Sticking to the script: Breast cancer patients' decision making regarding oral endocrine therapy.

OBJECTIVES: We sought to understand why some women with early-stage breast cancer decide to forgo or discontinue endocrine therapy (ET), and to identify factors that might lead to greater acceptance of, and long-term adherence to, this treatment. METHODS: We conducted in-depth interviews with N = 53 stage I-III HR+ women who were either non-initiators of ET, initiators who discontinued or initiators who continued with variable daily patterns of adherence. An inductive content analysis was performed to explore the decision-making process of women prescribed ET. RESULTS: Qualitative analyses revealed 55 themes that drove complex decision making. The initiators generally trusted their physicians and did little research before starting the medication. Non-initiators were more suspicious of the medical system, believing that ET presented more risks than benefits. Most discontinuers stopped ET because of side effects. Both non-initiators and discontinuers indicated that push-back from their physicians could have changed their decision. Stories and social support were important in decision making. CONCLUSIONS: Although ET can significantly reduce the risk of breast cancer recurrence, substantial barriers prevent many women from initiating or continuing it. PRACTICE IMPLICATIONS: Physicians have powerful influence over patients' decisions to initiate ET and can be important levers for motivating patients to persist.

An observational human laboratory assessment of nicotine delivery, vaping topography and subjective effects of usual brand electronic cigarette use among young adults.

AIMS: To measure nicotine delivery, vaping topography and subjective effects of current generations of disposable, cartridge-based and other types of electronic cigarettes (e-cigarettes) among young adults. DESIGN, SETTING, PARTICIPANTS: Observational, human laboratory assessment of e-cigarette use in Columbus, Ohio, USA (July 2020 to June 2021). Participants (n = 96, 60.4% female, age mean = 21.7 [standard deviation = 1.7] years, 82.4% white race) were identified via their participation in a cohort study or other convenience sampling and were 18 to 25 years old, vaped ≥4 days/week for ≥4 weeks and used other tobacco products for ≤5 days of past 30 days. Participants completed a pre-vaping questionnaire, vaped their usual brand of e-cigarette ad libitum for 30 min and completed a post-vaping questionnaire. MEASUREMENTS: Outcome variables included pre- and post-vaping measures of plasma nicotine (t = 0 and t = 30, respectively) and craving and withdrawal symptoms, as well as vaping topography (e.g. flow rate and inter-puff interval), pre-vaping expectancies and post-vaping product appeal. Variables used to characterize the sample included demographics, e-cigarette and other tobacco use history, e-cigarette dependence and e-cigarette device characteristics (e.g. device type, flavor and nicotine form). FINDINGS: Participants reported moderate nicotine dependence on average via the E-Cigarette Dependence Scale (mean = 6.9 [standard deviation = 4.0]). Following 30 min of ad libitum vaping, participants achieved substantial plasma nicotine boost (mean = 18.8 [standard deviation = 14.5] ng/mL), corresponding with statistically significant decreases in withdrawal symptoms measured via the Minnesota Nicotine Withdrawal Scale (pre-vaping mean = 9.0 [standard deviation = 5.1], post-vaping mean = 4.3 [standard deviation = 3.9]; P-value <0.0001). Pre-vaping, participants reported moderate vaping expectancies (e.g. mean = 2.5 [standard deviation = 1.0] on a scale from 0 to 4 for smell and taste expectancies); post-vaping, participants reported high satisfaction (mean = 4.6 [standard deviation = 1.2] on a scale from 1 to 7) and moderate reward (mean = 2.9 [standard deviation = 1.2]) and respiratory sensations (mean = 3.7 [standard deviation = 1.6]). Nearly half of participants (47.9%) used disposable e-cigarettes, and most used a mint/menthol or fruit flavored (99.0%) and nicotine salt (98.9%) e-liquid. CONCLUSIONS: Among young adults in the United States, the latest generations of e-cigarettes appear to deliver large quantities of nicotine (similar to cigarettes) and significantly relieve withdrawal symptoms, and they are appealing.

The case of young people who use e-cigarettes infrequently: Who is this population? What becomes of them?

BACKGROUND: Emerging data indicate that many adolescents and young adults ("youth") engage in infrequent, or occasional, e-cigarette use. However, little is known about this population as they are often subsumed into the broader "any past-30-day use" category used to define youth "current use." This study aimed to focus on infrequent e-cigarette use by youth, examining its correlates and transitional outcomes. METHODS: Participants were from a prospective cohort study of youth (aged 15-24 at baseline). Among youth who had used e-cigarettes, we classified "infrequent use" as using e-cigarettes ≤5 days in the last 30 days (n=273) and "frequent use" as using e-cigarettes ≥6 days in the last 30 days (n=278). Descriptive statistics, Markov modeling, and logistic regression were utilized. RESULTS: By the 12-month follow-up, 76.8% of those using infrequently at baseline remained in the "infrequent use" category, 6.3% reported no recent use, and 16.8% had escalated to the "frequent use" category. Among the youth using infrequently at baseline, those who did (vs. did not) escalate to frequent use by follow-up had higher baseline nicotine dependence and were more likely to have family members who used tobacco. CONCLUSIONS: Infrequent e-cigarette use is extremely common, and often fairly stable, among young people. Prevention efforts must certainly attempt to reduce escalation and attend to both individual and interpersonal factors (e.g., nicotine dependence, family use). Yet prevention efforts must additionally attend to the case of continued infrequent use, given the high prevalence of people in this category and their regular exposure to e-cigarette harms.

Chemotherapy safe handling practices in Ethiopia: A comprehensive multi-center evaluation.

INTRODUCTION: The increasing incidence of cancer and capacity for cancer care in Ethiopia has led to an upsurge in chemotherapy use in the country; however, studies indicate that there is a gap in the safe handling of chemotherapy by healthcare workers. There exists a need to understand if such unsafe practices occur in Ethiopia and, if so, which areas along the chemotherapy life cycle need the most improvement. METHODS: This study utilized a multi-method design through an online survey administered to health care professionals and evaluative site visits of eight cancer units in Addis Ababa, Ethiopia to understand the current conditions of chemotherapy handling. In addition, a survey was conducted among Ethiopian health care professionals from across the country. RESULTS: Fifty-five percent of survey participants disagreed or strongly disagreed that there are systems in place to identify, prevent, and address chemotherapy hazards in their workplace, and 71% of respondents denied having an active and effective health and safety committee and/or worker health and safety representative where they work. At evaluative site visits, only 30% of health care workers met the minimum guidelines for proper hand hygiene, and 20% of health care workers used adequate Personal Protective Equipment according to guidelines across the chemotherapy lifecycle. CONCLUSIONS: Results of this study indicate an urgent need for implementation of evidence-based interventions to improve chemotherapy handling in Ethiopia so that all patients and health care workers are protected from the hazardous toxicities of these drugs.

An evaluation of the cost-effectiveness of population genetic screening for familial hypercholesterolemia in US patients.

BACKGROUND AND AIMS: Familial hypercholesterolemia is an underdiagnosed genetic metabolic condition limiting the clearance of low-density lipoprotein cholesterol and increasing lifetime risk of cardiovascular disease. Population genetic screening in unselected individuals could quickly identify cases of familial hypercholesterolemia and enable early prevention, but the economic impact of widespread screening on patients has not been studied. METHODS: We assessed the cost-effectiveness of population genetic screening for familial hypercholesterolemia in 20 and 35-year-old adults in the United States from the perspective of patients. We developed a decision tree Markov hybrid model to examine diagnoses, cardiovascular disease, cardiac events, quality of life, and costs under population genetic screening compared to family-based cascade testing. RESULTS: While population genetic screening increased diagnoses and reduced incidence of cardiovascular disease, population genetic screening was not cost-effective compared to cascade testing at current levels of willingness to pay. Lower genetic testing costs, combined screening with other genetic conditions, and support to maintain lipid-lowering therapy use over time could improve the cost-effectiveness of population genetic screening. CONCLUSIONS: Future research is needed to examine how cost-sharing strategies may affect the cost-effectiveness of screening to patients and how families and providers experience the clinical and economic outcomes of population screening.

Nicotine information disclosed online by e-cigarette brands popular with young people.

INTRODUCTION: E-cigarette use is most prevalent among adolescents and young adults - and there are often misperceptions about product risk. The purpose of this study was to determine what nicotine information is provided on e-cigarette brand websites. METHODS: Based on national and local surveys, we identified 44 e-cigarette brands commonly used in the US by adolescents and young adults. For each of these brands, their associated websites were analyzed for disclosed nicotine information. Specifically, for each brand's website, we coded whether there was information on nicotine concentration (recorded if a numerical value was provided such as '5% nicotine'), nicotine form (free-base, nicotine salts, or not stated), and nicotine type (tobacco-derived, synthetically derived, or not stated). Coding allowed for both lay (e.g. 'nic salts') as well as scientific (e.g. 'isomers') terms. RESULTS: Of the 44 brands examined, all provided basic information on nicotine concentration (e.g. '5% nicotine'). However, 23% of brands did not disclose information on nicotine form (i.e. nicotine salt vs free-base), and 66% of brands did not disclose information on nicotine type (i.e. synthetic vs tobacco-derived). CONCLUSIONS: Overall, these results suggest that the e-cigarette industry is not fully informing its consumers about the nicotine in their products. Given that nicotine form and type have implications for e-cigarette addiction potential, these findings highlight a public health concern. There is a need for more comprehensive national regulations for mandating product constituents and emissions disclosures.

Challenges and opportunities for Lynch syndrome cascade testing in the United States.

Lynch syndrome is an underdiagnosed genetic condition that increases lifetime colorectal, endometrial, and other cancer risk. Cascade testing in relatives is recommended to increase diagnoses and enable access to cancer prevention services, yet uptake is limited due to documented multi-level barriers. Individual barriers such as feelings of fear, guilt, and anxiety and limited knowledge about Lynch syndrome as well as interpersonal barriers including complex family dynamics and language barriers limit family communication about Lynch syndrome and prevent uptake of genetic screening for relatives. Organizational and environmental barriers including a shortage of genetics professionals, high costs, and fears of discrimination also reduce cascade testing. These multi-level barriers may disproportionately impact underserved populations in the United States, such as individuals with lower incomes, limited English-speaking proficiency, lower educational attainment, and inadequate access to health systems. Multi-level facilitators of cascade testing include interpersonal support from family members, peers, and healthcare providers, educational resources, and motivation to improve family health. Taken together, these barriers and facilitators demonstrate a need for interventions and strategies that address multi-level factors to increase cascade testing in families with Lynch syndrome and other hereditary cancer conditions. We provide an example of a cascade testing intervention that has been developed for use in individuals diagnosed with Lynch syndrome and discuss the variety of current approaches to addressing these multi-level barriers.

Measuring Costs of Cardiovascular Disease Prevention for Patients with Familial Hypercholesterolemia in Administrative Claims Data.

INTRODUCTION: Familial hypercholesterolemia is a common genetic condition that significantly increases an individual's risk of cardiovascular events such as heart attack, stroke, and cardiac death and is a candidate for population-wide screening programs. Economic analyses of strategies to identify and treat familial hypercholesterolemia are limited by a lack of real-world cost estimates for screening services and medications for reducing cardiovascular risk in this population. METHODS: We estimated the cost of lipid panel testing in patients with hyperlipidemia and the cost of statins, ezetimibe, and PCKS9 inhibitors in patients with familial hypercholesterolemia from a commercial claims database and report costs and charges per panel and prescription by days' supply. RESULTS: The mean cost for a 90-day supply for statins was $183.33, 2.3 times the mean cost for a 30-day supply at $79.35. PCSK9 inhibitors generated the highest mean costs among medications used by patients with familial hypercholesterolemia. CONCLUSIONS: Lipid testing and lipid-lowering medications for cardiovascular disease prevention generate substantial real-world costs which can be used to improve cost-effectiveness models of familial hypercholesterolemia screening and care management.

Development of Porcine Accessory Sex Glands.

Accessory sex glands are recognized as targets of human disease and may have roles in reproductive success in livestock. The current experiments evaluated the influences of endogenous steroids on the development of porcine accessory sex glands, primarily in the neonatal period. When the aromatase inhibitor, letrozole, was used to inhibit the production of endogenous estrogens in the postnatal interval, growth of the seminal vesicles, prostate, and bulbourethral glands was stimulated. The weights of seminal vesicles, prostate, and bulbourethral glands approximately doubled at 6.5 weeks of age when the reduction in endogenous estrogens began at 1 week of age (p < 0.01). However, by 20 and 40 weeks of age, the weights of accessory sex glands were similar between the letrozole-treated boars and the vehicle-treated littermates indicating the growth stimulation was a transient effect when the treatment interval was short. The presence of both classical nuclear estrogen receptors and the G protein-coupled estrogen receptor in neonatal accessory sex glands indicated multiple signaling pathways might mediate the growth inhibition by endogenous estrogens. The absence of a detectable response when the classical estrogen receptors were blocked with fulvestrant (or when the androgen receptor was blocked with flutamide) suggests that endogenous estrogens act through the G protein-coupled estrogen receptor to inhibit the development of accessory sex glands during this neonatal to early juvenile interval.

Nicotine dependence among undergraduates who use nicotine salt-based e-cigarettes.

OBJECTIVE: This study examined the relationship between use patterns of a popular e-cigarette brand using nicotine salts, JUUL, and symptoms of nicotine dependence in a college cohort. PARTICIPANTS: Data for this study came from a prospective cohort of undergraduate students at a large Midwestern university from 2018 to 2019. METHODS: Among participants who had ever tried a JUUL (N = 411), univariate and multivariable logistic regression were used to test the associations between use frequency (past 30-day use) and quantity (time to finish a pod) and nicotine dependence at follow up. RESULTS: In the multivariable models, both frequency of use and quantity of use were associated with subsequent nicotine dependence, based on most indicators of dependence. CONCLUSIONS: As salt-based nicotine is now present in the most popular e-cigarette brands used by young people, such findings inform our contemporary understanding of e-cigarettes' addictive potential and can help inform campus-based interventions.

Demographic and Behavioral Differences Between Adolescents and Young Adults Who Use E-Cigarettes at Low and High Frequency.

BACKGROUND: Among adolescents and young adults (AYAs), "current use" of electronic cigarettes (e-cigarettes) is commonly defined as any use in the past 30 days. However, few studies have examined differences among those within this broad category. This study examined characteristics of AYAs who used e-cigarettes at a low frequency (within the last 3 months but <6 days out of the past 30 days) and those who used e-cigarettes at a high frequency (6+ days out of the past 30 days). METHODS: We conducted cross-sectional analyses among 551 Ohio AYAs (15- to 24-year-olds) who reported using an e-cigarette to vape nicotine in the past 3 months. We used descriptive statistics and logistic regression to characterize those using e-cigarettes at a low frequency and a high frequency. RESULTS: Among our sample of AYAs who reported past 3-month e-cigarette use, about half (50.8%) reported using an e-cigarette 6 or more days out of the past 30 days (ie, high frequency). In the multivariable analysis, reported nicotine dependence (Odds Ratio [OR]: 7.0, 95% CI: 4.8, 10.3) and current other tobacco product use (OR: 1.8, 95% CI: 1.1, 2.9) were associated with high-frequency e-cigarette use. CONCLUSION: Our results suggest that frequency of use is an important characteristic in understanding AYA e-cigarette use. Any use in the past 30 days may not be sensitive enough to understand dependence and tobacco-use behaviors. Further characterizing "current" e-cigarette use by frequency of use may provide meaningful information for public health professionals to better target intervention and cessation efforts to AYAs.

What do young people know about the nicotine in their e-cigarettes?

INTRODUCTION: In recent years, the nicotine in e-cigarettes has been available in either a 'free-base' (unprotonated) or 'nicotine salt' (protonated) form. Additionally, e-cigarette nicotine can be either 'synthetic' or 'tobacco-derived'. These dimensions of nicotine have implications for nicotine absorption, bioavailability and sensory experiences. However, it is unclear if the young people using e-cigarettes are aware of these nicotine dimensions. METHODS: Data came from a cohort of Ohio youth (aged 15-24) who reported using an e-cigarette in the past 4 months (N=271). Participants were enrolled and provided background information in 2021; their 12-month follow-up survey asked about the presence, form and type of nicotine in their usual e-cigarette. Individuals who reported that they could distinguish between tobacco-derived and synthetic nicotine were additionally asked to describe the difference. RESULTS: Of the 247 youth who reported that there was nicotine in their usual e-cigarette, 71.7% did not know whether it was free-base or nicotine salt and 75.7% did not know whether it was synthetic or tobacco-derived. Awareness was higher among youth who were using e-cigarettes at a greater frequency and quantity. The majority reported that they could not detect a difference between the experience of using synthetic vs tobacco-derived nicotine. CONCLUSIONS: These findings indicate the generally limited awareness about nicotine among youth who used e-cigarettes. Improvements in health communications and requirements for e-cigarette industry disclosures are necessary to ensure that consumers are better informed about the dimensions-and the risks-of the nicotine they are consuming.

Perceptions of oral nicotine pouches & their marketing among Ohio Appalachia smokers and smokeless tobacco users.

BACKGROUND: Oral nicotine pouches (ONPs) are novel products, gaining popularity and marketed as "tobacco-free" alternatives to cigarettes and smokeless tobacco (SLT), but their public health impact is unknown. This study qualitatively examined ONP appeal and perceptions among cigarette smokers and SLT users from Ohio Appalachia. METHODS: In 2022, we conducted 10 virtual focus groups with smokers (n = 19) and smokeless tobacco users (n = 18) from Appalachia Ohio aged ≥21 to examine perceptions of risks and benefits, substitutability for cigarettes and SLT, and ONP marketing. We transcribed focus groups verbatim, thematically coded transcripts, and analyzed coded data for prominent themes. RESULTS: Participants perceived ONPs to have similar or less risk than cigarettes/SLT but prominently discussed gastrointestinal and cardiovascular risks. Addiction risk was thought to be comparable to cigarettes/SLT, citing "nicotine is nicotine." Participants viewed ONPs to be situational rather than complete substitutes for cigarettes/SLT, viewing them as "cleaner," more socially acceptable, and discrete. Despite appealing features of ONP marketing, participants surmised ads would appeal to youth, new users, tobacco users seeking to cut down/quit, or to "high class," "white-collar" demographics. CONCLUSIONS: Participants' perceptions of ONPs and their marketing suggest ONPs are more likely to be used as situational versus complete substitutes for cigarettes and SLT. While situational substitution could exacerbate disparities in Appalachia by facilitating more frequent tobacco/nicotine use, complete substitution could reduce disparities. Research is needed to understand how perceptions, the appeal of ONP marketing, and novel product features translate to patterns of use to understand ONPs' potential impact.

Genetic Testing and Other Healthcare Use by Black and White Individuals in a Genomic Sequencing Study.

INTRODUCTION: Early adopters play a critical role in the diffusion of medical innovations by spreading awareness, increasing acceptability, and driving demand. Understanding the role of race in the context of other characteristics of potential early adopters can shed light on disparities seen in the early implementation of genomic medicine. We aimed to understand the association between self-identified race and individual experience with genetic testing outside of the research context. METHODS: We assessed factors associated with the odds of having ever received genetic testing prior to enrollment in a genomic sequencing study among 674 self-identified white and 407 self-identified African, African American, or Afro-Caribbean ("Black") individuals. RESULTS: Controlling for individual determinants of healthcare use (demographics, personality traits, knowledge and attitudes, and health status), identifying as Black was associated with lower odds of prior genetic testing (OR = 0.43, 95% CI [0.27-0.68], p < 0.001). In contrast, self-identified race was not associated with the use of non-genetic clinical screening tests (e.g., echocardiogram, colonoscopy). Black and white individuals were similar on self-reported personality traits tied to early adoption but differed by sociodemographic and resource facilitators of early adoption. CONCLUSION: Persistent racial disparities among early adopters may represent especially-entrenched disparities in access to and knowledge of genomic technologies in clinical settings.

Respiratory-Swallow Coordination in Individuals with Parkinson's Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Swallowing impairment, including altered physiology and aspiration, occur across the progression of Parkinson's disease (PD). The phase of respiration during which a swallow is initiated has been linked to swallowing impairment and aspiration in cohorts with dysphagia following stroke and head and neck cancer treatment, but has been understudied in PD. If similar findings are shown in individuals with PD, the implications for swallowing assessment and treatment are significant. OBJECTIVE: The aim of this systematic review and meta-analysis of literature was to examine respiratory-swallow coordination measures and potential implications on swallowing physiology in individuals with PD. METHODS: An extensive search of 7 databases (PubMed, EMBASE, Central, Web of Science, ProQuest Dissertations & Theses, Scopus, and CINAHL) with predetermined search terms was conducted. Inclusion criteria were individuals with PD and the use of objective evaluations of respiratory-swallow coordination. RESULTS: Of the 13,760 articles identified, 11 met the inclusion criteria. This review supports the presence of atypical respiratory swallow patterning, respiratory pause duration and lung volume at swallow initiation in individuals with PD. The meta-analysis estimated an occurrence of 60% of non-expiration-expiration and 40% of expiration-expiration respiratory phase patterns surrounding swallowing. CONCLUSION: Although this systematic review supports the occurrence of atypical respiratory-swallow coordination in individuals with PD, the evidence is limited by the variability in the methods of data acquisition, analysis, and reporting. Future research examining the impact of respiratory swallow coordination on swallowing impairment and airway protection using consistent, comparable, and reproducible methods and metrics in individuals with PD is warranted.

Factors Associated With Receipt of Molecular Testing and its Impact on Time to Initial Systemic Therapy in Metastatic Non-Small Cell Lung Cancer.

BACKGROUND: Despite recommendations for molecular testing irrespective of patient characteristics, differences exist in receipt of molecular testing for oncogenic drivers amongst metastatic non-small cell lung cancer (mNSCLC) patients. Exploration into these differences and their effects on treatment is needed to identify opportunities for improvement. PATIENTS AND METHODS: We conducted a retrospective cohort study of adult patients diagnosed with mNSCLC between 2011 and 2018 using PCORnet's Rapid Cycle Research Project dataset (n = 3600). Log-binomial, Cox proportional hazards (PH), and time-varying Cox regression models were used to ascertain whether molecular testing was received, and time from diagnosis to molecular testing and/or initial systemic treatment in the context of patient age, sex, race/ethnicity, and multiple comorbidities status. RESULTS: The majority of patients in this cohort were ≤ 65 years of age (median [25th, 75th]: 64 [57, 71]), male (54.3%), non-Hispanic white individuals (81.6%), with > 2 comorbidities in addition to mNSCLC (54.1%). About half the cohort received molecular testing (49.9%). Patients who received molecular testing had a 59% higher probability of initial systemic treatment than patients who were yet to receive testing. Multiple comorbidity status was positively associated with receipt of molecular testing (RR, 1.27; 95% CI 1.08, 1.49). CONCLUSION: Receipt of molecular testing in academic centers was associated with earlier initiation of systemic treatment. This finding underscores the need to increase molecular testing rates amongst mNSCLC patients during a clinically relevant period. Further studies to validate these findings in community centers are warranted.

Examining trends in health care access measures among low-income adult smokers in Ohio: 2012-2019.

Smokers are more likely to be low-income with limited access to health services. Although Medicaid expansion under the Patient Protection and Affordable Care Act improved access to care for low-income adults, long-term trends in health care access among low-income smokers remain uncharacterized. The study evaluated changes in five access measures among low-income nonelderly (19-64) adults (N = 28976) across smoking status using pooled data from a statewide survey in Ohio covering pre- (i.e., 2012) and post-Medicaid expansion periods (2015, 2017, and 2019) guided by a comprehensive framework of health care access. We found improvements in some, but not all, health care access measures among low-income smokers in the post-Medicaid-expansion period compared to the pre-expansion period. Compared to 2012, the odds for unmet dental care needs declined in 2015 (aOR = 0.67, 95 % CI = 0.45-1.01), 2017 (aOR = 0.53, 95 % CI = 0.35-0.81), and 2019 (aOR = 0.65, 95 % CI = 0.40-1.05) (p trend < 0.001). Similarly, the odds for unmet other health care needs (i.e., medical exams and supplies) were lower in 2015 (aOR = 0.64, 95 % CI = 0.39-1.06), 2017 (aOR = 0.56, 95 % CI = 0.34-0.93), and 2019 (aOR = 0.47, 95 % CI = 0.27-0.83) (p trend < 0.001). Difficulty paying medical bills was also significantly lower in 2015 (aOR = 0.62, 95 % CI = 0.43-0.89), 2017 (aOR = 0.57, 95 % CI = 0.39-0.83) and 2019 (aOR = 0.57, 95 % CI = 0.37-0.87) (p trend < 0.001). While there was notable progress in measures of affordability (i.e., paying medical bills) as well as care availability and accommodation (i.e., unmet needs), there were no meaningful changes in the approachability of care (i.e., having a usual source of care).