The Impact of Get It? on Long-Acting Reversible Contraception Use Among Adolescents and Young Adults.

OBJECTIVE: Long-acting reversible contraceptives (LARCs) are the most effective contraceptive method to decrease pregnancy rates among adolescents and young adults (AYAs). Get It? (www.getitnobaby.com) is an innovative peer-based digital intervention that aims to increase LARC awareness and use among AYAs. The purpose of this study was to describe the impact of Get It? on LARC awareness and use among AYAs after exposure. METHODS: A randomized controlled trial was conducted between 2 different Baylor College of Medicine Teen Health Clinics. Using a block randomization method, clinics were randomized to either the intervention or control group by week. Baseline and post-intervention surveys were conducted in addition to a 6-month post-intervention chart review to determine the primary outcome of LARC uptake and secondary outcomes including other LARC-specific behaviors and LARC attitudes. RESULTS: A total of 233 AYAs agreed to participate in the study, of which 134 were randomized to the control group and 99 to the intervention group. Initiation of LARC discussion with the provider was significantly higher in the intervention group than in the control group. Additionally, LARC uptake within 6 months after study was almost significantly higher in the intervention group than in the control group. Finally, intervention group respondents exhibited strong positive attitudes toward Get It? with regard to specific intervention components. CONCLUSION: This study supports Get It? as a tool to educate and motivate AYA girls to use the most effective form of birth control available to them. The digital format of this novel peer-based approach also contributes to the potential of this educational intervention by decreasing barriers to both dissemination and uptake. We recommend a larger multi-institutional study to confirm these results and determine the most efficient method of dissemination to reach at-risk AYAs before coitarche.

Development of a Peer-Based Intervention Educating Teenagers about Long-Acting Reversible Contraception.

OBJECTIVE: Despite a decrease in teenage pregnancy rates in the United States in the past decades, teen pregnancy continues to be a considerable health issue. In this paper, we outline the development of our novel peer-based intervention, Get It?, that aims to increase awareness of and self-efficacy to use long-active reversible contraceptives (LARCs) among teenagers. METHODS: Peer narrative videos were created from audio recording semi-structured, one-on-one interviews with teenage LARC users. Focus groups of young women 19 years old and younger were conducted to choose the most audience-appropriate videos to be included in the final intervention. Using a thematic content analysis approach, transcripts of the audio recorded focus groups were reviewed and manually coded. RESULTS: The final layout of Get It? included 4 videos that were chosen by participants of the focus groups, as well as supplemental activities that included a basic description of the LARC devices, the ability to anonymously post personal stories about LARCs that can be shared with others, and the opportunity to email the primary investigator questions about LARCs. Thematic analysis of the focus group discussions revealed that when it came to narrative videos, participants desired (1) an authentic narrator, (2) more information on the narrator, and (3) narrators displaying ample emotions. CONCLUSION: Peer narratives play a vital role in influencing a teenager's perspective on their health status; therefore, understanding what constitutes reliable narration from an online format was critical in the development of a peer-based electronic intervention that informs teenagers of the most effective contraceptive available to them.

Psychological factors that may influence use of long-acting reversible contraceptives (LARC): A qualitative study.

Although long-acting reversible contraceptives (LARC) remain the most effective method of contraception for teenagers, most adolescents continue to use less reliable methods. The purpose of this study was to investigate possible psychological factors that may lead to this low uptake rate by studying the LARC decisionmaking process among teenagers. In-depth, semistructured, open-ended interviews of sexually active teenagers who had LARC devices placed prior to 18 years of age were conducted. Four key themes emerged from the interviews: (a) the influences of peers (friends and family members) on LARC decision-making; (b) the lack of awareness about obtaining LARC devices; (c) the fear of weight gain as a driving force during contraceptive and LARC decision-making; and (d) the disproportional anxiety about pain from LARC insertion. The results suggest that a paradigm shift in contraceptive counseling is necessary in order to tackle these psychological barriers to teenage LARC use.

Quantifying interfacial substrate interactions via surface energy analyses.

Determination of a substrate's surface energy profile is a facile and inexpensive method to indicate the substrate's interfacial thermodynamics with another substance (e.g., microorganisms, biomacromolecules, medical devices, etc). The following protocol details a goniometric method to calculate a substrate's surface energy profile which (1) directly correlates to a substrate's interfacial Gibbs energy (ΔG) and (2) predicts the interfacial interactions with other substances. We also provide a calculation template using advanced mathematics to expedite surface energy profile determination. For complete details on the use and execution of this protocol, please refer to Cavitt et al. (2020).

Reasons Why Young Women in the United States Choose Their Contraceptive Method.

Background: Understanding reasons for birth control method choice may inform interventions that help young women choose the best method for them. The purpose of this study was to examine why young women in the general population select their method of contraception. Methods: An online survey was advertised through social media in 2017. After consenting, participants were gated through questions that ensured they were female, within the age range (16-25 years old), lived in the 50 U.S. states, and using intrauterine devices (IUDs), hormonal birth control, or barrier methods specified in the survey. Surveys with incompatible responses were excluded. Satisfaction, plans to discontinue, and primary reason for using current contraceptive method were examined and compared by contraception types using chi-square analyses. Multivariable binary logistic regression was used to examine satisfaction between contraceptive methods and races/ethnicities. Results: A total of 2632 responses were included. A high frequency of women using less effective methods (48.6% of nonhormonal birth control) chose them primarily to prevent pregnancy (20.6% of Copper T IUD, 23.0% of hormonal IUD, and 30.9% of Mirena IUD users), while other more effective birth control methods were often chosen primarily for other reasons. Recommendations from family or friends (14.6%) were used by some to make their contraception decision. Black respondents were less likely and Hispanic respondents were more likely to be satisfied with their birth control compared to white women. Conclusion: Providers should consider that their young patients may want to better understand benefits and side effects of their birth control outside of pregnancy prevention. Furthermore, young women may utilize their friends and family to make their contraceptive choice, which should be taken into consideration when counseling patients.

Thermodynamic Surface Analyses to Inform Biofilm Resistance.

Biofilms are the habitat of 95% of bacteria successfully protecting bacteria from many antibiotics. However, inhibiting biofilm formation is difficult in that it is a complex system involving the physical and chemical interaction of both substrate and bacteria. Focusing on the substrate surface and potential interactions with bacteria, we examined both physical and chemical properties of substrates coated with a series of phenyl acrylate monomer derivatives. Atomic force microscopy (AFM) showed smooth surfaces often approximating surgical grade steel. Induced biofilm growth of five separate bacteria on copolymer samples comprising varying concentrations of phenyl acrylate monomer derivatives evidenced differing degrees of biofilm resistance via optical microscopy. Using goniometric surface analyses, the van Oss-Chaudhury-Good equation was solved linear algebraically to determine the surface energy profile of each polymerized phenyl acrylate monomer derivative, two bacteria, and collagen. Based on the microscopy and surface energy profiles, a thermodynamic explanation for biofilm resistance is posited.

Management of Severe Coarctation of the Aorta During Pregnancy.

An 18-year-old primigravida woman underwent emergent percutaneous balloon stent repair of a severe coarctation of the aorta, allowing her to undergo an uneventful remaining pregnancy and the delivery of a healthy baby. Her case also demonstrates the association between maternal coarctation and fetal Shone complex. (Level of Difficulty: Beginner.).

Trends of Contraceptive Choices Among Young Women in Inner City Houston.

STUDY OBJECTIVE: Although long-acting reversible contraceptives (LARC) such as intrauterine devices and subdermal implants remain the most effective methods of contraception for teenagers, most adolescents continue to use less reliable methods. The purpose of this study was to determine: (1) the distribution of contraceptive type according to age of the patients in our clinic system (Baylor Teen Health Clinic); and (2) the differences in this distribution over the past decade. DESIGN: This study was a comprehensive chart review of at least 15,500 charts for the years 2005 to 2014. SETTING: Baylor Teen Health Clinic. PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Charts of patients less than 25 years of age who attended one of the 9 Baylor Teen Health Clinics were reviewed. Contraceptive uptake by age and year was the main outcome measured. RESULTS: The percentage of women younger than age 25 years who used LARC increased for all age groups from 2005 to 2014, with the greatest increase for women 20-24 years old (<1% to 9%). The percentage of women using no method decreased for all age groups from 2005 to 2014 with the greatest decrease for women 15-19 years old (9% to 5%). The percentage of women using less effective methods decreased for teenagers younger than 18 years old, but increased for women 20-24 years old and remained the same for women 18-19 years old. Use of pills/patches/rings decreased for all age groups and use of hormonal injections increased for all age groups, with the greatest increase for teenagers younger than 15 years of age (35% to 68%). Our clinic population has a greater proportion of teenagers and young women using LARC than the national average, possibly because of the increased access to LARC when these women enter our clinic system. Nevertheless, less than 10% of all age groups studied used LARC, with the proportion being lowest in teenagers younger than 18 years. CONCLUSION: More efforts need to be placed on determining the reasons for low LARC uptake despite greatest efficacy in this young, vulnerable population.

Changes in the Use of Contraception at First Intercourse: A Comparison of the National Survey of Family Growth 1995 and 2006-2010 Databases.

STUDY OBJECTIVE: To determine trends in characteristics associated with contraceptive use at coitarche from 1995 to 2006-2010. METHODS: The National Survey of Family Growth (NSFG) 1995 and 2006-2010 databases were used to abstract variables of interest. Generalized linear models (GLM) were applied to examine the association between the use of contraceptive methods at coitarche and variables abstracted for each database. RESULTS: Of the 9599 women from the 1995 database included in this study, 3885 (40%) used contraception at coitarche in comparison to 4860 (82%) out of 5931 women assessed in 2006-2010. For both time periods, Hispanic women were significantly less likely to use contraception at coitarche when compared to White women. In the 1995 database, only women from families with incomes >$50,000 were more likely to use contraception at coitarche, while women from families with income > $20,000 were more likely to use contraception at coitarche in 2006-2010. There were some differences noted in the association between age at coitarche and contraception use at coitarche, but in general, women who had a higher age at coitarche were more likely to use contraception. For both time periods, women were more likely to use contraception at coitarche if they used barrier methods as their first form of contraception or if they obtained their first contraceptive method from a spouse, partner, or friend. CONCLUSIONS: Our results suggest that access to contraception may be associated with use of a contraceptive method at coitarche. Innovative measures need to be investigated so that this young population has increased access to more reliable methods before their first sexual experience.

Differences in Women Who Choose Subdermal Implants Versus Intrauterine Devices.

Objective: To determine if there are any differences in the patient populations that choose subdermal implants versus intrauterine devices (IUDs) for contraceptive purposes. Study Design: Retrospective chart review. Electronic medical records of women who presented to the University of Texas Medical Branch in Galveston's Regional Maternal Child Health Program Clinics in southeast Texas from March 2011 to March 2013 and received a subdermal implant or IUD were reviewed. Differences in characteristics of women who chose either form of contraception were determined. Results: A total of 356 charts were reviewed. Of those, 188 (53%) women chose the subdermal implant and 168 (47%) chose an IUD. Patients who chose subdermal implants were more likely to have had a long-acting reversible contraceptive (LARC) method previously (p<0.01), previous vaginal deliveries (p<0.001), and an interval from delivery to LARC placement of >1 year (p<0.001). LARC choice was race-specific in that, when compared to Caucasian women, African-American women were significantly more likely to choose an IUD, while Hispanic women were significantly more likely to choose subdermal implants (p=0.002). Conclusion: Different populations choose subdermal implants versus IUDs for contraception. Further research is needed to determine etiologies for these differences.

Postpartum Teenagers' Views on Providing Contraception in School-Based Health Clinics.

BACKGROUND: To determine characteristics of teen pregnancies in southeast Texas and the opinions of postpartum teenagers with regard to having contraceptive services available in high school clinics. METHODS: A cross-sectional study of postpartum teenagers interviewed during their hospital stay. RESULTS: Of 404 postpartum teenagers interviewed, 86% had unplanned pregnancies. Approximately 53% of respondents first had intercourse at less than 16 years of age. Of the 130 teenagers who had used contraception prior to pregnancy, 85% became pregnant because they were unable to visit the clinic to obtain a contraceptive refill or replacement. In multivariate modeling, factors associated with using contraceptives prior to pregnancy included black race (p < .001) and more than 1 previous pregnancy (p < .001). Variables associated with having an unplanned pregnancy included having discussed contraceptives at home or school (p = 0.049). Of the 404 postpartum teenagers surveyed, 223 (82%) were in favor of having contraceptive services offered in high school clinics. CONCLUSIONS: Contraceptive education is not sufficient to prevent teenage pregnancy. Increase in access is critical as teenagers with previous pregnancies were more likely to use contraception, likely due to their interaction with the medical community during the antecedent pregnancy. One possible solution is to bring contraceptive services to the teenagers, by offering them at school based health systems. A majority of teenagers surveyed in this study supported this proposal.

Prenatal Discussion of Contraceptive Options in Teenage Pregnancies.

OBJECTIVE: To determine if contraceptive options are discussed during prenatal care among pregnant teenagers. MATERIALS AND METHOD: Hospital and outpatient clinical records were reviewed for teenagers between the ages 12 and 19, inclusive, who delivered at the University of Texas Medical Branch in Galveston (UTMB) John Sealy Hospital and received prenatal care at one of the UTMB-affiliated ambulatory clinics. RESULTS: A total of 244 postpartum teenagers were included in this study. The mean age was 17.6 ± 1.2 years. The majority of teenagers were Hispanic (57%), followed by white (34%) and black (9%). Of the patients, 41% had less than 10 prenatal visits. Only 14% of the patients had a discussion about contraception during these prenatal visits, most of which occurred after 29 weeks of gestation. CONCLUSIONS: Pregnant teenagers are not frequently counseled about postpartum contraceptives. When counseling does occur, it happens in the third trimester, which may not provide enough time for a teenager to thoroughly consider contraceptive options. Guidelines on when providers should discuss postpartum contraception are necessary.

Characteristics of Females Who Use Contraception at Coitarche: An Analysis of the National Survey of Family Growth 2006-2010 Database.

STUDY OBJECTIVE: To determine demographical and behavioral characteristics associated with contraceptive use at coitarche, or first sexual experience, to determine which populations are at greatest risk of contraceptive nonuse during early sexual experiences. DESIGN: Cross-sectional study. METHODS: We used the National Survey of Family Growth 2006-2010 database to abstract pertinent variables, including race, highest education, annual family income, parental living situation, importance of religion, age at coitarche, number of sexual partners, type of first contraception, and source of first contraception. Generalized linear models with logit link and binomial distribution were applied to examine the association between use of contraceptive methods at coitarche and the variables abstracted. RESULTS: Of the 5931 female participants included in the study, 1071 (18%) did not use contraceptive methods at coitarche. Only 199 (2%) of the female participants included in this study used the more reliable hormonal contraceptive methods at coitarche. Black females were significantly more likely than white females to use contraceptive methods at coitarche (p < 0.01). Females who initiated coitarche from 16 to 20 years of age were significantly more likely to use contraception at coitarche than females who had their first sexual experience at less than 16 years of age (p < 0.001). Females with greater educational background and greater family income were also significantly more likely to use contraception at coitarche (p < 0.001). Finally, females who obtained their first contraceptive methods from a spouse, partner, or friend were more likely to use contraception at coitarche than females who obtained their first method from a medical facility (p < 0.001). CONCLUSIONS: This study highlights several key differences between females who use contraceptive methods at coitarche versus those who do not. Greater effort needs to be focused on increasing access to more reliable contraceptive methods for young females, as females who obtain methods from nonmedical facilities are more likely to use contraceptive methods at coitarche.

Norepinephrine Reduces Reactive Oxygen Species (ROS) and DNA Damage in Ovarian Surface Epithelial Cells.

OBJECTIVE: To determine the role of norepinephrine (NE) on DNA damage and reactive oxygen species (ROS) generation in ovarian surface epithelial cells. METHOD: Non-tumorigenic, immortalized ovarian surface epithelial cells were treated with NE, bleomycin, and bleomycin followed by NE. The comet assay was performed on each treatment group to determine the amount of single and double-strand breaks induced by treatments. ROS levels for each treatment group were measured using the H2DCF-DA fluorescence assay. Finally, RNA transcripts were measured for each treatment group with regards to the expression of DNA repair and oxidative stress genes. RESULTS: The mean tail moment of untreated cells was significantly greater than that of cells treated with NE (p=0.02). The mean tail moment of cells treated with bleomycin was significantly greater than that of cells treated with bleomycin followed by NE (p<0.01). Treatment with NE resulted in significantly less ROS generation than in untreated cells (p<0.01). NE treatment after hydrogen peroxide treatment resulted in a noticeable decrease in ROS generation. Genes associated with oxidative stress were upregulated in cells treated with bleomycin, however this upregulation was blunted when bleomycin-treated cells were treated subsequently with NE. CONCLUSION: NE is associated with decreased DNA damage and ROS production in ovarian surface epithelial cells. This effect is protective in the presence of the oxidative-damaging agent bleomycin. These results suggest an additional physiologic role for the stress hormone NE, in protecting ovarian surface epithelial cells from oxidative stress.

Patient characteristics associated with pregnancy ambivalence.

BACKGROUND: The objective of our study was to determine demographic characteristics, health and sexual behaviors, and psychological health associated with pregnancy ambivalence. We used a cross-sectional design for our study. METHODS: A self-administered cross-sectional survey was conducted among nonpregnant women 16-40 years old from southeast Texas from July 2010 to August 2011. The survey included questions pertaining to demographics, pregnancy intentions, health behaviors, sexual behaviors, violence exposure, pregnancy coercion, and psychological behaviors. Multivariate logistic regression analyses were performed to determine differences between ambivalent and nonambivalent females. RESULTS: Of the 1,388 women included in this analysis, 529 (38%) were ambivalent toward pregnancy. Ambivalent women were younger (p=0.03), had fewer children living at home (p<0.01), and were less likely to have been previously pregnant (p=0.01). Multivariate analysis showed that ambivalent women were more likely to smoke (p<0.01), sleep poorly (p=0.02), have had more sexual partners in the past month (p<0.01) and in their lifetime (p=0.01), not used contraception at last sex (p=0.01), be a victim of violence (p=0.01), and have experienced pregnancy coercion (p<0.01). In addition, these women exhibited higher scores on scales measuring depressive symptoms (p=0.01) and perceived stress (p<0.01). CONCLUSIONS: Women ambivalent toward pregnancy are not only less likely to use contraception but also more likely to have unhealthy behaviors and psychological risk factors. As this combination of characteristics may put a future pregnancy and child at risk, awareness about the possible consequences of pregnancy ambivalence needs to increase among the public and medical community. Providers need to focus efforts on screening for this patient population and preventive education through contraceptive counseling.

Assessment of minimally invasive surgical skills of pre-medical students: What can we learn from future learners?

OBJECTIVE: Knowledge of baseline laparoscopic and robotic surgical skills of future learners is essential to develop teaching strategies that best fit them. The objectives of this study are to determine baseline laparoscopic and robotic skills of high school and college students and compare them to those of current obstetrics and gynecology residents. MATERIAL AND METHODS: A cross-sectional (Class II-2) pilot study. Laparoscopic and robotic surgical skills of college and high (secondary) school students were evaluated using simulators and compared to those of obstetrics and gynecology residents. In addition, questionnaire data were collected regarding video game playing and computer use. RESULTS: A total of 17 students, both high school (n=9) and college (n=8), in addition to 11 residents, completed the study. Overall, students performed comparably to the residents in simple exercises (p>.05). However, students took significantly longer time to complete complex exercises (p=.001). Finally, students played video games significantly more than residents (p<.001). CONCLUSION: Future learners may have a different background skill set. This difference may be related to improved hand-eye coordination, possibly due to playing video games. The results of this pilot study should spur more research into surgical teaching strategies.

The internet's role in HPV vaccine education.

The internet is the second most popular source, after healthcare providers, of information regarding human papillomavirus (HPV). These online searches usually begin with the user entering generic terms in the search engine, and then reading the first few results that the engine returns. Unfortunately, research shows that much of this information obtained about the HPV vaccine is inaccurate and incomplete. In this review, we summarize the literature pertaining to online information concerning the HPV vaccine and review concerns related to obtaining online medical information. Finally, we propose possible solutions medical providers can employ in their everyday practice to help their patients obtain accurate information through their online searches.

Trends in the national distribution of laparoscopic hysterectomies from 2003 to 2010.

STUDY OBJECTIVE: The purpose of this analysis was to compare the trends in undergoing laparoscopic hysterectomy (versus abdominal or vaginal hysterectomy) based on patient age, race, median income and insurance type, from 2003 to 2010. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: National sample of hospital admissions after hysterectomy. PATIENTS: Health Cost and Utilization Project-Nationwide Inpatient Sample database was used to review records of women who underwent hysterectomy for either menorrhagia or leiomyoma from 2003-2010. INTERVENTION: The predicted probability of undergoing laparoscopic hysterectomy was determined for each year according to patient age, race, median income, and insurance type. The slopes of these values (i.e. the trend) was compared for each subgroup (i.e. black, white, Asian, etc.) in these categories. MAIN RESULTS: A total of 530, 154 cases were included in this study. Total number of hysterectomies decreased by 39% from 60,364 to 36,835 from 2003 to 2010. The percent of hysterectomies that were laparoscopic increased from 11% in 2003 to 29% in 2010. All groups analyzed experienced an increase in predicted probability of undergoing a laparoscopic hysterectomy. Of all women undergoing hysterectomy, the probability of undergoing a laparoscopic hysterectomy remained highest for women who were less than 35 years old, white, with the highest median income, and with private insurance from 2003-2010. The slope was significantly greater for (1) white females versus all other races analyzed (p<0.01), (2) females in the highest income quartile versus females in the lowest income quartile (p<0.01) and (3) females with private insurance versus females with Medicaid (p<0.01) or Medicare (p<0.01). CONCLUSIONS: There remains a gap in distribution of laparoscopic hysterectomies with regards to age, race, median income and insurance type that does not seem to be closing, despite the increased availability of laparoscopic hysterectomies.

Outpatient robotic hysterectomy: clinical outcomes and financial analysis of initial experience.

BACKGROUND: Robotic surgery is associated with several advantages but also high costs. This study evaluates clinical outcomes and financial feasibility of outpatient robotic hysterectomy. METHODS: Retrospective cohort study (Class II-2) of patients who underwent robotic hysterectomy for benign conditions by the same surgeon (M.A.B.) at the University of Texas Medical Branch, Galveston, TX, USA, during November 2010-February 2013. The study only included cases considered appropriate for outpatient management. Clinical outcomes and costs for patients discharged the same day (outpatients) were compared to those electively admitted (hospitalized). RESULTS: Twenty-nine cases (14 outpatient and 15 hospitalized) were analysed. Demographic, pre-, peri- and postoperative characteristics and payer types were not different among the groups (p > 0.05). Outpatient hysterectomy was associated with $4968 hospital savings (p < 0.001), $410 payer savings (p = 0.775) and $4558 improvement in net profit/loss (p = 0.01). CONCLUSIONS: In well-selected patients, adopting a well-designed programme, outpatient robotic hysterectomy seems to be safe and financially feasible.

Outcomes of robotic sacrocolpopexy using barbed delayed absorbable sutures.

STUDY OBJECTIVE: To evaluate 1-year outcomes of robotic sacrocolpopexy (RSC) for pelvic organ prolapse using barbed delayed absorbable sutures. DESIGN: Retrospective cohort study (Class II-3). SETTINGS: University-based hospital in Southeast Texas. PATIENTS: Patients with symptomatic apical pelvic organ prolapse who underwent RSC using barbed delayed absorbable sutures between January 2011 and August 2012. Patients were examined postoperatively at least twice (after 6 weeks and 1 year). INTERVENTIONS: RSC procedure. MEASUREMENTS AND MAIN RESULTS: The study included a total of 20 patients, of them 15 had grades 3 or 4 whereas 5 had grade 2 apical defects according to the Baden-Walker classification system. Fourteen patients (70%) underwent concomitant hysterectomy while 9 (45%) underwent concomitant anti-incontinence surgery. Mesh suturing times were 46.9 ± 12.6 and 20.5 ± 9.3 minutes in the first 10 versus the last 10 cases, respectively (p < .001). The mean follow-up duration was 17.3 months (range, 12-24 months). There were no recurrences of apical defects or mesh/suture exposure/erosion. However, 1 patient developed a grade 2 cystocele, and another developed new-onset urinary incontinence, both after 1 year. A third patient's urine leakage did not improve postoperatively. Lastly, a fourth patient developed port site incisional hernia and underwent repair 5 months later. CONCLUSION: Our study suggests that barbed delayed absorbable sutures are safe and effective in RCS procedures over 1 year. Larger, comparative, and randomized trials are recommended for definitive conclusions.