New report looks at the latest on breast cancer

The breast cancer death rate in the United States continues to fall by around 2% a year, as it has since 1990, according to Breast Cancer Facts & Figures 2007-2008, a biennial report on breast cancer statistics and trends produced by the American Cancer Society. That’s an impressive winning streak for an important indicator of success in the fight against cancer, made possible in large part, the report says, by advances in early detection and treatment. Those advances have benefited women of some races more than others, data shows. For instance, the cancer death rate for white and Hispanic/Latina women fell by 2.4% between 1995 and 2004, but only by 1.6% for African-American women. And during the same time period, no change was seen in cancer death rates of Asian Americans/Pacific Islanders or American Indians/Alaska Natives. Also, authors note a decline in breast cancer incidence, that is, the rate at which new cancers are diagnosed, but suggest it may be due in part to fewer women getting mammograms. “Perhaps most troubling,” said Harmon J. Eyre, MD, chief medical officer of the American Cancer Society, “is the striking divergence in long-term mortality trends seen between African-American and white females that began in the early 1980s and that by 2004 had led to death rates being 36% higher in African-American women.”

Other key statistics include: An estimated 178,480 new cases of invasive breast cancer in women will be diagnosed in 2007, and approximately 40,460 deaths will be recorded. Only lung cancer accounts for more cancer deaths in women. In 2004 (the latest year for which figures are available), approximately 2.4 million women living in the US had a history of breast cancer. Breast cancer accounts for more than 1 in 4 cancers in US women. On average, the breast cancer death rate decreased by 2.2% each year between 1990 and 2004. Younger women saw an even more significant decline during that period. Breast cancer incidence among white women fell by 3.7% a year during 2001-2004. Also declining during this time: the use of mammography and hormone replacement therapy (HRT) by white women. There was no significant change in breast cancer incidence among African-American women during this time, coinciding with stable mammography rates and HRT use. Among women 50 and older, incidence rates have been on a steep decline (by 4.8% per year) since 2001. Among women under age 50, incidence rates have remained stable since 1986. Since 2000, the incidence rate of smaller tumors has declined by 3.8% per year. In contrast, the incidence rate of larger tumors (>5.0 cm) has increased by 1.7% per year since 1992. Both trends may be tied to an increase in obesity in postmenopausal women, HRT use, or both.

Major risk factors for breast cancer that women have some control over include: Obesity increases a woman’s risk of postmenopausal (but not premenopausal) breast cancer, as does weight gain during adulthood. Women who drink just 2 alcoholic beverages a day face a 21% increase in their risk for breast cancer. Women can lower their risk of breast cancer by exercising vigorously for 45 to 60 minutes on 5 or more days per week. Postmenopausal women can lower their risk, according to one study, with any level of physical activity performed on a regular basis. The report also takes note of groundbreaking breast cancer research, such as studies looking at the chemoprevention of cancer and at the development and testing of so-called “rational therapeutics,” drugs that are tailored to the unique characteristics of each patient and tumor. For more information see THIS LINK

WHO: Cholera in Iraq intensifies

Since late August 2007, an outbreak of cholera has spread to 25 districts of Northern Iraq and 4 districts in Southern Iraq and across the centre of the country. It is estimated that more than 30,000 people have fallen ill with acute watery diarrhea, among which 2,116 were identified as positive for Vibrio cholerae. The case fatality rate is 0.52% and has remained low throughout the outbreak, although it continues to spread across Iraq and dissemination to as yet unaffected areas remains highly possible. The outbreak was first detected in Kirkuk province, where 68% of laboratory-confirmed cholera cases have so far been reported, and then spread to Sulaymaniah and Erbil provinces. Additional isolated cases of Cholera have also been identified in other parts of the country, including Tikrit (6 cases confirmed), Mosul (2 cases confirmed), Basra (1 case confirmed), Baghdad (2 cases confirmed) and Dahuk (1 case confirmed).

The Government of Iraq has mobilized a multi-sectoral response to the outbreak. Specific control measures have been reinforced and preventive measures to reduce the risk of transmission to unaffected areas have been put in place. However, a severe shortage of chlorination products has been noted and replenishment is urgently needed to enable water supplies to be treated to render it safe for human consumption. Provision of safe water is the highest priority in controlling an outbreak of cholera. The World Health Organization (WHO) continues to support the National and local health authorities in the ongoing response operations. Ten interagency diarrheal disease kits, each sufficient to treat 400 moderate and 100 severe cases, arrived in Erbil International airport on 16 September. Rapid diagnostic tests are being pre-positioned in remote health care facilities. In addition, 10% of all positive stool samples are being sent to NAMRU 3 reference laboratory (US Navy Advanced Research Unit) in Cairo for further confirmation and phenotypic characterization. In controlling the spread of cholera, WHO does not recommend any special restrictions to travel or trade to or from affected areas.

US hospitals report infections increasing in frequency and cost

A new review of inpatient data from US hospitals shows that the number of infections caused by a common bacterium increased by over 7 percent each year from 1998 to 2003. The attendant economic burden to hospitals increased by nearly 12 percent annually. The research is published in the November 1 issue of Clinical Infectious Diseases, now available online. Staphylococcus aureus (also known as staph) is a significant cause of a wide range of infectious diseases in humans, ranging from minor skin infections to life-threatening diseases such as pneumonia and meningitis. In 1998, US hospitals reported a little more than a quarter-million staph infections and slightly over 7 percent of those patients died. By the final year of this study, 2003, hospitals reported nearly 390,000 infections, representing 1 percent of that year’s inpatient stays.

The authors suggest one possible reason for the increase in infections is the documented increase of a particularly dangerous type of antibiotic-resistant staph infection known as MRSA (methicillin-resistant Staphylococcus aureus). A more benign possibility is that doctors and hospitals have improved their infection detection and reporting practices. The good news is that the staph-related in-hospital mortality rate dropped by almost 5 percent each year. The decrease in the in-hospital mortality risk may be due to the introduction of more stringent infection control programs or due to appropriate early treatment of MRSA infections with an effective antibiotic, the authors write.

Hospital expenditures associated with staph infections are substantial, increasing from $8.7 billion in 1998 to $14.5 billion in 2003. This economic burden incorporates such factors as extended length of hospitalization and additional surgery, medications, lab tests, and radiologic studies. Lead author Gary Noskin, MD, of Northwestern Memorial Hospital in Chicago, hypothesized that the reason the economic burden increased at a faster pace than the number of infections is because hospital costs are increasing more quickly. The authors used data from the Agency for Healthcare Research and Quality’s Nationwide Inpatient Sample database, which contains data from approximately 7 million hospital stays annually. Unfortunately, the authors were not able to determine the contribution of MRSA infections to costs or outcomes because hospitals generally use the same codes for MRSA and regular staph infections. “We do suggest that coding standards should be changed to more accurately reflect the difference between these two bacteria so we can better understand the impact of MRSA,” said Dr. Noskin.
 

International Classification of Diseases, 9^th revision, Official Guidelines for Coding and Reporting

Effective October 1, 2007, The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). These guidelines should be used as a companion document to the official version of the ICD-9-CM as published on CD-ROM by the U.S. Government Printing Office (GPO). These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself. Adherence to these guidelines when assigning ICD-9-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Volumes 1-2) have been adopted under HIPAA for all healthcare settings. Volume 3 procedure codes have been adopted for inpatient procedures reported by hospitals.

A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be reported. For more information see THIS LINK

Massachusetts: Insurers’ hospital payments soon online

Massachusetts consumers soon will have access to information long kept confidential by the healthcare industry: The prices individual hospitals are paid by insurers for performing specific procedures, data state officials hope will encourage comparison shopping and reduce medical costs. State regulators, who approved the plan last week, said their goal is to begin posting the information on the Internet by March. They will spend the next few months deciding what treatment and procedures will be included in the data. The move by the state’s new Health Care Quality and Cost Council makes Massachusetts one of the first states to make this normally secret information public. New Hampshire recently began disclosing similar information for care, including emergency room visits, CT and MRI scans, arthroscopic knee surgery, and childbirth. The state’s mandatory health insurance law requires insurers and hospitals to disclose to the state payments for procedures, which are negotiated rates that take into account a variety of factors, including discounts for insurers that direct large numbers of patients to a hospital.
 

Dolores Mitchell, a council member and executive director of the state’s Group Insurance Commission, said “shining a bright light” on costs will let “the public know how each institution compares and whether there is a justification for one hospital to be twice as expensive as another.” The council also plans to include quality measures, whether hospitals adhere to best practices and achieve good outcomes for patients, for the procedures for which it decides to disclose payments. So, for example, if a hospital charges far more than other institutions for treating heart attack or pneumonia patients, but has lower quality scores, consumers might conclude the extra cost is not justified. Massachusetts officials hope that the disclosure of the information will help reduce healthcare costs.

The theory is that consumers provided with detailed information will choose high-quality, low-cost providers for nonemergency care, which in the long run will put pressure on high-cost providers to become more efficient. Without cost controls, many health policy specialists say, the state might be unable to subsidize adequate coverage for thousands of uninsured residents, as required by the new health insurance law. “The institutions themselves will become more responsive when they know everything is out there,” Mitchell said. The theory is unproven, though, and others involved in healthcare said posting the information may have unintended consequences. “No one really knows what will happen when you put this information out there,” said Dr. Thomas Lee, a council member and president of the physician network for Partners HealthCare System, which includes Massachusetts General and Brigham and Women’s hospitals. “Most people would predict a flattening of the market,” meaning that prices for all hospitals will move toward an average. But, he said, hospitals that receive lower payments than their competitors could use that information to demand more money from insurers during negotiations, driving up costs rather than reducing them.

No Massachusetts hospitals are voluntarily disclosing the payments they receive, according to the Massachusetts Hospital Association, but there clearly is wide variation in what insurers pay. Blue Cross and Blue Shield pays from about $3,000 at one Massachusetts hospital to more than $5,000 at another for its HMO members for a normal delivery, including the cost of caring for the mother over a two-day hospital stay. New Hampshire’s HealthCost website shows even larger disparities. (The Boston Globe) To read the complete article see THIS LINK

Univ. of Cincinnati health provost to step down

The highest-ranking executive at the University of Cincinnati Medical Center has decided to leave her post, citing differences with UC’s board and President Nancy Zimpher. “The vision and the management philosophy used to guide the academic health center by the UC board of trustees and the president is substantially different than the one I was recruited to pursue in 2003,” said Dr. Jane Henney, senior vice president and provost for health affairs, in a Sept. 7 message to employees. In an interview Tuesday, Zimpher indicated that UC will explore “different models for how to organize” its health-related units. That could mean abolishing Henney’s provost position altogether. Zimpher said she’ll spend the next few months consulting with faculty and leadership on the UC medical campus, along with research partners at Cincinnati Children’s Hospital Medical Center. If the provost's office isn’t filled, Zimpher said UC will likely replace it with another structure that clusters health-related colleges under a single management unit.

The UC medical campus has been through a rough year, with $89 million in cost overruns in its construction program for new lab space and rising deficits in a multi-year program aimed at bringing 200 new researchers to the school. UC cut that recruitment goal to 68 researchers this year. UC faces additional financial pressure thanks to a decision by Christ Hospital and the St. Luke Hospitals to leave the Health Alliance of Greater Cincinnati. (Business Courier of Cincinnati)

The Council of Supply Chain Executives announces new corporate member

The Council of Supply Chain Executives (The Council), a division of the Institute of Healthcare Executives and Suppliers (IHES), announces the addition of Luminetx Corporation to its list of healthcare supplier clients. Luminetx Corporation is a privately held company from Memphis, TN, that discovers, develops, and commercializes bioscience technologies. Their premier product, The VeinViewer, uses a combination of near-infrared light and patented technologies to image vascular structures, which allows physicians, nurses and other healthcare professional to clearly locate subcutaneous veins directly on the skin, thereby eradicating the possibility of numerous needle sticks. The Council provides consulting, insight and educational networking opportunities for leading healthcare suppliers of products and services utilizing a roster of the premier supply chain executives in the country. For more information see THIS LINK
 

Angel Medical Center adopts new infusion pump technology
from B. Braun

In an effort to boost patient safety and healthcare efficiency, Angel Medical Center announced its rapid and successful conversion to B. Braun Medical Inc.’s Outlook 300 Safety Infusion System. The hospital’s new infusion system now enables improved patient safety and streamlined patient care, as well as enhanced communication between nurses and pharmacists, through use of the its unique barcoding capabilities and dose monitoring software, DoseTrac. These two cutting-edge safety features help clinicians ensure that the right medication, in the right dose, is delivered to the right patient. Electronic barcoding matches the pharmacy-prepared medication to the patient’s infusion pump, while dose monitoring software helps clinicians monitor the appropriate use and dosing of medications. After reviewing possible options, Angel Medical’s senior leadership selected the wireless Outlook 300 System for its ease of use and advanced features. Angel Medical completed its conversion to the Outlook 300 system within five weeks. For more information see THIS LINK

United States continues to have highest level of health spending

The United States continues to spend the most on healthcare when compared to other Organization for Economic Cooperation and Development (OECD) countries. Healthcare prices and higher per capita incomes are major factors for higher U.S. spending, according to a study by researchers at the Johns Hopkins Bloomberg School of Public Health and Princeton University. Compared to the average OECD country in 2004, the United States has fewer health resources, physicians, nurses and hospital beds, and lower utilization of these resources. Health spending for chronic health issues, such as obesity, alcohol consumption and smoking, also contributes to high health spending in the United States. The study is published in the September/October 2007 issue of Health Affairs. “We spend so much more money on healthcare in the United States than other industrialized countries primarily because our prices are so much higher,” said lead author of the study, Gerard Anderson, PhD, a professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health.

Using 2004 data, which is the most recent available, the researchers report the following key study results: U.S. healthcare spending per capita was 2.5 times greater than the median OECD country. The United States spent 15.3% of our gross domestic product on healthcare, which is substantially higher than any other OECD country. U.S. growth in healthcare spending per capita from 1994 to 2004 was similar to the OECD median. The United States has promoted policies to reduce the number of hospital days as a way to contain costs. It is now ranked fourth highest among OECD countries for hospital spending per capita. The United States spent 3.6 times what the median OECD country spent in 2004 for outpatient care. Most of the difference between the United States and other countries is attributable to higher spending on physician services. The United States had fewer physicians, nurses and hospital beds per capita than the OECD median. The United States also had lower utilization rates than the OECD median for physician visits per capita, acute care bed days and average length of inpatient stay. The study authors examined the prevalence of chronic disease as an increasing financial burden in the United States and other countries. Five chronic diseases, diabetes, respiratory disease, cerebrovascular disease, heart disease and malignant neoplasm, cause two-thirds of deaths in the United States. Compared to other OECD countries, we have the highest mortality rate for some of these chronic diseases, but not all.

Cost of health insurance rises again, but at a slightly slower rate

The cost of employer-sponsored health insurance premiums has increased 6.1 percent this year, well ahead of wage trends and consumer price inflation, but below the 7.7 percent increase in 2006, the Kaiser Family Foundation reported. Because doctor and hospital costs continue to rise at an even faster rate, the modest slowdown in insurance inflation mainly reflects cutbacks in coverage by many health plans, which have found ways to make employees pay more for their care. Industry experts said that without those measures, premium costs would have risen by 9 percent or more. The total average annual cost for family coverage premiums rose this year to $12,106. Drew Altman, president of the Kaiser Foundation, a nonprofit group that produces the annual survey noted that health costs had increased 78 percent since 2001, more than four times the pace of prices and wages.

The 2007 increase was the smallest annual rise since 1999, when health premiums jumped 5.3 percent. Kaiser did not try to project 2008 costs for health premiums. But research houses are forecasting increases for next year that include 6.7 percent by Mercer Health and Benefits; 9.9 percent by PricewaterhouseCoopers; 10.5 percent by the Segal Company; and 11 percent by AON Consulting. The costs of hospital and doctor care seem to be “outpacing premium increases,” said Jon Gabel, a principal investigator for the Kaiser survey. That could squeeze insurance company profit margins, which have been running at 6 percent to 7 percent, he said.

Sixty percent of employers offer health benefits, including nearly all large companies with 200 or more workers. But fewer than half of small businesses with three to nine employees do so, the survey found. The telephone survey, which ended in May and was conducted by Kaiser and the Health Research and Educational Trust, queried 3,078 public and private employers and was based on 1,997 that responded to the full survey. It found that employers and workers are still slow to embrace the widely publicized high-deductible plans with savings options that have been promoted by the Bush administration and many insurance companies and banks. Such health savings account plans attained only a “modest enrollment” of 3.8 million workers, according to Kaiser. That was 5 percent of all covered employees, compared with 4 percent in 2006.

Almost one in five large employers currently offer some sort of health savings option, combined with high-deductible insurance. But only 2 percent of employers that do not already offer health savings accounts said they were very likely to add them next year. Most preferred-provider organizations, or P.P.O.’s, the networks that cover 57 percent of all workers, now pay for services like immunizations and mammograms without charging the employee. Also, nearly half of all employers that offer health benefits now cover unmarried domestic partners of the opposite sex, and about 37 percent cover same-sex partners. As for drug plans, three in four covered employees are in them, with average out-of-pocket payments of $11 for generic drugs, $25 for the health plan’s preferred brand-name drugs and $43 for brands not on the preferred list. (The New York Times) To read the original article see THIS LINK
 

The hospitalist is in, and taking over a role played by primary care physicians

In the past 10 years, despite resistance from primary care physicians and fears that the development could erode continuity of care, the ranks of hospitalists have exploded from a few hundred physicians in 1997 to 20,000 today, about as many as there are gastroenterologists or neurologists. That’s the fastest growth for any medical specialty in the country, according to the nonprofit Society of Hospital Medicine (SHM), the professional society for hospitalists. Initially, the trend was driven by hospitals and managed-care groups, seeking to cut costs and improve care quality. But with hospital reimbursement rates failing to keep up with their costs, many primary care physicians are being won over and now find the hospitalist arrangement saves them time and money. And although many patients may resent not having their doctor at their bedside, just when they need him or her the most, the hospitalist movement, by most accounts, is here to stay. “The majority of hospitals in the United States have hospitalists, because it’s a better utilization of resources, of time, of communication skills and quality of care,” said Ahmed Nawaz, who leads a hospitalist practice based at Holy Cross Hospital in Silver Spring.

Yet many patients are unaware of the trend. “We don’t introduce ourselves as ‘hospitalists,’” said Washington internist Michael Molineux, director of the hospitalist program at Georgetown University Hospital. “Most patients don’t know what it is or what it means.” Molineux said he stopped using the word when many patients understood him to say “hospice” and thought they were at death's door. “I say I'm an attending physician in internal medicine and I'll be in charge of the team taking care of them,” he said. That means assuming responsibility for everything from admission to discharge, including making patient rounds and ordering all needed tests and procedures. Most hospitalists are internists; 11 percent are pediatricians. By 2010, SHM projects 30,000 hospitalists will be practicing. Medical students may soon choose which side of the hospital divide they want to work on: inpatient or outpatient. For now, it’s your physician’s choice whether to refer you to a hospitalist or to follow your inpatient care. If you have no primary care physician, a hospitalist will probably manage your hospital stay. Although patients are often confused about the role of hospitalists, hospitals embrace the new model, nationally subsidizing $50,000 to $60,000 of the average hospitalist's $169,000 salary.

Managed-care organizations, such as Kaiser, have established their own hospitalist practices. There is financial incentive to do so: Studies show hospitalists manage care more efficiently and reduce hospital stays. Hospitalists say they think that's because they order tests and procedures more promptly. Hospitals and managed-care organizations are betting that the use of hospitalists will result in better care. In the largest hospitalist study to date, presented at the 2007 Hospital Medicine annual meeting, Peter K. Lindenauer, associate professor of medicine at Tufts University School of Medicine, found that hospital stays are a half-day shorter if managed by a hospitalist, with mortality and readmission risks comparable to those of family physicians or general internists. Smaller studies found improved patient satisfaction and quality of care. Hospitalists’ biggest selling point is that they’re always on-site. But other patient advocates worry that although hospitalists are expert at managing hospital stays, they also may contribute to the fragmentation of care. (The Washington Post) To read the original article see THIS LINK

More studies cast doubt on safety of diabetes drug

Two more studies published in yet another prominent medical journal have raised questions about the safety of Avandia, a once-popular diabetes medicine. One study found that Avandia, made by GlaxoSmithKline, doubled the risks of heart failure and raised the risks of heart attack by 42 percent. A second study found that Actos, a similar drug made by Takeda, actually lowered the risks of heart attacks, strokes and death but, like Avandia, also raised risks of heart failure. Taken together, some of the authors said, the two studies in The Journal of the American Medical Association confirm what doctors and patients using Avandia have already done in great numbers, that is, switch to another drug. Sales of Avandia have plunged. GlaxoSmithKline said in a written statement that the studies were flawed and “offered no new information on the safety of Avandia.” The company “continues to support Avandia as safe and effective when used appropriately,” the statement said.

In July, a federal advisory panel voted overwhelmingly that Avandia should remain on the market even though it raised the risks of heart attacks. In June, the Food and Drug Administration said it would place its strictest warnings on the labels of both Avandia and Actos because of heart failure risks. Riven by internal disagreements, the drug agency is still pondering further regulatory actions regarding Avandia. Some in the agency say that the drug should be withdrawn, while others say that all diabetes drugs have risks and that doctors need a variety of options. Richard Hellman, president of the American Association of Clinical Endocrinologists, said that the new studies were “more evidence that we should have a very high level of caution” regarding the use of Avandia. The drug agency should further strengthen the warnings on Avandia’s label to make it clear that the drug should be used very sparingly. (The New York Times) To read the original article see THIS LINK

CompView Medical forms strategic alliance with GE Healthcare

CompView Medical, a provider of integrated audio-visual systems for healthcare environments, announced a partnership with GE Healthcare through their General Electric Healthcare OEC Surgery Division (GE OEC), whereby GE OEC will be a distributor of the CompView Medical NuBOOM video integration and equipment management system. This unique agreement enhances the minimally invasive surgical (MIS) procedure market that GE OEC supports as the combined efforts of both companies provide a complete surgical solution for in-patient hospital facilities and outpatient ambulatory surgical centers (ASC's). This is the first time video integration equipment has been represented by a surgical fluoroscopic imaging company. NuBOOM is the only all-in-one equipment management and video visualization system that delivers four fully adjustable high definition (HD) monitors around the operating room table. The system provides surgeons and members of the operating room (OR) staff ergonomically-sound viewing angles of high quality images from anywhere within the operating field. GE OEC, part of the GE Healthcare division, is a provider of Mobile C-Arm Fluoroscopy systems. The company develops computer-based X-ray and fluoroscopic imaging systems for hospitals, outpatient clinics and surgical centers. The firm’s X-ray imaging systems combine radiographic and fluoroscopic imaging with digital image-processing capabilities to improve image quality, lower X-ray dosage and reduce costs.   

New HIV diagnoses rising in New York City among young men
who have sex with men

HIV infection is on the rise among young men who have sex with men (MSM) in New York City, according to preliminary data from the Health Department. New HIV diagnoses among MSM under age 30 have increased by 33% during the past six years, the agency reported today, from 374 in 2001 to almost 500 in 2006. New diagnoses have doubled among MSM ages 13 to19, while declining by 22% among older MSM. The under-30 group now accounts for 44% of all new diagnoses among MSM in New York City, up from 31% in 2001. Blacks and Hispanics still bear a disproportionate share of New York City’s HIV burden. Among all MSM, blacks received twice as many HIV diagnoses as whites in 2006 (232 versus 101), and Hispanics received 55% more than whites (157 versus 101). The disparity is even more striking among adolescents; more than 90% of the MSM under age 20 diagnosed with HIV in 2006 were black or Hispanic (81 out of 87). To focus on more recent trends in HIV infection, this analysis excluded MSM who were diagnosed with HIV and AIDS at the same time, generally indicating that the infection has progressed for many years. In 2006, 20% of MSM diagnosed with HIV received a concurrent diagnosis of AIDS (285 men), meaning that they had missed opportunities for care to stay healthy and may have unknowingly spread HIV to others.