Tuesday, 9 October 2018

Helen Dagg's experience of a BEVA Trust day

As a two year graduated mixed practitioner, my opportunities for equine castrates can be few and far between, so when I saw the advert on the BEVA website I jumped on the opportunity to be a part of a BEVA Trust Castration Clinic. This did however mean that I had to step/leap out of my comfort zone. I was worried that the other members of the team would be more confident than myself and that my limited experience would be a hindrance to the team rather than a help. So it was a rather anxious drive to Ardingly in West Sussex on a very bleak Wednesday morning.

Our base camp was the South of England Showground which was ideal as we had a lot of undercover work space, a luxury that cannot always be provided on these days. We were expecting 65 horses/ponies for passporting, microchipping, worming and 35 of these were booked for castration.  These were performed in individual scaffolding pens and each vet was provided with an assistant. After a group meeting and a vets huddle my concerns about the day diminished. I felt like a valuable member of the team right from the off and it was clear that we would be supported all day. All that was left to do was don some overalls and get on with the job in hand. Before long I was grabbing my equipment with gusto and getting stuck in.

The day was ran with military precision – I have never seen more clip boards in one location. The support staff had the arduous task of organising vets and owners alike, which at points looked as difficult as herding cats. A huge help was the ability of the trained volunteers to complete the passports silhouettes, a job that I was very grateful to bypass, particularly when the majority of the ponies on our day were skewbald or piebald.  The support team were incredible throughout the day and these clinics could not run without them.

I’m not sure how it happened. Perhaps it is my vertically challenged physique (5’4) – but I managed to lead the charge on castrating the Shetlands. Throughout the day I was struck by how engaged the owners were by the advice that we were all giving on after care following the castrations, worming and dental care.

After just one day of castrations my confidence was rejuvenated. I have taken my experiences of the day back with me into practice, happy to perform castrations when required. The work of the BEVA Trust continues and I would urge anyone who is passionate about equine welfare to get involved. On a personal level I set out to feel more confident in castrating – Mission Accomplished.  Volunteer for a BEVA Trust Day – you will not regret it!

Tuesday, 7 August 2018

Rossdales joins the campaign against equine obesity

Words by Lucy Grieve

Rossdales held their first 'Weight Wise' clinic on 16th June 2018 at the Diagnostic Centre in Exning, Newmarket. Horse owners were invited to book an appointment where their horse was weighed on an electronic weighbridge, nutrition and body condition scoring was discussed with Georgina Gatehouse from Spillers, and weight-tape and veterinary advice was discussed with the ambulatory vets, Mark Grant, Lucy Grieve and Paul Martynski. 

Owners received goody-bags containing a weight record chart, baseballs caps, the NEWC grazing muzzle advice leaflet, weight-tapes from Virbac and forage hand scales donated by Horse Requisites of Newmarket. 

There was a super uptake of the clinic and owner feedback was extremely encouraging. The opportunity for some dedicated one-to-one advice on all things regarding weight, nutrition and management, was welcomed. Similarly, getting an accurate starting weight and learning how to body condition score and use a weight tape, meant that owners had a clearly defined start point and end goal, with the confidence to know what they were aiming for and how they could achieve it. 

The practice was inundated with owners who couldn't make the date and so there are plans to run a second clinic towards the end of autumn. It appears that there are plenty of owners who are determined to achieve a healthy weight for their horses, they just need the information and the support to do so. 

Tackling Equine Obesity In The UK – What can we learn from small animals and humans?

Words by Nicky Jarvis

Government statistics show that nearly 62% of people in the UK are overweight with 27% considered to be clinically obese (body mass index of 30 or higher) compared to just 15% in 1993. With rising obesity levels questions have been raised over how to tackle patient issues and how best to achieve effective weight loss. Studies also show that between 29-39% of dogs and 19-29% of cats are thought to be overweight and many small animal practices have invested time in weight management clinics. But how much success do our human and small animal counterparts have and what lessons can we take forward to the equine world?

In companion animal practice only a few studies exist on the success of weight loss programmes and many are focused on short-term results rather than return of the animal to optimal weight. In one study, which included client education, only 53% of the dogs enrolled completed a six month weight loss programme. Owner related issues such as lack of compliance and illness were cited as reasons for not completing the course and interestingly the more obese animals were most likely to be lost to follow up. One factor for lack of compliance may be that diets aim to achieve a safe weight loss of 1% bodyweight per week and for the first 6 to 7 weeks this is meaningful to the owner. However, without regularly reducing the feed ration further, weight loss quickly falls to 0.3% BW per week. Whilst still a significant percentage for a cat or a dog, this can prove frustratingly slow to the owner.

Like humans, cats and dogs also show the ‘rebound effect’ when it comes to weight loss. One study showed 48% of dogs and 46% of cats began to gain weight at the end of a weight loss programme. So is finding ways to support and motivate horse owners long-term just as important as that initial short term success?

Weight gain is often insidious and in small animals many risk factors have been identified. Breeds such as the Labrador, Pug and Golden Retriever have a higher prevalence of obesity thought to be linked to early life rapid weight gain seen in the growing phase of these breeds. Certainly in humans, rapid weight gain in growing children has now been linked to an increased likelihood of obesity in adulthood. The existence of a ‘thrifty gene’ is often discussed and debated in native ponies and cobs. And with recent studies demonstrating specific genetic markers in horses which result in elevated insulin levels, increased obesity and laminitis could we soon be soon be able to identify ‘at risk’ horses before they become obese?

And what becomes of those animals that never even enroll on a weight management programme. Two small animal studies from 2008 and 2014 suggested that vets discussed the weight and body condition of overweight dogs in less than 2% of consultations. So do some of us struggle to raise the subject of an overweight horse?

Guidelines for human doctors recommend regular screening of patient weights and active encouragement to join commercial weight loss programmes that have been found to be far more effective than ‘going it alone’. In fact a doctor can now refer a patient to Slimming World and similar organisations on the NHS. However doctors find that lack of time and knowledge, fear of causing offence and a belief that intervention would be ineffective hold them back from raising the subject with patients during routine consultations.

A study led by Professor Paul Aveyard and published in the Lancet looked at the efficacy of a scripted ‘brief’ opportunistic intervention by GP’s in terms of encouraging patients to lose weight without the advice being deemed ‘inappropriate’. Patients attending a routine consultation were invited by the practice receptionists to weigh themselves on arrival at the surgery and then at the end of the consultation the GP was asked to spend just 30 seconds advising those patients deemed to be overweight:

GP: “While you’re here I just wanted to talk about your weight. You know the best way to lose weight is to go to (Slimming World or Rosemary Conley) and that’s available free on the NHS.”
Patient: “Oh?”
GP: “Yes and I can refer you now if you are willing to give it a try?”
Patient: “Yes, OK.”
GP: “Ok, what you need to do is to take this envelope to reception…….. And I’d like to see you again in 4 weeks time please if that is OK?”

The study found that 77% of patients offered the service agreed to take part and over 40% went on to successfully attend the weight management programme. This success was also replicated in Hugh Fearnley-Whittingstall’s experiment featured in BBC One’s ‘Britain’s Fat Fight’ where a group of Bristol based GP’s were trained in the brief intervention technique. And 4 out of 5 patients reported they found the conversation both helpful and appropriate.

So perhaps this is something we can learn from the human world. If one of our biggest struggles is getting horse owners to recognise that their horse is overweight and motivate them to address the problem perhaps we need to start with that opportunistic conversation, our own ‘brief’ intervention at the end of a routine consultation. And as most weight gain is insidious perhaps by automatically producing a weight tape or body condition chart at every vaccination or dental check we can show owners with how much their horse has gained (or lost) in a few months rather than waiting until the situation harder to manage.

There are no studies out there to tell us how successful weight management programmes are in the equine world and that’s why I will be asking equine practices, who currently run weight clinics, what advice and tips they can give us on how to encourage and support horse owners to achieve the right weight for their horse. I will be sharing what I find over the coming weeks on the obesity resource webpage

Libby Smith's experience of setting up an equine weight clinic

I'm thrilled to be asked by BEVA to write a blog on Westover's recently launched Equine Weight and Condition Club. RVN's within equine practice are such an under-utilised resource in comparison to their small-animal counterparts, introducing the idea of nurse-lead clinics to make use of the wealth of knowledge RVN's have is the perfect opportunity to create greater challenge within practice, whilst tackling one of the biggest health issues our profession faces.

Although we aim not to dissuade those with thin horses being interested in our service (following medical workup), this clinic is primarily aimed at dealing with the rising number of overweight and obese horses we see within practice. I can't stress enough how much easier it is to launch a service like this with a "whole-practice" approach. Within first-opinion practice, the ambulatory vets are those in most contact with clients, and therefore it's critical the nursing team can rely on those vets to upsell this service at any and every call they attend with an overweight horse. The flip-side of this is those that do embrace nurse-lead weight consults see their own workload reduced, as they can refer clients to nurses to discuss all things weight-related, freeing themselves up to do more challenging work. I'm sure many vets can relate to the difficulty of being stuck at a consult way beyond the scope of time left for a vaccine discussing variables like diet.

That's not to paint a picture that we are fortunate to gain every upsell the vets send our way - sadly as many will already realise, the issues surrounding obesity do not gain the sort of recognition or concern from clients that we would like, and therefore we don't get the volume of consults booked in that we would ideally like to see. By ensuring weight remains a high profile issue and not being deterred from discussing it we hope in time to secure a wider audience.

The most effective consults are held at the horses' location as opposed to the practice, as it removes subjectivity about grass quality and grazing management, and is particularly important if you have a predominantly leisure-horse caseload who may not all have transport. We aim to have an objective assessment of the horses’ condition and weight, as well as an open discussion about factors that may limit compliance to a diet and exercise plan: these plans must be bespoke in order to be successful, so if a client can only ride once a week due to work commitments or a horse is recovering from injury we need to take this into account. We weigh their current diet to the gram, usually creating great amusement amongst owners who prefer a “handful” method! We also discuss our starting point in terms of exercise and management. Much like the subjectivity over grass quality, you may have to be quite probing - I'm still amazed at how many feel a 20 minute walk around the block constitutes a physical challenge!

This consult is predominantly fact finding, so unless emergency measures need to be put into place we usually return to create a written plan incorporating diet, exercise and management changes to be sent to the client within 24 hours. This bides us time to consider all the variables at play in order to create the most effective plan possible.

Maintaining regular contact with our client's is also pivotal to our vision of the Westover weight programme. There is significant evidence in human medicine that those enrolled in group meetings see greater weight loss than those trying alone, so mimicking this feels like the obvious step. We are trying to create a forum group, giving clients the opportunity to discuss their difficulties with others going through the same. Although this is challenging whilst numbers are low, once you get a handful starting at the same time this soon adds additional value to the programme for minimal staff input. This forum is interspersed with regular information-based emails from myself as an RVN tackling weight related subjects –research articles on grass intake whilst grazing and how to use a grazing muzzle effectively as examples. This is a great way to engage with your client’s more, as well as upselling more services like nurse-lead clipping clinics or EMS blood sampling. This is all an additional revenue stream nurses can provide that is new to the practice.

The main struggle we face is retaining re-sees in cases receiving other ongoing veterinary intervention, or in cases that have improved to now be at a non-critical state.  This relates to both the vets and clients perception of what a weight consult offers. If a horse has a vaccine and the vet puts a weigh band around the horse, this is enough for some clients, but I hope in time to alter this mindset and show that we could offer them so much more in terms of advice and support. Similarly, much like Weight Watchers offers it's gold membership to those who reach their target weight as a nod to the idea weight loss is a lifestyle, and not a one-off diet, I hope that by continually banging the drum that it's important to frequently re-assess our horses' health status and condition, client's will see the benefit of a re-examination even when their horse has dramatically improved to help formulate the most appropriate plan moving forward.

Understandably, starting anything new like this is a daunting task, and I'm well aware that this was made easier for me in a supportive, open-minded practice. My advice to anyone else interested in starting something similar in their own practice is to try and make your enthusiasm rub off on at least one other member of the clinical team, so you have one other person to upsell the service and to bounce ideas with when you meet a challenging patient. For the nurses out there that may be asked if they’d like to take part in something like this, grab the opportunity for autonomy with both hands and you’ll never look back!

Thursday, 14 June 2018

How I ended up on route 66

Dear BEVA enthusiasts,

Our BEVA executive assistant Fiona who completed the 66 mile challenge has asked me to write you a blog about how I intended doing the 30 mile cycle on the 3rd of June but accidentally ended up cycling the 66 mile challenge which I playfully call Route 66’. Being Irish necessitates an innate talent for taking “the mick” out of oneself so I gladly accepted the opportunity to write my ‘Route 66’ blunderful revelations.

I will begin by explaining what my mid breeding season BEVA sportive preparation actually consisted of. While the rest of the Donnington Grove team committed themselves to regular weekend cycles, I only managed one cycle that was 24 miles long wearing an ugly horse-riding helmet “borrowed” from the practice. After only 24 miles of cycling, one of my regular stud farms found my new gait concerning and gave me some bicycle shorts. This in itself was enough to put me off further training. I spent the next few weeks preceding the challenge avoiding Bruce who would have sacked me if he found out that I had no intention of cycling 91 miles.

On Saturday following stud rounds I set off to Yorkshire. I bought a helmet in Halfords that morning purely to blend in with the other cyclists. It was an easy journey following the two other Donnington Grove vehicles and listening to their terrible attempts at road trip singing via whatsapp. Approaching Birmingham it dawned on me that I had left my gift bicycle shorts and any form of comfortable underwear at home in Newbury. But this wouldn’t matter since I was only doing 30 miles - right? I met the rest of the team in a restaurant that evening and was surprised to see them looking rather apprehensive. This was because Bruce had taken them for a drive around the 91 mile course and consequently driven them ... around the bend. It seemed like the only thing keeping a smile on the faces of at least the men on the team was the prospect of meandering their way across two hills they affectionately christened “the bosoms of Yorkshire.”

Let me tell you about the Donnington Grove team. Georgio is a cool, collected Italian surgeon who had put in plenty of training. Emma, a Kiwi housevet who has cycled thousands of miles around South Island was calm and confident. Surgeon Alastair hails from Yorkshire, can lift three times his own body weight, and looked similarly confident. Naomi, the most experienced housevet is a keen cyclist so the impending pain didn’t seem to faze her. Marc, one of DG’s talented ambulatory vets was an enigma to me. I had not seen him on a bicycle but he definitely had all the gels and electrolytes to complete 91 miles. Abbie, also a Donnington Grove housevet was petrified but remarkably determined. Bruce, our team leader and motivator, who needs no introduction to BEVA members, had very worryingly run out of words.  Then of course there is yours truly, smug at the prospect of cycling a mere 30 miles and enjoying coffee and cake along the way.

And they were off! Half an hour later I was at the start line. I got the general lecture and guidelines about the course from the gentleman at the start line. I stopped listening after “follow the green signs”. How hard could it be for an Irish to follow some green signs right?

I set off with a banana and half a bottle of water. I’d be back soon. With my head down, I cycled with determination. I skipped Hovingham’s most amazing coffee shop (already obliviously off course) in order to quickly pedal round to the finish line, drive to the Donnington 91 milers and offer them moral support and Volvo draft. As I kept cycling with blinkered focus, it started to dawn on me that I had been cycling for some time now and that there seemed to be more hills than I had anticipated. Upon acquisition of internet signal, google maps confirmed that I was 45 km away from the finish line by the shortest route and I had been cycling for almost 3 hours! I called my most patient friend Shelley who pulled up the routes on her computer and confirmed that since I had passed through Kirkbymoorside (35 miles from the start) I was in fact on the 66 mile challenge. Shelley is still wondering how I navigated my way through vet school, let alone this thing called life. 

I sat in the grass and pulled out my banana and half a bottle of water and considered my options ... of which there were none. I had to finish the 66 mile challenge. I was lucky to be discovered in said position by Gem who is a small animal vet at Calder vets in York and her husband Steve. They offered me all the moral support, patience, and water to get me through a despondent middle third of Route 66. Antique tractors offering a draft for 5 miles around Malton were also welcomed. Team Donnington’s geographically challenged member finished 66 miles strong in 6 hours 12 minutes, a time that somewhat softened the stupidity of ending up so far off course. I was just happy that I made it in time to cheer on the Donnington Grove 91 milers on their arrival back.

One person on the Donnington team deserves a very special mention. This is the story of a girl who does not love cycling, got attacked by road bollards and had a nasty fall in the first stretch of the 91 mile challenge, but still refused to abandon the challenge. She continued to complete more than 91 miles over Yorkshire highs and lows. Abbie finished with a damaged ankle and a giant smile on her face. She also completed a day of work the following Monday. She is the newest qualified veterinary surgeon at Donnington Grove and exemplifies all the mental fortitude and positive attitude that’s needed to tackle the inevitable bumps in the road to success. After 91+ miles I think this photo says it all.

So what did I learn on completion of this surprise challenge? 

Prior preparation prevents poor performance ... make time for all those P’s.

Sometimes life will throw you off course and the lesson is to embrace and “ride on” because you might meet some fantastic people on the new route and end up in a better place.

Abbie exemplified riding the hard road, your attitude defines your altitude.

And finally;

Victoria’s Secret is great for certain activities ... and cycling is not one of those activities.

See you all at the next BEVA challenge!

Wednesday, 16 May 2018

Victoria Gregory : Being an Equine RVN

I started working at Rossdales Equine Hospital in 2003 and qualified as an Equine Veterinary Nurse in 2007. In 2010 I took a sabbatical to work at Scone Equine Hospital, Australia, during their foaling season. I enjoy teaching so in 2015 I decided to move to a university hospital so that I could continue to be an equine nurse but teach as well. I spent some time at the Royal Veterinary College in Hertfordshire before moving to Scotland to work at Weipers Centre Equine Hospital at the University of Glasgow.
When I’m not at work I enjoy spending time exploring the Scottish countryside with my Springer Spaniel, Jonty.

I grew up with horses and all I wanted to do was work with horses. After leaving school I attended Moulton Agricultural College where I completed a BSc (Hons) in Equine and Estate Studies. It was during my time there that I saw a job advertised for an equine veterinary nurse and decided that that was the career for me. When leaving college I sent my CV to several equine practices enquiring about trainee nursing positions. During the summer I took a temporary position at an equine rehabilitation centre to enhance my CV.

I was lucky enough to get a job as a trainee nurse at Rossdales Equine Hospital, which was already an established training practice. After a year of working as a theatre assistant I was enrolled on the Equine Nursing course which was then an NVQ level 2 & 3. I went to college one day a week for two years and completed a portfolio at work to show that my clinical skills were up to standard. I had to sit multiple choice question exams at the end of year 1 and 2 as well as practical exams at the end of year 2.

The role as an equine veterinary nurse can vary greatly between practices, some giving nurses more responsibility than others. No day is ever the same, you can set a basic daily routine but this can be disrupted by emergencies and patient compliance! The basic daily routine where I work is:
8.30 – start. The students have started the morning checks and treatments, nurses assist with this when necessary. If there is a surgery booked in, the nurse guides the students through catheter placement, administering any medications and removing the horse’s shoes.
9.00 – Rounds, each patient is presented by the student in charge of that case.
9.30 – the first surgery is anaesthetised. Any inpatient procedures are started, such as x-rays, re-exams and bandage changes
10.00 – the first outpatient appointments start – the university is close to the city so owners often get stuck in traffic if asked to arrive earlier than this.
Inpatient care and outpatient appointments continue throughout the day until the work is completed. The nurses are on a rolling rota, spending a week with the medicine team, a week with the orthopaedic team and a week on the late shift, helping out wherever. As well as helping with the patients the nurses work as a team to ensure that stock orders are placed, rooms are fully stocked and cleaned, bins are emptied, equipment is in full working order, necessary equipment is clean and sterile for procedures, medications are ready for dispensing with patients that are going home, the bills are up to date for when the owners enquire and the list goes on! Being a teaching hospital the nurses are also responsible for teaching and assessing students for their Direct Observation of Procedural Skills. These include tasks such as x-raying, shoe removal, IV catheter placement and bandaging.

I would describe my job as rewarding. There is nothing better than seeing horses going home, after a stay in hospital, with their owners so happy to have them home again. In the university it is also rewarding to see the student’s progression in the time that they spend with us. The vast majority are not horsey but they are always keen to learn and be involved. It is extremely tough at times when there is nothing more that you can do to help a patient but at least it is possible to end their suffering and know that they had the best possible care until the end. The thing I love most about my job is the horses!

I was extremely proud when I qualified as an equine veterinary nurse; I had worked really hard to get there. My proudest achievement though, is probably being asked to make a DVD for Lantra to promote equine veterinary nursing as a career choice.

For the future I would like to carry on advancing my equine nursing knowledge in order to care for the patients as best as I can. I would also like to continue to be involved in teaching veterinary nursing students and veterinary students.  

Thursday, 10 May 2018

Marie Rippingale : Being an REVN

My name is Marie Rippingale. I have worked in equine veterinary practice since 2003. I qualified as a Registered Equine Veterinary Nurse (REVN) in 2007. I obtained my Advanced Diploma in Equine Veterinary Nursing (DipAVN Equine) in 2013. I work as a senior equine nurse at Scarsdale Vets, and as a lecturer in equine veterinary nursing at Bottle Green Training. I live with my other half who is a small animal vet, and a small 15 year old ginger and white cat called Dougal, who constantly declares that he is hungry, regardless of how much he is fed! I also own a 20 year old Irish Sports Horse called Chaplin. We mainly compete in British Eventing (BE) 80 competitions, and Novice dressage. Chaplin specialises in running away on the cross country course, and spooking at random things in dressage arenas! I also enjoy scuba diving and snowboarding (badly!).

I completed a BSc (Hons) in Equine Sports Science in 2005, and as part of this course, I took a year out to work as an equine nursing assistant at Scarsdale Vets. I enjoyed this year out so much that I went back to work at Scarsdale as soon as I graduated from university. I have always loved horses, and cannot think of any better job than caring for them, and treating them, when they are unwell.

I took the vocational route of training. This involved me working at Scarsdale four days per week, and attending college one day per week. The course lasted two years, and was assessed with exams, a practical portfolio and practical exams (OSCEs). It was a lot of work, and was really challenging both academically and practically. Working full time and training at the same time was hard, but it was totally worth it in the end.

The structure of my day depends on what area I am working on that week (the nurses all rotate      around areas spending 1 week on each). The areas we rotate around are:
Pharmacy (8am-4.30pm): This involves helping with Artificial insemination (AI) mares first thing in the morning. After that we unpack the drugs order, put it away insuring correct stock rotation and update all of the stock records. The rest of the day is usually spent helping out in the hospital or with the inpatients. You will often go out and assist with ambulatory procedures when on this area e.g. radiographs, ultrasound scans and endoscopes. In the afternoon we construct a new drugs order, and an order for the hospital. Due to the reduced contact with inpatients on this area, this nurse is usually nominated to look after the isolation cases when they are admitted.
Hospital (8.30am-5.00pm): This involves helping out with procedures in the hospital e.g. lameness work ups, gastroscopes, radiographs, ultrasound scans, shockwave treatment, general anaesthesia and assisting in theatre. There are usually two nurses on this area and they work together with the hospital vet for that day to get everything done, and make sure it all runs smoothly.
Inpatient care (8.30am-5.00pm): On this shift you check and TPR all of the inpatients and give them their medication. You will consult the case vet for each patient, and obtain a plan for that patient for the rest of the day. We compile and fill out nursing care plans for the critical patients we get at the practice, and fill these in when we are on this area. We also groom the horses and pick their feet out. This is good for their general health and well-being, as well as supplying them with some much needed TLC – happy horses heal faster! When working on this area, you will also prepare the horses for general anaesthesia, including intravenous (IV) catheter placement, clipping, mouth washing and giving pre-anaesthetic medications.
Although it says here that we should finish at 5pm, we all know that horses do not just get sick during working hours, so if a patient needs care after this time, one of us will often stay behind to help. We also work on a weekend on call rota.

I find my job challenging, fascinating, exciting and rewarding. I really love seeing our longstanding patients, either for a re-examination, or when they come in for a vaccination. It is so nice to see them looking well in themselves and enjoying life. You build up a rapport with the client too which is really nice. I also really love it when inpatients start to improve and look better.

My proudest achievement as an equine veterinary nurse was volunteering for the BEVA Trust to go out to the Gambia in West Africa to work at The Gambia Horse and Donkey Trust (GHDT). I have taken two trips so far, one in 2015, and one in December 2017. These trips were challenging and fascinating all at the same time. I was delighted to find that I could actually help out there, but I learned an enormous amount in return. I have an limitless amount of respect for the staff at GHDT for the amazing job they do out there. I am very proud to have met and worked with them.

My ambitions for the future are to continue to develop my skills and knowledge, and pass these on through teaching. I will also continue to raise awareness of equine nursing within the veterinary industry, and with the public also. I would like to see better recognition for veterinary nursing as a profession overall.