Chapter in ASCO Book
APOS past president, Paul Jacobsen, contributed to an American Society for Clinical Oncology (ASCO) educational book, writing “Psychosocial Screening for Cancer Patients.” This is a topic he recently presented at ASCO’s annual meeting as part of an educational symposium, summarizing the current status of psychosocial screening in oncology care, and discussing how there is growing momentum to expand and improve psychosocial care. The session was very well attended (about 300 people) and well received.
APOS Member Interview on Survivorship Julia Rowland, Director of the National Cancer Institute’s Office of Cancer Survivorship and APOS member, served as chair of the ASCO annual meeting session on survivorship. In an interview with ASCO Daily News, she states,“What many survivors tell us happens is that after definitive treatment ends, they fall into an abyss. It is not clear to them who should be following them, where they should go for care, or how their care will be coordinated. Recent survivorship trends are raising awareness of what survivor care should be like once their active treatment ends and, importantly, who should be responsible for this care.”
APOS Member Leads Track at ASCO Meeting
Lynne Wagner, APOS’ representative on the American College of Surgeons Commission on Cancer, served as the track leader for Health Services Research at the ASCO annual meeting, and also championed ASCO inclusion of information on psychosocial screening.
Poster Presentation and Handbook Chapter Mary Hughes, APOS 2012 conference chair, presented a poster, “10-year Analysis of Sexual Dysfunction in Women seen by a Psychiatric Clinical Nurse Specialist,” at the Cancer Survivor and Sexual Health Symposium in Washington, DC this month. She also moderated the APOS Lecture by Chris Nelson, “Communication and Intimacy - Enhancing Interventions for Men Diagnosed with Prostate Cancer and their Partners.”
PNDP Peer Learning Workshop
Health Disparities SIG Co-Chair, Kimlin Ashing-Giwa, presented her talk “Patient Navigation: Bridging the Gap by Delivering Culturally and Linguistically Competent Care” at the Patient Navigator Outreach and Chronic Disease Prevention Demonstration Program (PNDP) Peer Learning Workshop in Bethesda, MD. PNDP is a demonstration program to improve health care outcomes for individuals with cancer or other chronic diseases, with a specific emphasis on health disparity populations.
Spotlight on APOS
APOS is featured in the May edition of the American College of Surgeons Commission on Cancer’s enewsletter, the CoC Flash.
Bending the Rules
APOS members Karen Mustian, PhD and Alyson Moadel, PhD were featured in the spring issue of Cure in a an article on yoga as complementary therapy for cancer patients.
Finding a Good Life After Cancer, Roger Granet, MD Dr. Granet’s article “Finding a Good Life After Cancer,” was featured in Coping Magazine(September/October 2010). Coping also featured a spotlight on APOS in the November 2010 issue. posted 24 March 2011
The Art of Conversation Through Serious Illness, Richard McQuellon PhD
The Art of Conversation Through Serious Illness by Richard McQuellon PhD and Michael Cowan PhD (Oxford University Press 2010), garnered a glowing review in Health Progress (January/February 2011). Reviewer Diane Kreslins wrote the book is “a must-read,” recommending it to “professional health care providers, para-professional caregivers, medical student interns, religious and spiritual leaders and other caregivers who provide support to those living with serious illness.” posted 24 March 2011
Oncology Nursing Forum, Mary K. Hughes MS, CNS, CT
Mary Hughes’ article made it to the top ten list of articles published from June 2009 to May 2010 in the Oncology Nursing Forum (ONF) and Clinical Journal of Oncology Nursing. She received this for her September 2009 ONF article of her 2009 Mara Morgensen Flaherty Lectureship: “Sexuality and Cancer: The Final Frontier for Nurses” (online exclusive). The top ten list can be found in ONF January 2011 on Page 7 (editorial). The article is titled "Top 10 from the Top Two." posted 24 March 2011
The ASCO Post Includes Psychosocial Information
ASCO began a new free monthly newsletter for its 40,000 members last spring. Cara Glynn, as an Editor, solicited Jimmie Holland to serve as a consultant for suggesting short articles, which would update oncologists about “hot button” psychosocial issues. The first issue (ASPO Post 1:1:2010, page 55) contained a piece by Holland: The New Standard of Quality Cancer Care: Integrating the Psychosocial Into Routine Care. (Copies available from her office.) The October issue contained another article of importance to oncologists about the right antidepressant to give to patients receiving tomaxifen. Bill Breitbart MDwrote a superb piece that provides background and direction as to which drugs to use or avoid: “Do Antidepressants Reduce the Effectiveness of Tamoxifen?” (ASCO Post 1:5: pages 28-29, October). This article is extremely helpful for psycho-oncologists as well. A third will be out in the new year by Paul Jacobsen PhD on monitoring the quality of psychosocial care by chart audit, presently being used by the self-audit community practices through ASCO and QOPI. posted 22 December 2010
The Oxford Textbook of Palliative Social Work (Terry Altilio MSW, ACSW, LCSW and Shirley Otis-Green MSW, ACSW, LCSW, OSW-C editors) is a comprehensive, evidence-informed text that addresses the needs of professionals who provide interdisciplinary, culturally sensitive, biopsychosocial-spiritual care for patients and families living with life-threatening illness. Social workers from diverse settings will benefit from its international scope and wealth of patient and family narratives. Unique to this scholarly text is its emphasis on the collaborative nature inherent in palliative care. This definitive resource is edited by two leading palliative social work pioneers who bring together an array of international authors who provide clinicians, researchers, policy-makers and academicians with a broad range of content to enrich the guidelines recommended by the National Consensus Project for Quality Palliative Care. posted 22 December 2010
Emotion work: disclosing cancer
Grace J. Yoo, Caryn Aviv, Ellen G. Levine, Cheryl Ewing and Alfred Au
This paper focuses on the emotion work involved in self-disclosing a breast cancer diagnosis in a racially or ethnically diverse population. The results indicate self-disclosing was done at a time when important decisions about treatment needed to be made. Different strategies for disclosure were used, all of which entailed emotion work. Respondents talked about the various elements of emotion work in the disclosure process including: managing others’ worry, protecting and soothing others, and educating and instructing others. For many respondents, disclosure without calculating emotional management meant opening up to others which meant support and an increase in emotional resources. Conclusions: The findings in this paper have implications for women with breast cancer and demonstrate the need for women to be involved in honest disclosure and less emotional management of others’ feelings. There is also a need for education about the nature of the cancer experience among people who are not well educated about the treatment and consequences of cancer. This need may be even stronger among racial and ethnic minorities. posted 22 December 2010
ExCel in Social Work
Shirley Otis-Green, MSW, ACSW, LCSW, OSW-C is the Primary Investigator of an NCI-funded educational project for oncology social workers which provides training for all oncology social workers and isn’t limited to AOSW (Association of Oncology Social Workers) or APOSW (Association of Pediatric Oncology Social Workers) members. ExCEL in Social Work: Excellence in Cancer Education and Leadershipis a five-year National Cancer Institute-funded educational initiative that strives to improve the delivery of psychosocial-spiritual care for oncology patients through an innovative oncology social work-specific leadership-training program. ExCEL is a collaborative partnership between the City of Hope, AOSW and APOSW. Co-Investigators are Betty Ferrell, Marcia Grant, Brad Zebrack and Barbara Jones. This training will enhance competitively-selected oncology social workers’ critical leadership skills through a focus upon the recommendations of the Institute of Medicine (IOM) 2008 Report – Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Applicants will receive: free registration, one night hotel stay, meals associated with the pre-conference, extensive course materials & contact hours. (Provider-approved by the California Board of Behavioral Sciences, Provider #2401 for 7.25 contact hours). The application deadlines are January 21, 2011 (for the AOSW Pre-Conference May 2-3, 2011 in St. Louis, MO) and January 28, 2011 (APOSW Pre-Conference May 9-10, 2011, Atlanta, GA). Organizational membership is encouraged, but not required. To apply: http://www.cityofhope.org/education/health-professional-education/nursing-education/excel/Pages/default.aspx. For more information, contact ExCEL Project Coordinator, Lisa Kilburn: ExCEL@coh.org. posted 22 December 2010
APOS Member John Peteet MD has been published in the following articles:
Peteet JR, Narrow W, Lu F (eds). Religious and Spiritual Issues in Psychiatric Diagnosis: A Research Agenda for DSM-5. Washington, D.C. American Psychiatric Publishing. 2011.
Peteet JR. Depression and the Soul. A Guide to Spiritually Integrated Treatment. New York, Routledge. 2010.
Peteet JR, Maytal G, Rokni H. Unimaginable loss: contingent suicidal ideation in oncology family members. Psychosomatics 2010;51:166-170.
ACoS Standard of Care
Lynne Wagner PhD represented APOS on the American College of Surgeons Commission on Cancer. On behalf of APOS, she proposed a new Standard of Care for institutions to begin developing programs to conduct psychosocial screening of cancer patients. This standard is being advanced and she will be presenting at a March 3rd ACoS-sponsored meeting with other APOS members, Matt Loscalzo MSW and Paul Jacobsen PhD, on how to conduct distress screening. posted 22 December 2010
MD Anderson Manual of Psychosocial Oncology
APOS Member, Alan Valentine, MD is one of the editors of the newly published MD Anderson Manual of Psychosocial Oncology, McGraw-Hill, 2010. APOS members who contributed chapters include: Alan Valentine, MD, Anis Rashid, MD, Kathie Rickman, RN, DPH, CNS, Mary Hughes,RN, CNS, CT, and Michelle Fingeret, PhD. posted 22 December 2010
APOS featured in Coping with Cancer magazine
APOS resources, including the toll-free Helpline were highlighted in the November/December 2010 issue of Coping with Cancer.
Not Just the Blues
Jimmie Holland, MD discussed depression in cancer patients as well as the resources available through the APOS helpline in an article published on page 27 of the Fall issue of Cure Magazine
Several APOS members collaborated on an article about cancer-related fatigue published in the
August 2010 Issue of the Journal of the National Comprehensive Cancer Network.
Adult Cancer Pain
Several APOS members contributed to an article about adult cancer pain published in the
August 2010 Issue of the Journal of the National Comprehensive Cancer Network.
Article by Jimmie Holland in ASCO Post An article by APOS Founding President, Jimmie C. Holland, MD, entitled "The New Standard of Quality Cancer Care: Integrating the Psychosocial into Routine Care" has been published in the June 2010 ASCO Post. Read article.
New Psychiatric Oncology Center Launched Massachusetts General Hospital Cancer Center has launched the Center for Psychiatric Oncology and Behavioral Sciences under the direction of APOS member, William Pirl MD, MPH. The Spring 2010 issue ofthe MGHCC's newsletter, Synergy, quotes Pirl as saying that "he hopes to rapidly translate their research into 'screening for and targeting those emotional and behavioral factors that affect survival, just as we screen for genetic mutations in tumors.'" View announcement on the MGHCC website.
Don't Let Fear Hold You Back
Thank you to Board member, Lynda Mandell MD, PhD, FACR, for her contribution to the MediaPlanet insert in the 2 April 2010 issue of USA TODAY. Dr. Mandell’s article addresses colorectal screening issues.
Articles by APOS Members
Some very informative articles by various APOS members have been published in the April 2010 issue of the Journal of the National Comprehensive Cancer Network. View abstracts.
A New View, After Diagnosis Experimental Group Therapy Aims to Help Cancer Patients Find Meaning in Face of Mortality
APOS member and IPOS President William Breitbart, MD is featured in a 16
in the Wall Street Journal Health Section.
Victoria Champion Appointed
to National Cancer Advisory Board
Bethesda, Maryland, October 2008 — Victoria
an APOS member
since 2003, has been appointed
to the Board of Directors of
the National Cancer Advisory
Board (NCAB) of the
Institute. This is a six-year
appointment, with the term ending
in 2014. Dr. Champion
is the Associate
Dean for Research
and Professor of
Nursing at the Indiana
University School of Nursing in Indianapolis,
Caring for the Whole Person: Jimmie Holland profiled in CR
CR is the American Association
for Cancer Research’s award-winning
magazine about cancer
survivorship and advocacy,
and connects everyone
who is personally affected
by cancer, caring for
patients and working toward preventing and
curing the disease.
Every issue features profiles of survivors
and advocates, useful
articles on health and
wellness, helpful tips for caregivers, and the latest updates
in cancer research.
Ruth McCorkle Honored
with Distinguished Researcher Award
Ruth McCorkle was recently awarded
the "Distinguished Researcher Award" by
the National Hospice
and Palliative Care
at their annual conference in New Orleans.
The NHPCO Distinguished
recognizes an outstanding body of research that has contributed
to the enhancement of hospice and palliative
care. The award is
given to an individual who has made substantial and sustained
contributions to his or her field of hospice
and palliative care
through a body of research investigation. It is expected
that the recipient will have made multiple
the published literature over his or her career. Given
that this is NHPCO's highest research award,
it is expected that
individuals who are nominated will be senior in rank
and well-established researchers.
The APOS 5th Annual Conference is covered in a feature
article in the 25 March 2008 issue of Oncology Times.
The Society of Nuclear Medicine Thanks APOS
for Support of Funding Legislation
"On behalf of the Society of Nuclear Medicine, we wanted to let you know
that nuclear medicine research funding was restored
in the omnibus and thank you for lending your considerable support to this
from patient advocacy groups and research groups
such as yours definitely helped make the case that his funding is needed. The
the funding at $17.5 million. We really appreciate
all of your help. On to '09 :) We look forward to working with you in 2008."
Research supports the idea that a few kind words
from an oncologist — what used to be called bedside
manner — can go a long way toward helping people
with cancer understand their treatment, stick with
it, cope better and maybe even fare better medically.
Studies have shown that about one-third of cancer
patients have significant distress that needs treatment.
We've developed a whole series of scales to help physicians
get over their enormous bias that you can't trust what
people say, that you can't trust subjective data….We
now have good quantitative scales that are validated
as reliable, and can begin to measure pain, anxiety,
depression, and fatigue more accurately, and they're
improving all the time….Someday I'd like to see
the distress thermometer up on the wall of clinics
like an eye chart, next to a list of phone numbers
with people who could do the psychological care.
Requested by Congress and the National
Institutes of Health, this report breaks new ground
in approaching the care of cancer patients. APOS
President, Dr. Ruth McCorkle and Founding President,
Dr. Jimmie Holland were members of the panel that wrote
the report. To
view the report brief or order the report please visit www.iom.edu/cancerwholecare.
Receives The Wellness Community’s Partner Award
is Dr. Alan Valentine, APOS President, accepting The
Wellness Community’s "Wellness
Partner Award" at TWC’s "Evening of Inspiration," Thursday, 4 November 2004 in
Washington DC. Dr. Valentine is flanked by Ms. Kim Thiboldeaux on his
right, Executive Director of TWC – National, and Ms. Barbara Harrison, on his
left, anchor on NBC NEWS4Today show. The award is granted to an organization
that has demonstrated ongoing dedication to working in alliance with The Wellness
Community to improve and enhance the lives of all people with cancer and their
loved ones. Below is a close-up of the award.
Jacquillat Award for Achievement in Clinical Oncology
Jimmie Holland MD, APOS Founding President and Attending Psychiatrist, Memorial
Sloan-Kettering Cancer Center, has been awarded the 12th Claude Jacquillat Award
for Achievement in Clinical Oncology, during the 16th International Congress
on Anticancer Treatment in Paris. Dr Holland is recognized internationally
as the founder of the subspecialty of psycho-oncology. This award honors those
have made outstanding contributions to cancer patient care. It was established
in 1991 in memory of Claude Jacquillat, an outstanding leader in clinical cancer
research by his collaborators, students and friends. APOS congratulates Dr Holland
on this achievement.
TEN Report: Budget Recently Passed by Congress
2 December 2004. We have just learned that the budget recently passed by Congress provided $1,000,000 to fund a study regarding the delivery of psychosocial care to individuals with cancer and their families. This measure originated in conjunction with efforts to leverage the learnings from the ICAN Program-a Florida based demonstration of the delivery of psychosocial services to cancer patients and their families delivered in the community setting, provided as a philanthropic program of the Bristol-Myers Squibb Foundation. Read
the full report .
Two Oncology Publications
Added to APOS Member Benefits for 2005
18 November 2004. ONCOLOGY and Oncology News International
will be circulated to the APOS membership on a complimentary
basis beginning in January 2005. We believe that these
publications complement the member benefits already
provided by APOS and are proud to be able to offer this
new benefit to APOS members beginning in 2005. APOS
members in 2004 (paid as of 15 November 2004) will automatically
begin receiving the publications in January 2005. Members
who join after 15 November 2004 will be added to the
circulation of these two publications quarterly.
If you would like to unsubscribe to either publication,
you may do so by notifying PPS Medical Marketing Group
at the following address: ONCOLOGY, c/o PPS Medical
Marketing Group, Inc., 264 Passaic Avenue, Fairfield,
NJ 07004-2595, or by phone (973-575-4400) or fax (973-575-4408).
Effective in 2005, you can also visit at www.cancernetwork.com.
This page includes a form to unsubscribe. Please contact
APOS Headquarters if you have any questions.
President Featured in Oncology News International
18 November 2004. Jimmie C. Holland, MD, APOS Founding
President recently contributed an editorial entitled
“An Unacknowledged Gap in Services Compromises Quality
Cancer Care” to the August 2004 issue of Oncology News
International. Dr. Holland writes that the “enormous
gap in quality care results from the fact that, despite
(the body of research based on randomized clinical trials),
psychological and social services are extremely limited
for patients with cancer….” Dr. Holland goes on to write
that the alarming fact is that “we now know that one
third of patients are suffering from distress and that
our interventions have been proven effective, but, nevertheless,
patients do not routinely receive these services.” You
may visit www.cancernetwork.com for more information on Oncology News International.
Cancer Network (NCCN)
The National Comprehensive Cancer Network has released
the new NCCN/ACS patient treatment guideline entitled, Distress Treatment Guidelines
for Patients, Version I, July 2004.
This booklet provides patients with their first access
to information about how distress is treated at the
nation's leading cancer centers. This collaboration
between the NCCN and the American Cancer Society (ACS)
provides an authoritative and understandable source
of cancer treatment information for the general public.
The Distress Treatment
Guidelines for Patients will help patients better understand distress management
and a physician's advice. Topics covered by this guideline
Definition of Distress
Tools to Measure Distress
Coping Strategies for Distress
Treatment of Distress
Glossary of Terms
In addition to the paper format,
the latest version of the distress patient guidelines
and an online order form will soon be accessible via the
Internet on the NCCN Web site: http://www.nccn.org.
These guidelines will also be accessible on the American
Cancer Society Web site: http://www.cancer.org.
APOS Special Interest
APOS is forming Special Interest Groups (SIGs) in the
areas listed below. The SIGs will focus on information
and activities in these areas that are of relevance to
the APOS membership. If you would like to become involved
in one or more of the groups, please check the box on
Application (or on your Dues Invoice if you
already are a member) for the group(s) in which you
to participate. Now is your chance to get in on the ground
floor and help define the role of these exciting new
forums! For more information, contact APOS at firstname.lastname@example.org.
Supportive Care Services
Sexual and Reproductive
Spirituality and Survivorship
Introduction to CAPO Standards
After two years of interdisciplinary committee work, and
collaboration with key agencies and informants, the Canadian
Association of Psychosocial Oncology: its Board and membership
voted in 1999 to adopt the National Standards. Recognizing
that most Canadian programs would initially not be in
compliance, the standards were written to guide national
and provincial policy toward a uniform standard of psychosocial
care and program development that would facilitate excellence
in service, research and education.
The Standards have been endorsed by key cancer stakeholders
in Canada. These include: the Canadian Cancer Society,
The Canadian Association of Provincial Cancer Agencies,
The Canadian Council of Health Services Accreditation,
and the Canadian Strategy for Cancer Control.
Since acceptance of the CAPO
Standards, CAPO has hosted two national Standards
Implementation meetings-with invited representatives from
each region of Canada. The Standards are well used and
referenced and have proven an effective strategy to guiding
and improving psychosocial oncology programs. In some
jurisdictions, it has served as a catalyst to add additional
psychosocial resources to be in compliance with the CAPO
Foundation Funds Development of an Online Core Curriculum
in Psychosocial Aspects of Cancer Survivorship
16 September 2004 - Charlottesville, Virginia. The Lance
Armstrong Foundation has approved A Pilot Project to Develop
an Online Core Curriculum in Psychosocial Aspects of Cancer
Survivorship, a proposal made by the American Psychosocial
Oncology Society (APOS) in August. Drs. Jimmie Holland,
Attending Psychiatrist at Memorial Sloan-Kettering Cancer
Center, Alan Valentine, Associate Professor of Medicine
(Psychiatry), Deputy Chief, Psychiatry Section at M. D.
Anderson Cancer Center, and Paul Jacobsen, Director, Psychosocial
and Palliative Care Program at H. Lee Moffitt Cancer Center,
co-authored the proposal. The growing number of almost
10 million survivors in the U.S. is putting the care of
the survivor under a bright light. The goal of the project
is to assure that all cancer survivors receive follow-up
cancer care in which the psychosocial aspect is fully
integrated and that no survivor who is distressed goes
unrecognized and untreated. When completed, this program
will include four new online lectures: Recognizing the
Survivor who is Distressed, The Common Psychosocial Problems
of Young Survivors, The Common Psychosocial Problems of
the Middle Aged and Older Adult Survivor and A Model Survivor
Program at Memorial Sloan-Kettering Cancer Center. The
lectures will be located on the APOS Web site Continuing
Education credit will be available to physicians, psychologists,
nurses, social workers, marriage and family therapists
and pastoral care counselors. The program is scheduled
to launch at the APOS 2nd Annual Conference, 27 – 29 January
2005, in Phoenix, Arizona. For further information on
this and other APOS programs, pleased contact APOS Headquarters,
2365 Hunters Way, Charlottesville, VA 22911, 434.293.5350, email@example.com.
- West Los Angeles Launches Continuing Education Course
The Wellness Community - West Los Angeles (TWC-WLA) has
created a first of its kind for any TWC; a CE course for
health care professionals. Psychosocial Aspects of Comprehensive
Cancer Care: A Guide for Professionals is a CE course
created by Malcolm Schutz, JD, MFT, TWC facilitator, and
Ms. Michael States, MFT, Clinical Program Director on
behalf of TWC-WLA. CE credits will be provided for Psychologists,
MFTs, LCSWs, and Nurses. The course is being delivered
on Saturday, 6 November 2004 at Skirball Cultural Center
in Los Angeles and will provide breakfast, lunch, and
free parking. Please visit www.twc-wla.org for more details.
APOS Online Multidisciplinary
Curriculum Highlighted in Oncology Times
An article featuring APOS webcasts, "Psychosocial Training
Goes Online," by Rabiya S. Tuma, PhDAn, appeared in the
June 25, 2004, issue of Oncology Times. An online
version of this article may be found on the OT Web
site Another article about two presentations delivered
at the APOS 1st Annual Conference has been published in
the journal's July 25, 2004, issue and may appear soon
on their Web site
APOS Founding President published in the Journal of the
National Cancer Institute
Jimmie C. Holland, MD, reflects on the evolution of Psychosocial
Oncology over the past 25 years and current challenges
in the field. The interview, "'Mother of Psycho-Oncology'
Discusses Field’s Need for Parity and People Power," is
available online at http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;96/1/8?etoc
Paula Zahn Interviews
Dr. Jimmie C. Holland on CNN
In this interview providing high-profile exposure to the
field of psychosocial oncology, Dr. Holland and Dr. Nancy
Snyderman, vice president with Johnson & Johnson, discuss
a study about the impact of optimism on cancer survival
and on quality of life while coping with cancer. A transcript
is available at http://us.cnn.com/TRANSCRIPTS/0402/09/pzn.00.html,
approximately two thirds of the way down the page.
APOS Launches First
Online, Multidisciplinary Curriculum in Psychosocial Oncology
The American Psychosocial Oncology Society (APOS) is pleased
to announce the launch of the online "Multidisciplinary
Curriculum in Psycho-Oncology." This innovative educational
program includes fifteen CE-accredited webcast lectures
by key experts from around the United States in medical
oncology, psychiatry, psychology, social work, and nursing.
The curriculum will eventually be expanded to address
six core areas including: introductory courses, symptom
detection and management, cancer site-specific issues,
psychosocial and pharmacological interventions, issues
with specific populations, and quality of life research.
The Wellness Community Launches New Web site Providing
Online Support for Teens with Cancer
The Wellness Community (TWC) announces the launch of a
new, innovative and groundbreaking Web site, www.GroupLoop.org.
Group Loop will provide teenagers with cancer a one-of-a-kind
online community offering Online Support Groups (OSGs),
valuable resources and information, understanding and
acceptance. The site will also provide OSGs and resources
for the parents of teens with cancer.