Peer Recovery Specialists and Referrals to Treatment: Clinical Correlates Among Patients of an Opioid Overdose Recovery Program in New Jersey.

BACKGROUND: Peer recovery programs increase recovery support and treatment engagement among individuals with opioid use disorder. Peer recovery specialists (PRS) are critical in the cascade of care of treating addiction and related conditions. Work remains to help identify the benefits of PRS, particularly time spent with a PRS as a clinical indicator associated with referral to substance use treatment services. Gaps in the literature do not consider the nested hierarchical intercorrelations of opioid recovery data within multiple emergency departments. PURPOSE: The current study examined demographic and clinical correlates with referral to substance use treatment services including prior engagement within an opioid overdose recovery program, mental health diagnosis, the number of naloxone administrations, prior overdoses, and hospital-level variability of PRS time associated with treatment referrals. METHOD: This study used data collected by providers among patients who engaged in an opioid overdose recovery program. Data were collected between January 2016 and September 2020. Generalized linear mixed effect multilevel regression analyses tested the associations on clinical referral to substance use services. RESULTS: A total of 5655 patients participated in the study (male: 68.91%; age: mean = 37.75 ± 12.43; White non-Hispanic: 62.48%). Significant individual-level associations were identified between demographic and clinical variables and referral to substance use treatment services. At the hospital level, recovery specialist time spent with the patient also showed a positive and significant association with referral to substance use treatment services. CONCLUSION: The cross-level interaction effect displayed that any period of time spent with PRS played an important role for those patients with a greater number of prior overdoses on referral to treatment. Results provide important information on the role of PRS in the cascade of care, as well as the time spent with those in this role for both individuals with varying number of prior overdoses.

Advancing the behavioral health workforce: An innovative integrated care and substance use disorder training model to improve outcomes for people in medically underserved communities.

INTRODUCTION: It is critical that we strengthen the ability of the behavioral health workforce to better manage the complex behavioral and physical health needs of people in medically underserved areas. Despite the knowledge that integrated care (IC) models improve patient outcomes and experience, provider satisfaction, and health care costs, educational and experiential training in IC is limited, limiting workforce capacity to deliver this care. METHOD: Through the Health Resources and Services Administration-funded Rutgers University Integrated Substance Use Disorder Training Program (RUISTP), we partner with community-based primary care clinics to implement an interprofessional fellowship program for psychologists, social workers, physician assistants, and advanced practice nurses. The RUISTP simultaneously provides training and implements IC within these community-based systems. Our multiple-methods evaluation design examines data-driven indicators of feasibility, uptake, and program success during implementation and sustainability phases and assesses changes in organizational beliefs and practices, provider competencies, and service utilization throughout the project period. RESULTS: This article describes the significance and innovation of (a) an IC training program, (b) an implementation plan for sustained change within systems of care, and (c) evaluative methodology to assess and improve IC and SUD service delivery and training. These data will be used to create a template for other academic and health care systems nationally. DISCUSSION: It is the mission of this program to use an innovative training, implementation, and evaluation design to enhance IC and SUD services, bolster the behavioral health workforce trained to provide high-quality IC, and inform replications of this model in other geographic and clinical settings, particularly those in medically underserved communities. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Knowledge of Predatory Practices within the Substance Use Disorder Treatment Industry: Development of a Measurement Instrument.

The increase in predatory practices in the substance use disorder treatment industry calls for the development of measures to assess individuals' knowledge about these practices. METHODS: This study describes the development of the Knowledge of Predatory Practices Scale (KPPS), a newly developed measure designed to assess the knowledge of predatory practices within the substance use disorder treatment industry. An exploratory factor analysis was conducted to determine the factor structure of this measure. RESULTS: The final 11-item KPPS consisted of two factors-knowledge about general predatory practices (9 items) and knowledge about unethical practices (2 items). Overall, these factors explained 61.75% of the total variance. The Cronbach's alpha for the KPPS was 0.81. CONCLUSIONS: The KPPS is a reliable measure of knowledge of predatory practices within the substance use disorder treatment industry and can be used as a measurement tool to educate individuals seeking help for their loved ones who are misusing substances.

Polysubstance use latent class membership in New Jersey: Association with prior overdoses, prior emergency department peer recovery engagement, and mental health diagnosis among participants in an opioid overdose recovery program.

Background: Epidemiological research has indicated higher polysubstance use among individuals who misuse opioids in the United States. Polysubstance use is also associated with multiple emergency department (ED) engagements in intervention services. Less is known about polysubstance use among individuals who use opioids or were engaged in an ED setting as part of an opioid recovery intervention program. Examining emerging patterns of polysubstance use among individuals who use opioids may help shape policy and practice around developing drug markets and social norms. The objective of this study was to understand subpopulations who demonstrated distinct patterns of polysubstance use among participants in an ED Opioid Overdose Recovery Program (OORP) in New Jersey. Method: This study investigated patterns of polysubstance use among participants in a New Jersey OORP using latent class analysis (LCA; N = 1690; 70.2% male; 84.7% White non-Hispanic; meanage = 35.72 ± 11.95). Multinomial logistic regression analyses examined latent class (LC) membership based on clinically relevant indicators. Results: Five latent classes were identified (Model fit: L2 = 33.76, BIC = 4482.69, AIC = 4245.01, and the bootstrap L2p-value =0.27; standard R2 value of 0.85). Multinomial logistic regression analyses showed that subgroups with the greatest odds of prior OORP engagement related to those participants in subgroups with heroin and polysubstance use. Conclusion: It is critical to examine the heterogeneity among people engaging in prescription opioid use and polysubstance use in the United States. This study represents an important contribution in identifying polysubstance use LC membership groups and associations with clinically relevant indicators among those engaged in an opioid recovery program. Results can be valuable in understanding the nature of the larger epidemic and how it can be addressed.

Testing Relationships Between Racial-Ethnic Identity, Racial-Ethnic Discrimination, and Substance Misuse Among Black and Latinx Older Adults in a Nationally Representative Sample.

Older adults (aged 55+) comprise a rapidly growing population both in number and racial-ethnic diversity. In recent years, substance misuse prevalence among older adults has increased and is expected to continue rising, highlighting the need to understand risk and protective factors in this population. Using nationally representative data, this study examines the association of racial-ethnic identity and racial-ethnic discrimination with alcohol and illicit drug use among Black and Latinx older adults, and whether racial-ethnic identity moderates the relationship between discrimination and substance misuse. Findings show that among Latinx older adults discrimination is associated with increased substance misuse, and higher ethnic identity is associated with decreased illicit drug use. Higher racial-ethnic identity buffers the effects of discrimination on illicit drug use for Latinx, but not for Black respondents. Findings of this study highlight the complex associations between racial-ethnic identity, discrimination, and substance misuse, varying across racial-ethnic group, age, context, and other factors.

Social Isolation Profiles and Older Adult Substance Use: A Latent Profile Analysis.

OBJECTIVES: The aim of this study was to determine substance use among older adults based upon their social isolation and loneliness profiles. METHODS: Data were derived from the New Jersey Older Adult Survey on Drug Use and Health. Latent profile analysis (LPA) was used to determine the profiles of older adults (N = 801) based on 5 dimensions of social isolation and loneliness. Logistic and generalized ordered logistic regressions were conducted to assess the relationship between the latent profiles and substance use. RESULTS: LPA identified 5 social isolation/loneliness profiles. The "connected and active" group had the lowest odds of cigarette use. The "alone but not lonely" group had the highest odds of cigarette use, alcohol use, and high-risk drinking. The "alone and lonely" group had the highest odds of nonmedical drug use. DISCUSSION: In working with older adults who are using substances, it is important to inquire about their social isolation and loneliness. Cognitive behavioral therapy for the "alone and lonely" group may be beneficial, as it has been deemed effective in reducing loneliness and enhancing social networks.

Measuring Youth Empowerment: An Item Response Theory Analysis of the Sociopolitical Control Scale for Youth.

Sociopolitical control (SPC) has been identified as a key element of the intrapersonal component of psychological empowerment. The Sociopolitical Control Scale (SPCS) is a widely used measure and has been modified for use among youth (SPCS-Y). In light of the emerging interest in SPC among youth within community-based research, this study applied item response theory (IRT) to examine the psychometric properties of the SPCS-Y and to explore a brief version. Data were collected between 2006 and 2013 from a convenience sample of high school students (N = 1,808), located in a midsized, economically disadvantaged urban community in the northeastern United States. Findings indicate that the two subscales, leadership competence, and policy control, were unidimensional and items functioned well. Most items functioned particularly well at low and moderate levels of the construct, but a few were able to capture higher levels of the construct. Based on our IRT analyses of the performance of items on the subscales, we selected items to create a brief version of the SPCS-Y (BSPCS-Y) and performed structural equation modeling for further examination. Results provide empirical evidence to support the reliability and validity of the SPCS-Y and suggest a brief version based on high-performing items is possible.

Measurement invariance of the Brief Sense of Community Scale across non-Hispanic, Black and Hispanic college students.

Ethnic-racial background may influence college students' psychological sense of community (PSOC). Thus, it is critical to examine whether this construct is conceptualized similarly between non-Hispanic, Black and Hispanic students. This study tested the measurement invariance of the Brief Sense of Community Scale (BSCS) across the two groups. We used data from a self-administered online survey provided to college students in 2016 in a Northeastern urban university (non-Hispanic, Black = 307; Hispanic = 409). We tested the measurement invariance of the BSCS using a series of nested multigroup confirmatory factor analyses with increasingly restrictive sets of parameters. Measurement invariance of the BSCS across non-Hispanic, Black and Hispanic college students was achieved. The BSCS successfully measures the multidimensionality of PSOC across the two groups in a college setting. Students' score on the BSCS is not biased by measurement invariance related to cultural influences. When using the BSCS, community psychologists and researchers can have confidence that the observed differences in PSOC across non-Hispanic, Black and Hispanic college students are attributable to true differences rather than a cultural understanding of the construct.

Psychometric properties of a Recovery Empowerment Scale: Testing emotional, cognitive, behavioral, and relational domains.

Psychological empowerment (PE) is a multidimensional construct comprised of emotional, cognitive, behavioral, and relational domains. Although context-specific measures of PE exist, no study to date has introduced and tested a measure of the construct that captures all four domains for both women and men in recovery from substance misuse. Furthermore, research has largely neglected the relational dimension, particularly in studies involving people in recovery. In this study, we tested a measure of PE among a diverse sample (n = 200) of people in recovery who participated in a program designed to expand access to medications for opioid use disorder in the northeastern United States. Factor analysis results supported the hypothesized four-factor structure of the scale, and dimensions of PE were found to be associated in expected ways with measures of quality of life, self-reported health, and depression. Implications of the study are described and directions for future research discussed.

Participation in community organizing: Cross-sectional and longitudinal analyses of impacts on sociopolitical development.

This article reports cross-sectional (Study 1) and longitudinal (Study 2) results from analyses of civic behaviors and attitudes among two groups: participants in grassroots community organizing in five US cities and a geographically balanced sample of their neighbors, many of whom were participating with other types of voluntary organizations (e.g., neighborhood-based or school-based groups). This analytic approach allowed for tests of differences between groups, differences within groups over time, and interactions between groups and time on indicators of sociopolitical development including civic behaviors, psychological sense of community, and the emotional and cognitive components of psychological empowerment. Results showed that community organizing, as a particular type of mediating institution, cultivates sociopolitical development by elevating psychological empowerment and civic engagement over time.

Online Simulation Model to Estimate the Total Costs of Tobacco Product Waste in Large U.S. Cities.

Tobacco product waste (TPW) is one of the most ubiquitous forms of litter, accumulating in large amounts on streets, highways, sidewalks, beaches, parks, and other public places, and flowing into storm water drains, waste treatment plants, and solid waste collection facilities. In this paper, we evaluate the direct and indirect costs associated with TPW in the 30 largest U.S. cities. We first developed a conceptual framework for the analysis of direct and indirect costs of TPW abatement. Next, we applied a simulation model to estimate the total costs of TPW in major U.S. cities. This model includes data on city population, smoking prevalence rates, and per capita litter mitigation costs. Total annual TPW-attributable mean costs for large US cities range from US$4.7 million to US$90 million per year. Costs are generally proportional to population size, but there are exceptions in cities that have lower smoking prevalence rates. The annual mean per capita TPW cost for the 30 cities was US$6.46, and the total TPW cost for all 30 cities combined was US$264.5 million per year. These estimates for the TPW-attributable cost are an important data point in understanding the negative economic externalities created by cigarette smoking and resultant TPW cleanup costs. This model provides a useful tool for states, cities, and other jurisdictions with which to evaluate a new economic cost outcome of smoking and to develop new laws and regulations to reduce this burden.

Youth Cognitive Empowerment: Development and Evaluation of an Instrument.

Psychological empowerment (PE) is a multicomponent construct that involves the mechanisms through which people and groups gain control over their lives and environments. Psychological empowerment has previously been operationalized using measures of sociopolitical control among young people, with findings indicating links between PE and other positive developmental outcomes. Sociopolitical control, however, is only an indicator for the emotional component of PE. Research has largely neglected the cognitive component of PE, particularly in studies of younger people. In fact, few studies to date have presented and empirically tested measurement instruments for the cognitive component of PE among youth. In this study, we adapted a measure, which previously had been validated and used among adults, for use among young people and tested it in a sample of high school students (53% female, 75% Hispanic) in an urban school in the northeastern U.S. Confirmatory factor analyses were used to assess the hypothesized three-factor structure of cognitive empowerment, and the measure was examined for association with the construct of social justice orientation. Results indicate an adequate fit for the second-order factor, and an expected relationship with the related construct.

Promoting opioid overdose prevention and recovery: An exploratory study of an innovative intervention model to address opioid abuse.

BACKGROUND: Fatal opioid overdose is a national public health concern in the United States and a critical problem confronting New Jersey's addiction treatment system. New Jersey developed an innovative program, the Opioid Overdose Recovery Program (OORP), to address the epidemic and the issue of low treatment admissions following a non-fatal overdose. The OORP utilizes an intervention model with peer recovery specialists (RSs) and patient navigators (PNs) to engage individuals within emergency departments (EDs) immediately following an opioid overdose reversal. The purpose of this exploratory s/tudy was to examine the process through which the OORP was implemented in its first year and determine facilitators and barriers to implementation. METHODS: Data were collected in 2016-2017, through 17 telephone interviews and focus groups with 39 participants. Participants were OORP staff and stakeholders selected through purposeful, non-random sampling. Standardized, open-ended interview guides were used. Thematic analysis was conducted to identify, analyze, and report overall patterns. RESULTS: Participants detailed stories from the field and policymakers illuminated the process of implementation. Findings revealed logistical barriers to treatment including patients' lack of insurance and cell phones, lack of immediately available detox beds, and program ineligibility for some patients due to medical conditions. The model using peers as first responders had a positive impact as their experiences with addiction enabled them to more successfully engage patients. The PNs were critical in addressing high needs for case management and referral and external partners were also important for implementation. CONCLUSIONS: Results underscore the effort needed to integrate this important model within EDs as part of a multi-level approach to address opioid misuse. The identified challenges led to statewide strategic planning and areas for further development. OORP is a promising intervention that might increase the number of individuals suffering with opioid disorders linked to peer support, treatment and recovery.

Temporal trends and survivorship of total hip arthroplasty in very young patients: a study using the National Joint Registry data set.

AIMS: The aim of this study was to describe temporal trends and survivorship of total hip arthroplasty (THA) in very young patients, aged ≤ 20 years. PATIENTS AND METHODS: A descriptive observational study was undertaken using data from the National Joint Registry (NJR) for England, Wales, Northern Ireland and the Isle of Man between April 2003 and March 2017. All patients aged ≤ 20 years at the time of THA were included and the primary outcome was revision surgery. Descriptive statistics were used to summarize the data and Kaplan-Meier estimates calculated for the cumulative implant survival. RESULTS: A total of 769 THAs were performed in 703 patients. The median follow-up was 5.1 years (interquartile range (IQR) 2.6 to 7.8). Eight patients died and 35 THAs were revised. The use of metal-on-metal (MoM) bearings and resurfacing procedures declined after 2008. The most frequently recorded indications for revision were loosening (20%) and infection (20%), although the absolute risk of these events occurring was low (0.9%). Factors associated with lower implant survival were MoM and metal-on-polyethylene (MoP) bearings and resurfacing arthroplasty ( vs ceramic-on-polyethylene (CoP) and ceramic-on-ceramic (CoC) bearings, p = 0.002), and operations performed by surgeons who undertook few THAs in this age group as recorded in the NJR ( vs those with five or more recorded operations, p = 0.030). Kaplan-Meier estimates showed 96% (95% confidence interval (CI) 94% to 98%) survivorship of implants at five years. CONCLUSION: Within the NJR, the overall survival for very young patients undergoing THA exceeded 96% during the first five postoperative years. In the absence of studies that can better account for differences in the characteristics of the patients, surgeons should consider the association between early revision and the type of implant, the number of THAs performed in these patients, and the bearing surface when performing THA in very young patients. Cite this article: Bone Joint J 2018;100-B:1320-9.

Measuring Sense of Community Responsibility in Community-Based Prevention Coalitions: An Item Response Theory Analysis.

Research on sense of community (SOC) has traditionally been approached from a resource perspective. Recently, however, research on the experience of SOC has evolved to include a related but distinct construct of sense of community responsibility (SOC-R), or feelings of accountability for the well-being of a community. This study applied item response theory to examine the psychometric properties of a SOC-R scale used in an evaluation of community-based substance abuse prevention coalitions. Data were collected in 2017 from coalition members (analytic sample = 309) in the northeastern United States. Findings indicate that the scale was reliable, unidimensional, and functioned well, particularly at low and moderate levels of the construct. The addition of two items intended to capture higher levels of the construct improved the scale's functioning at higher levels of SOC-R. The adapted SOC-R scale was also shown to have moderately strong relationships with conceptually relevant variables, including SOC, coalition participation, number of roles performed in the coalition, and engagement in community action activities. These findings provide empirical evidence to support the reliability and validity of the SOC-R scale, and have critical implications for our conceptualization of the SOC construct, its measurement, and for the evaluation of community-based prevention interventions.

Critical Hopefulness Among Urban High School Students.

Psychological empowerment encompasses several key aspects of youth civic and sociopolitical development. Most research has focused on psychological empowerment's emotional component, which entails learned hopefulness about one's own ability to participate in and lead community change efforts. Fewer studies have assessed critical awareness of how social power operates-psychological empowerment's cognitive component. The confluence of these two components has been termed critical hopefulness. A complex relationship exists between these two components, and previous research has found relatively small proportions of participants reporting both high levels of critical awareness and simultaneously high levels of hopefulness about their ability to exert influence in the sociopolitical domain. The current study of urban high school students in the Northeastern U.S. (n = 389; 53.5% female) investigates heterogeneity according to these two components of psychological empowerment. Latent class cluster analyses were conducted and seven distinct groups of participants emerged. Students identifying as Hispanic/Latinx were more likely to be classified into a profile group exhibiting critical hopefulness. Differences were observed between psychological empowerment profile groups on self-reported levels of psychological sense of community, civic engagement, and social justice orientation. Furthermore, a larger proportion of this overall sample was classified into groups that exhibited critical hopefulness than in a previous study of adults. These findings provide useful insights for efforts to engage young people in civic life and to promote sociopolitical development.

Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage

"IMPORTANCE: More than 100 million units of blood are collected worldwide each year, yet the indication for red blood cell (RBC) transfusion and the optimal length of RBC storage prior to transfusion are uncertain. OBJECTIVE: To provide recommendations for the target hemoglobin level for RBC transfusion among hospitalized adult patients who are hemodynamically stable and the length of time RBCs should be stored prior to transfusion. EVIDENCE REVIEW: Reference librarians conducted a literature search for randomized clinical trials (RCTs) evaluating hemoglobin thresholds for RBC transfusion (1950-May 2016) and RBC storage duration (1948-May 2016) without language restrictions. The results were summarized using the Grading of Recommendations Assessment, Development and Evaluation method. For RBC transfusion thresholds, 31 RCTs included 12 587 participants and compared restrictive thresholds (transfusion not indicated until the hemoglobin level is 7-8 g/dL) with liberal thresholds (transfusion not indicated until the hemoglobin level is 9-10 g/dL). The summary estimates across trials demonstrated that restrictive RBC transfusion thresholds were not associated with higher rates of adverse clinical outcomes, including 30-day mortality, myocardial infarction, cerebrovascular accident, rebleeding, pneumonia, or thromboembolism. For RBC storage duration, 13 RCTs included 5515 participants randomly allocated to receive fresher blood or standard-issue blood. These RCTs demonstrated that fresher blood did not improve clinical outcomes. FINDINGS: It is good practice to consider the hemoglobin level, the overall clinical context, patient preferences, and alternative therapies when making transfusion decisions regarding an individual patient. Recommendation 1: a restrictive RBC transfusion threshold in which the transfusion is not indicated until the hemoglobin level is 7 g/dL is recommended for hospitalized adult patients who are hemodynamically stable, including critically ill patients, rather than when the hemoglobin level is 10 g/dL (strong recommendation, moderate quality evidence). A restrictive RBC transfusion threshold of 8 g/dL is recommended for patients undergoing orthopedic surgery, cardiac surgery, and those with preexisting cardiovascular disease (strong recommendation, moderate quality evidence). The restrictive transfusion threshold of 7 g/dL is likely comparable with 8 g/dL, but RCT evidence is not available for all patient categories. These recommendations do not apply to patients with acute coronary syndrome, severe thrombocytopenia (patients treated for hematological or oncological reasons who are at risk of bleeding), and chronic transfusion-dependent anemia (not recommended due to insufficient evidence). Recommendation 2: patients, including neonates, should receive RBC units selected at any point within their licensed dating period (standard issue) rather than limiting patients to transfusion of only fresh (storage length: <10 days) RBC units (strong recommendation, moderate quality evidence). CONCLUSIONS AND RELEVANCE: Research in RBC transfusion medicine has significantly advanced the science in recent years and provides high-quality evidence to inform guidelines. A restrictive transfusion threshold is safe in most clinical settings and the current blood banking practices of using standard-issue blood should be continued."

High-Risk Obtainment of Prescription Drugs by Older Adults in New Jersey: The Role of Prescription Opioids.

OBJECTIVES: To explore the high-risk ways in which older adults obtain prescription opioids and to identify predictors of obtaining prescription opioids from high-risk sources, such as obtaining the same drug from multiple doctors, sharing drugs, and stealing prescription pads. DESIGN: Logistic regression analyses of cross-sectional survey data from the New Jersey Older Adult Survey on Drug Use and Health, a representative random-sample survey. PARTICIPANTS: Adults aged 60 and older (N = 725). MEASUREMENTS: Items such as obtaining prescriptions for the same drug from more than one doctor and stealing prescription drugs were measured to determine high-risk obtainment of prescription opioids. RESULTS: Almost 15% of the sample used high-risk methods of obtaining prescription opioids. Adults who previously used a prescription opioid recreationally had three times the risk of high-risk obtainment of prescription opioids. CONCLUSION: These findings illustrate the importance of strengthening prescription drug monitoring programs to reduce high-risk use of prescription drugs in older adults by alerting doctors and pharmacists to potential prescription drug misuse and interactions.

Dispersal by rodent caching increases seed survival in multiple ways in canopy-fire ecosystems.

Seed-caching rodents have long been seen as important actors in dispersal ecology. Here, we focus on the interactions with plants in a fire-disturbance community, specifically Arctostaphylos species (Ericaceae) in California chaparral. Although mutualistic relationships between caching rodents and plants are well studied, little is known how this type of relationship functions in a disturbance-driven system, and more specifically to systems shaped by fire disturbance. By burying seeds in the soil, rodents inadvertently improve the probability of seed surviving high temperatures produced by fire. We test two aspects of vertical dispersal, depth of seed and multiple seeds in caches as two important dimensions of rodent-caching behavior. We used a laboratory experimental approach to test seed survival under different heating conditions and seed bank structures. Creating a synthetic soil seed bank and synthetic fire/heating in the laboratory allowed us to have control over surface heating, depth of seed in the soil, and seed cache size. We compared the viability of Arctostaphylos viscida seeds from different treatment groups determined by these factors and found that, as expected, seeds slightly deeper in the soil had substantial increased chances of survival during a heating event. A key result was that some seeds within a cache in shallow soil could survive fire even at a depth with a killing heat pulse compared to isolated seeds; temperature measurements indicated lower temperatures immediately below caches compared to the same depth in adjacent soil. These results suggest seed caching by rodents increases seed survival during fire events in two ways, that caches disrupt heat flow or that caches are buried below the heat pulse kill zone. The context of natural disturbance drives the significance of this mutualism and further expands theory regarding mutualisms into the domain of disturbance-driven systems.