eight affected counties in New York State, based on data of 2005-2014. The immediate impact was estimated by comparing the ED visits of pregnancy complications during the Sandy period to the non-Sandy periods. For the lasting impact of Sandy, we estimated the RRs by contrasting the ED visits in the following 12 months after Sandy with the same months of other years. RESULTS: We found that ED visits for overall pregnancy complications increased 6.3% (95% confidence interval (CI): 2.2%, 10.5%) during the Sandy month. ED visits increased for threatened abortion (9.9%, 95% CI: 4.4%, 15.7%), threatened labor (10.1%, 95% CI: 1.9%, 18.9%), early onset of delivery (115.9%, 95% CI: 6.9%, 336.3%), renal disease (73.2%, 95% CI: 0.3%, 199.4%), and diabetes (42.3%, 95% CI: 15.0%, 76.0%). Gestational hypertension and renal disease were elevated 7-8 months after Sandy. The ED visits of mental illness increased gradually after Sandy and peaked eight months later with visits increasing 33.2%. CONCLUSIONS: This study suggests that hurricanes may impact pregnancy health immediately and that some negative health may last for months thereafter.

A pilot study comparing peer supported web-based CBT to self-managed web CBT for primary care veterans with PTSD and hazardous alcohol use.

OBJECTIVE: Many combat veterans struggle with posttraumatic stress disorder (PTSD) and hazardous alcohol use and are hesitant to engage in behavioral health services. Combining peer support with an eHealth intervention may overcome many barriers to care. This pilot study investigated the feasibility of adding peer support to a web-based cognitive behavior therapy (CBT) targeting PTSD symptoms and hazardous drinking, called Thinking Forward. METHOD: Thirty primary care patients with PTSD and hazardous alcohol use were randomized to receive Thinking Forward with or without peer support. Participants were assessed at pretreatment, posttreatment, and 24-week follow-up. Feasibility was analyzed with descriptive statistics. Preliminary outcomes were analyzed with multilevel modeling and effect sizes are presented. RESULTS: Peer support specialists can be feasibly trained to support the Thinking Forward intervention with good fidelity. Both participants and peers reported good satisfaction with the protocol; although peers discussed a mismatch between the philosophies of peer support and diagnostically focused CBT. All participants experienced significant improvements in PTSD, quality of life, resiliency, and coping from pre- to posttreatment, with no differences between conditions. Pretreatment patient activation predicted outcomes regardless of whether participants received peer support. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Peer support interventions to facilitate eHealth programs should strive to be consistent with the person-centered, recovery orientation of peer support, explicitly focus on patient activation, and consider characteristics of the patients, such as their level of problem recognition and willingness to engage in traditional behavioral health modalities. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Eye of the beholder: Risk calculators and barriers to adoption in surgical trainees.

BACKGROUND: Accurate risk assessment before surgery is complex and hampered by behavioral factors. Underutilized risk-based decision-support tools may counteract these barriers. The purpose of this study was to identify perceptions of and barriers to the use of surgical risk-assessment tools and assess the importance of data framing as a barrier to adoption in surgical trainees. METHODS: We distributed a survey and risk assessment activity to surgical trainees at four training institutions. The primary outcomes of this study were descriptive risk assessment practices currently performed by residents, identifiable influences and obstacles to adoption, and the variability of preference sets when comparing modified System Usability Scores of a current risk calculator to a purpose-built calculator revision. Risk calculator comparison responses were compared with simple and multivariable regression to identify predictors for preferentiality. RESULTS: We collected responses from 124 surgical residents (39% response rate). Participants endorsed familiarity with direct verbal communication (100%), sketch diagrams (87%), and brochures (59%). The most contemporary risk communication frameworks, such as best-worst case scenario framing (38%), case-specific risk calculators (43%), and all-procedure calculators (52%) were the least familiar. Usage favored traditional models of communication with only 26% of residents regularly using a strategy other than direct verbal discussion or anatomic sketch diagrams. Barriers limiting routine use included lack of electronic and clinical workflow integration. The mean modified System Usability Scores domain scores were widely dispersed for all domains, and no domain demonstrated one calculator's superiority over another. CONCLUSION: Risk assessment tools are underutilized by trainees. Of importance, preference sets of clinicians appear to be unpredictable and may benefit more from a customizable, bespoke approach.