This scenario is professionally challenging due to the inherent complexities of advanced structural heart disease management, which often involves balancing novel, albeit less established, evidence with established clinical guidelines and patient-specific factors. The rapid evolution of interventional techniques and devices necessitates a rigorous approach to evidence appraisal and decision-making to ensure patient safety and optimal outcomes. Careful judgment is required to navigate the nuances of emerging data, potential biases, and the ethical imperative to provide the best possible care within the existing regulatory and ethical frameworks. The best professional approach involves a comprehensive synthesis of all available evidence, including high-quality randomized controlled trials, robust observational studies, and meta-analyses, alongside expert consensus guidelines. This synthesis should then be critically evaluated for its applicability to the individual patient, considering their specific comorbidities, anatomical variations, and treatment preferences. The decision-making process should be collaborative, involving the multidisciplinary structural heart team, the patient, and their family, ensuring informed consent based on a thorough understanding of the risks, benefits, and uncertainties associated with each treatment option. This aligns with ethical principles of beneficence, non-maleficence, and patient autonomy, and implicitly adheres to regulatory expectations for evidence-based practice and patient-centered care. An incorrect approach would be to solely rely on the most recent, potentially preliminary, data from a single small study without considering the broader evidence base or established guidelines. This fails to acknowledge the potential for bias in early research and overlooks the accumulated experience and consensus reflected in current guidelines, potentially leading to suboptimal or even harmful treatment decisions. Another incorrect approach would be to dismiss emerging evidence entirely and strictly adhere to older guidelines, even when newer data suggests potential improvements or alternative strategies. This can lead to missed opportunities for better patient care and may not reflect the current standard of practice as it evolves, potentially falling short of the duty to provide the most effective care. Finally, making a decision based primarily on the availability of a specific device or technology, rather than a comprehensive assessment of evidence and patient suitability, is professionally unacceptable. This prioritizes commercial or logistical factors over patient well-being and evidence-based medicine, violating core ethical and professional responsibilities. Professionals should employ a structured decision-making framework that begins with a thorough patient assessment, followed by a systematic review and critical appraisal of all relevant evidence. This evidence should then be integrated with clinical expertise and patient values to formulate treatment recommendations. Regular multidisciplinary team meetings are crucial for discussing complex cases and ensuring consensus on the best course of action, fostering a culture of continuous learning and evidence-based practice.

Scenario Analysis: This scenario is professionally challenging because it involves a critical decision regarding patient care in a complex structural heart disease context, where timely intervention is paramount but requires careful consideration of patient-specific factors and evolving clinical evidence. The physician must balance the urgency of the patient’s condition with the need for a thorough, evidence-based assessment, navigating potential conflicts between established protocols and emerging treatment options. Correct Approach Analysis: The best professional practice involves a comprehensive, multidisciplinary assessment that integrates the patient’s specific clinical presentation, comorbidities, and preferences with the latest evidence-based guidelines for structural heart disease management. This approach ensures that the chosen treatment strategy is not only clinically appropriate but also ethically sound, respecting patient autonomy and promoting optimal outcomes. It necessitates collaboration with relevant specialists (e.g., interventional cardiologists, cardiac surgeons, anesthesiologists) to achieve a consensus on the most suitable intervention. This aligns with the ethical principles of beneficence and non-maleficence, ensuring the patient receives the best possible care based on a holistic evaluation. Incorrect Approaches Analysis: Proceeding with a treatment solely based on the physician’s personal experience without a formal multidisciplinary review risks overlooking critical patient factors or newer, potentially superior treatment modalities. This approach fails to uphold the principle of shared decision-making and may not represent the most evidence-based or safest option for the patient. Delaying treatment indefinitely due to a lack of absolute certainty about the optimal approach, while seemingly cautious, can be detrimental to the patient’s prognosis in structural heart disease, where timely intervention is often crucial. This inaction can violate the principle of beneficence by withholding potentially life-saving or quality-of-life-improving treatment. Opting for a treatment that is not fully supported by current evidence or guidelines, even if it appears simpler or more familiar, exposes the patient to unnecessary risks and may not achieve the desired clinical outcome. This approach deviates from the standard of care and could lead to suboptimal results or adverse events. Professional Reasoning: Professionals should employ a systematic decision-making process that begins with a thorough patient assessment, followed by consultation with relevant specialists. This collaborative approach, grounded in evidence-based medicine and ethical principles, allows for the identification of the most appropriate treatment pathway. When faced with uncertainty or novel situations, seeking expert opinion and adhering to established guidelines, while remaining open to evolving knowledge, is paramount. The patient’s best interests, informed consent, and shared decision-making should always be at the forefront of any clinical decision.

The risk matrix shows a complex patient profile with multiple comorbidities and a history of previous interventions, necessitating a thorough evaluation of the patient’s suitability for advanced structural heart disease procedures. This scenario is professionally challenging because it requires balancing the potential benefits of a novel intervention against significant patient-specific risks, demanding a high degree of clinical judgment and adherence to established competency frameworks. The decision-making process must be guided by the purpose and eligibility criteria of the Applied Global Structural Heart Disease Medicine Competency Assessment to ensure patient safety and procedural success. The best approach involves a comprehensive review of the patient’s medical history, imaging, and functional status, followed by a multidisciplinary team discussion to determine if the patient meets the specific eligibility criteria for the proposed structural heart intervention, as outlined by the competency assessment guidelines. This ensures that the patient is an appropriate candidate for the procedure and that the treating team possesses the necessary skills and experience, aligning with the core purpose of the competency assessment, which is to validate the proficiency of healthcare professionals in managing complex structural heart disease cases. This systematic evaluation directly addresses the assessment’s aim of ensuring that only qualified individuals undertake these procedures on suitable patients. An incorrect approach would be to proceed with the intervention based solely on the patient’s desire for treatment without a rigorous assessment of eligibility against the competency framework. This fails to uphold the primary purpose of the assessment, which is to safeguard patients by ensuring that interventions are performed by competent professionals on appropriate candidates. Another incorrect approach would be to delegate the final decision-making solely to the interventional cardiologist without consulting other relevant specialists, such as cardiac surgeons, anesthesiologists, and imaging experts. This bypasses the multidisciplinary evaluation crucial for complex structural heart disease cases and neglects the collaborative spirit inherent in competency assessments. Finally, opting for the intervention without confirming that the procedural team has undergone and passed the Applied Global Structural Heart Disease Medicine Competency Assessment would be a significant ethical and regulatory failure, directly contradicting the assessment’s mandate. Professionals should employ a structured decision-making process that begins with understanding the specific purpose and eligibility requirements of the Applied Global Structural Heart Disease Medicine Competency Assessment. This involves a thorough patient-centric evaluation, followed by a collaborative assessment by a multidisciplinary team. The decision to proceed should be unequivocally linked to meeting the defined competency standards and patient eligibility criteria, ensuring that all aspects of the assessment framework are satisfied before any intervention is undertaken.

This scenario is professionally challenging because it requires the clinician to integrate complex imaging findings with a patient’s clinical presentation to arrive at an accurate diagnosis and treatment plan for structural heart disease. The pressure to make timely and correct decisions, especially when dealing with potentially life-threatening conditions, necessitates a systematic and evidence-based approach to imaging selection and interpretation. Misinterpretation or inappropriate selection of imaging modalities can lead to delayed diagnosis, suboptimal treatment, and adverse patient outcomes. The best professional approach involves a comprehensive review of the patient’s history, physical examination, and initial diagnostic tests to formulate a differential diagnosis. This is followed by the judicious selection of imaging modalities that are most appropriate for investigating the suspected structural heart disease, considering factors such as diagnostic yield, patient safety, and cost-effectiveness. Interpretation of these images must be performed by experienced professionals, integrating findings with clinical context and adhering to established guidelines for reporting. This systematic process ensures that the diagnostic reasoning is sound and that the chosen imaging directly addresses the clinical question. An incorrect approach would be to proceed with advanced imaging without a clear clinical indication or a well-defined diagnostic question. This could lead to unnecessary radiation exposure, increased costs, and the generation of incidental findings that may cause patient anxiety or lead to further, potentially invasive, investigations without clear benefit. Another incorrect approach is to rely solely on imaging findings without correlating them with the patient’s clinical presentation. Structural heart disease is a clinical diagnosis supported by imaging, not solely defined by it. Ignoring the patient’s symptoms or other clinical data can lead to misdiagnosis or inappropriate management. Finally, interpreting imaging in isolation without considering the broader clinical picture or consulting with other specialists when necessary represents a failure in collaborative patient care. Professionals should employ a decision-making framework that begins with a thorough clinical assessment, followed by the formulation of specific diagnostic questions. Based on these questions, the most appropriate imaging modality or combination of modalities should be selected, prioritizing those with the highest diagnostic accuracy and lowest risk. Interpretation should be systematic, evidence-based, and integrated with all available clinical information. A multidisciplinary approach, involving cardiologists, radiologists, and other relevant specialists, is often crucial for complex cases to ensure comprehensive and optimal patient management.

Scenario Analysis: This scenario is professionally challenging because it requires navigating the inherent tension between a candidate’s desire to progress and the assessment body’s responsibility to maintain rigorous standards for patient safety and professional competence. The candidate’s personal circumstances (e.g., career advancement, perceived mastery) must be balanced against objective evidence of performance and the established policies designed to ensure that only qualified individuals are certified. The pressure to pass, especially after multiple attempts, can lead to emotional decision-making, making adherence to policy crucial. Correct Approach Analysis: The best professional approach involves a thorough and objective review of the candidate’s performance against the established blueprint weighting and scoring criteria, coupled with a clear and consistent application of the retake policy. This means examining the specific areas where the candidate demonstrated weakness, correlating these with the blueprint’s emphasis, and determining if the performance met the minimum passing threshold as defined by the scoring rubric. The retake policy, which outlines the number of attempts permitted and the conditions for re-examination, must be applied impartially. This approach is correct because it upholds the integrity of the assessment process, ensures fairness to all candidates by applying consistent standards, and prioritizes patient safety by certifying only those who have demonstrably met the required competencies. Adherence to documented policies and objective scoring is a fundamental ethical and professional obligation in any certification or licensing process. Incorrect Approaches Analysis: One incorrect approach would be to allow the candidate to retake the assessment based solely on their expressed commitment to improve and their previous experience, without a formal review of their prior performance against the blueprint and scoring. This fails to acknowledge the objective data from previous attempts and bypasses the established retake policy, potentially compromising the assessment’s validity and fairness. It introduces subjectivity and can lead to a perception of favoritism, undermining trust in the certification process. Another incorrect approach would be to deny the candidate a retake based on an arbitrary interpretation of their previous performance, without a clear link to the blueprint weighting or scoring criteria. If the retake policy allows for further attempts under certain conditions, and the candidate meets those conditions, denying them this opportunity without objective justification based on the assessment’s design is unfair and potentially discriminatory. It also fails to provide the candidate with constructive feedback tied to the assessment’s structure. A further incorrect approach would be to modify the scoring criteria or blueprint weighting for this specific candidate to allow them to pass. This is a severe ethical and professional breach. It directly undermines the standardization and validity of the assessment, rendering the certification meaningless. It creates an unfair advantage for the individual and devalues the achievements of other certified professionals. Professional Reasoning: Professionals facing such situations should always refer to and strictly adhere to the documented policies and procedures governing the assessment. This includes understanding the blueprint’s weighting of different domains, the scoring methodology, and the retake policy. Decision-making should be guided by objective evidence of performance, not by personal appeals or perceived candidate hardship. A structured approach involves: 1) reviewing the candidate’s previous assessment results in detail, mapping them against the blueprint and scoring rubric; 2) confirming the candidate’s eligibility for a retake according to the established policy; 3) communicating the outcome clearly and professionally, referencing the specific policy and performance data; and 4) if a retake is permitted, ensuring the candidate understands the areas for improvement based on the blueprint and scoring.

Scenario Analysis: This scenario is professionally challenging because the candidate is seeking guidance on preparing for a high-stakes competency assessment in a specialized medical field. The challenge lies in balancing the need for comprehensive preparation with the efficient use of time and resources, while also adhering to ethical guidelines regarding professional development and assessment integrity. Misguided preparation can lead to an inaccurate self-assessment of readiness, potential ethical breaches if relying on inappropriate materials, and ultimately, failure to achieve the required competency. Careful judgment is required to select preparation strategies that are both effective and ethically sound. Correct Approach Analysis: The best approach involves a structured, multi-faceted preparation strategy that prioritizes official assessment blueprints, reputable peer-reviewed literature, and simulated practice scenarios. This method is correct because it directly aligns with the stated objectives of the Applied Global Structural Heart Disease Medicine Competency Assessment, which aims to evaluate a candidate’s applied knowledge and skills. Utilizing the official blueprint ensures that preparation is targeted to the specific domains and depth of knowledge assessed. Engaging with peer-reviewed literature from established journals in interventional cardiology and cardiac surgery provides the most current and evidence-based information. Practicing with realistic case simulations, ideally those mirroring the assessment format, allows for the application of knowledge in a practical context and helps identify areas needing further refinement. This comprehensive and evidence-based approach respects the integrity of the assessment process and maximizes the likelihood of demonstrating genuine competency. Incorrect Approaches Analysis: One incorrect approach involves relying solely on informal online forums and anecdotal advice from colleagues. This is professionally unacceptable because such sources often lack rigorous validation, may present outdated or inaccurate information, and do not reflect the official scope or difficulty of the competency assessment. Ethical concerns arise from potentially basing preparation on unsubstantiated claims or personal opinions rather than evidence-based medicine and assessment guidelines. Another incorrect approach is to focus exclusively on memorizing a large volume of disparate facts without understanding their clinical application or interrelationships. This fails to meet the “applied” nature of the competency assessment, which requires candidates to synthesize knowledge and make clinical judgments. Ethically, this approach can lead to a superficial understanding that does not translate into safe and effective patient care, which is the ultimate goal of any medical competency assessment. A third incorrect approach is to dedicate an excessively long timeline to preparation, leading to burnout and potentially delaying the candidate’s ability to practice. While thorough preparation is important, an inefficient or overly protracted timeline can be detrimental. This approach is professionally questionable as it suggests a lack of strategic planning and time management, which are themselves important professional skills. Furthermore, delaying the assessment unnecessarily could impact patient access to care by qualified professionals. Professional Reasoning: Professionals should approach competency assessment preparation with a strategic mindset. This involves first thoroughly understanding the assessment’s objectives, format, and content domains, typically outlined in an official blueprint or guide. Next, they should identify and prioritize high-quality, evidence-based resources that directly address these domains. This includes academic literature, professional society guidelines, and official assessment preparation materials. Finally, they should develop a realistic and structured study plan that incorporates active learning techniques, such as case-based discussions, problem-solving exercises, and simulated practice, to ensure they are not just acquiring knowledge but also developing the ability to apply it effectively. Regular self-assessment and seeking feedback from mentors or peers can further refine this preparation process.

The assessment process reveals a complex clinical scenario involving a patient with structural heart disease requiring nuanced management across acute, chronic, and preventive care pathways. This situation is professionally challenging due to the inherent variability in patient presentation, the dynamic nature of structural heart disease, and the imperative to integrate evidence-based guidelines with individual patient needs and preferences. Careful judgment is required to balance immediate therapeutic interventions with long-term disease management and risk reduction strategies, all while adhering to established medical standards and ethical principles. The best approach involves a comprehensive, multi-faceted strategy that prioritizes guideline-directed medical therapy (GDMT) as the cornerstone of chronic management, coupled with timely and appropriate intervention for acute exacerbations, and a proactive, personalized plan for preventive care. This approach aligns with the principles of evidence-based medicine, which mandate the use of treatments proven effective through rigorous research. Specifically, adherence to current clinical practice guidelines for structural heart disease, such as those published by relevant professional bodies, ensures that management decisions are informed by the highest quality evidence. Furthermore, this approach emphasizes shared decision-making with the patient, respecting their values and preferences in treatment planning, which is an ethical imperative. The integration of preventive strategies, such as lifestyle modifications and risk factor management, is crucial for improving long-term outcomes and reducing the burden of disease, reflecting a holistic and patient-centered philosophy of care. An incorrect approach would be to solely focus on acute symptom management without establishing a robust chronic care plan. This fails to address the underlying structural pathology and its progressive nature, potentially leading to recurrent acute events and poorer long-term prognosis. Ethically, it neglects the professional responsibility to provide comprehensive and ongoing care. Another incorrect approach is to exclusively rely on interventional procedures without optimizing medical therapy. This overlooks the significant role of GDMT in improving outcomes, reducing complications, and managing comorbidities, and may not be cost-effective or appropriate for all patients. It also disregards the evidence supporting a stepped approach to treatment. A further incorrect approach is to implement preventive measures without considering the specific structural defect and its associated risks. Generic preventive advice may be insufficient or even inappropriate, failing to address the unique needs of patients with structural heart disease and potentially leading to missed opportunities for effective risk reduction. Professional reasoning in such situations should follow a structured decision-making process. This begins with a thorough assessment of the patient’s current clinical status, including the severity and type of structural heart disease, presence of acute symptoms, comorbidities, and functional capacity. Next, relevant evidence-based guidelines and the latest research findings should be consulted to inform potential management options. Individual patient factors, including age, preferences, values, and socioeconomic considerations, must then be integrated into the decision-making process, fostering shared decision-making. Finally, a personalized, integrated care plan encompassing acute, chronic, and preventive strategies should be developed and regularly reviewed, with ongoing monitoring of treatment effectiveness and patient well-being.

The assessment process reveals a scenario where a clinician must integrate foundational biomedical science knowledge with clinical decision-making in the context of structural heart disease. This is professionally challenging because it requires not only understanding the underlying pathophysiology of conditions like aortic stenosis or mitral regurgitation but also translating that knowledge into practical, patient-centered management strategies. The complexity arises from the need to consider individual patient factors, the evolving landscape of treatment options, and the ethical imperative to provide the best possible care. Careful judgment is required to balance the risks and benefits of various interventions, ensuring that decisions are evidence-based and aligned with patient values. The best approach involves a comprehensive evaluation of the patient’s clinical presentation, integrating detailed knowledge of the specific structural heart defect’s biomechanical properties and its impact on cardiac function. This includes correlating imaging findings (echocardiography, CT, MRI) with the patient’s symptoms, functional status, and comorbidities. The clinician must then apply this integrated understanding to formulate a treatment plan that considers the patient’s overall health, life expectancy, and personal preferences, while also adhering to established clinical guidelines and ethical principles of beneficence and non-maleficence. This approach prioritizes a holistic view of the patient and the disease process. An incorrect approach would be to solely focus on the anatomical defect identified on imaging without adequately considering the functional implications or the patient’s overall clinical picture. This fails to integrate foundational biomedical science (understanding how the structural abnormality affects hemodynamics and organ systems) with clinical medicine (patient symptoms, comorbidities, and goals of care). Such a narrow focus risks recommending interventions that may not be appropriate or beneficial for the individual patient. Another incorrect approach is to rely exclusively on patient-reported symptoms without a thorough biomedical and clinical assessment. While patient experience is crucial, symptoms alone may not fully capture the severity or progression of the structural heart disease, nor do they account for potential silent but significant underlying pathology. This approach neglects the objective scientific data essential for accurate diagnosis and effective treatment planning. A further incorrect approach is to prioritize a single treatment modality based on its perceived technological advancement or popularity, without a rigorous comparative analysis of its suitability for the specific patient and their condition. This overlooks the critical need to match the intervention to the individual’s unique circumstances, potentially leading to suboptimal outcomes or unnecessary risks. Professionals should employ a systematic decision-making framework that begins with a thorough patient history and physical examination, followed by targeted diagnostic investigations informed by foundational biomedical principles. This data should then be synthesized to understand the interplay between the structural abnormality, its physiological consequences, and the patient’s overall health status. Treatment options should be evaluated based on evidence-based guidelines, considering the specific biomechanical characteristics of the disease, the patient’s comorbidities, functional capacity, and personal values. Shared decision-making with the patient is paramount throughout this process.

The assessment process reveals a scenario that is professionally challenging due to the inherent conflict between a patient’s expressed wishes and the perceived best medical interest by the healthcare team, further complicated by the complexities of a novel and potentially life-altering treatment. Navigating this requires careful judgment to uphold patient autonomy while ensuring ethical care within the established health system. The best professional approach involves a comprehensive and documented discussion with the patient and their surrogate decision-maker, exploring the patient’s values, goals of care, and understanding of the risks and benefits of the structural heart intervention. This approach prioritizes shared decision-making, respecting the patient’s right to self-determination, even if their choices differ from the medical team’s recommendations. It aligns with the ethical principles of autonomy and beneficence, and regulatory frameworks that mandate informed consent. Specifically, in the context of UK regulations and CISI guidelines, the emphasis is on patient-centered care, ensuring that patients are provided with sufficient information in an understandable format to make voluntary decisions. This includes discussing alternatives, the potential for complications, and the long-term implications of the procedure. Documenting this process thoroughly is crucial for accountability and to demonstrate that all ethical and legal requirements have been met. An incorrect approach would be to proceed with the intervention based solely on the medical team’s assessment of the patient’s best interest without adequately addressing the patient’s expressed reservations and ensuring their understanding. This fails to respect patient autonomy and violates the principle of informed consent, as the patient’s decision is not truly voluntary or informed. Ethically, it prioritizes paternalism over self-determination. Another incorrect approach would be to unilaterally withdraw the patient from consideration for the procedure due to the surrogate’s expressed concerns without a thorough exploration of the patient’s own wishes and capacity. This could be seen as a failure to advocate for the patient and could lead to a denial of potentially beneficial treatment without due process. It neglects the importance of understanding the patient’s perspective and their right to make decisions about their own body. A further incorrect approach would be to solely rely on the surrogate’s interpretation of the patient’s wishes without direct engagement with the patient, especially if the patient has some capacity to communicate. This risks misinterpreting the patient’s true desires and could lead to decisions that do not align with their values. It bypasses the essential step of verifying the patient’s understanding and consent directly. Professionals should employ a decision-making framework that begins with understanding the patient’s values and goals. This involves open communication, active listening, and a commitment to shared decision-making. When conflicts arise, the framework should include steps for clarification, exploration of underlying concerns, and seeking consensus where possible, always prioritizing the patient’s autonomy and well-being within the legal and ethical boundaries.

The assessment process reveals a critical challenge in addressing structural heart disease disparities: balancing the need for broad population-level interventions with the ethical imperative to ensure equitable access and outcomes for all demographic groups. Professionals must navigate complex epidemiological data, understand the social determinants of health, and implement strategies that actively mitigate existing inequities. This requires a nuanced understanding of how systemic factors influence disease prevalence, diagnosis, and treatment utilization. The best approach involves a comprehensive, multi-faceted strategy that prioritizes identifying and addressing specific barriers to care within underserved populations. This includes conducting targeted epidemiological studies to understand the unique disease burden and risk factors in different communities, developing culturally sensitive outreach and education programs, and advocating for policy changes that improve access to screening, diagnosis, and advanced treatment options. This approach is correct because it directly confronts the root causes of health inequity by acknowledging that a one-size-fits-all model is insufficient. It aligns with public health principles that emphasize equity and social justice, and implicitly supports regulatory frameworks that mandate non-discrimination and the promotion of health for all citizens. An approach that focuses solely on increasing overall screening rates without considering differential access or outcomes is professionally challenging because it risks exacerbating existing disparities. While seemingly beneficial, it fails to address the underlying reasons why certain populations may be less likely to access or benefit from screening. This can lead to a widening gap in diagnosis and treatment, where already disadvantaged groups remain underserved. This approach is ethically problematic as it does not actively promote health equity. Another professionally challenging scenario arises from an approach that relies on existing healthcare infrastructure without actively seeking to improve its reach or accessibility to marginalized communities. This assumes that equitable access is a natural consequence of available services, which is often not the case. It overlooks the systemic barriers, such as geographic location, insurance status, language, and cultural mistrust, that prevent many individuals from utilizing these services. This approach fails to meet the ethical obligation to ensure that healthcare is accessible to all, regardless of socioeconomic status or background. A further professionally challenging scenario involves an approach that prioritizes the most technologically advanced treatments without a parallel focus on ensuring equitable access to these innovations. While innovation is crucial, an exclusive focus on cutting-edge therapies can create a two-tiered system where only those with superior resources can benefit, further entrenching health inequities. This approach neglects the fundamental ethical principle of distributive justice in healthcare. The professional decision-making process for similar situations should involve a continuous cycle of data analysis, stakeholder engagement, and adaptive strategy implementation. Professionals must first critically analyze epidemiological data to identify disparities. This should be followed by engaging with community leaders and patient advocacy groups to understand lived experiences and barriers. Based on this understanding, targeted interventions should be designed and implemented, with ongoing monitoring and evaluation to assess their impact on health equity. Finally, professionals must be prepared to adapt their strategies based on the evaluation results and evolving community needs, always prioritizing the principles of justice, fairness, and the promotion of health for all.