stroke risk assessment scale

changes in age ranges. the use of a reliable risk assessment tool. Blessed-Dementia Information-Memory-Concentration Test. The National Institutes of Health Stroke Scale (NHISS), considered the Gold Standard Acute Stroke Assessment, is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. The sooner a person receives treatment for a stroke, the less damage is likely to happen. Braden scale subscales include: 1) Sensory subscale to measure the ability to feel and relieve discomfort. The NIHSS is the preferred stroke scale and the total score (0 to 42) correlates to stroke outcome (Filho & … Further studies on the association of the Braden Scale score with stroke outcomes are needed. Thefinal average (15.23), the median (16.50) and standard deviation (±11.034). Blessed-Dementia Scale. Even participants with only 1 ideal factor had a lower stroke risk as compared to those with none. Caprini score. It is a simplification of the Glasgow Coma Scale, which assesses a patient response in three measures: eyes, voice, and motor skills. If you have a 10% risk, it means that if there were 100 people with the same risk as you, we would expect 10 of them to have a heart attack or stroke in the next 5 years. The ABCD2 score is a validated, seven-point, risk-stratification tool to identify patients at high risk of stroke following a transient ischemic attack (TIA). National Institutes of Health Stroke Scale Action Research Arm Test Barthel Index Berg Balance Scale Box and Block Test Chedoke McMaster Stroke Assessment Scale Chedoke Arm and Hand Activity Inventory Clinical Outcome Variables Scale Functional Ambulation Categories Functional Independence Measure Frenchay Activities Index Motor Assessment Scale The NIHSS has been shown to be a predictor of both short and long term outcome of stroke patients. nursing assessment for stroke patients Stroke is a chronic or acute condition that affects the brain cells and tissues. Stroke Risk Assessment This stroke risk assessment tool will help you quantify your risk for a stroke. Nursing staff completes the scale at rehabilitation admission, and periodically throughout the stay. 1, 2 The AF population is heterogeneous with a variable risk of stroke. The Waterlow consists of seven items: build/weight, height, visual assessment of the skin, sex/age, continence, mobility, and appetite, and special risk factors, divided into tissue malnutrition, neurological deficit, major surgery/trauma, and medication. The Essen stroke risk score predicts the 1-year risk of recurrent (fatal and non-fatal) stroke on a 10-point scale. Research authors: CAPRIE steering committee. CAPRIE Steering Committee. A randomised, blinded, trial of Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events (CAPRIE). Lancet.1996;348:1329-1339. In this review, we will describe functional assessment scales in stroke, concentrating on three of the more commonly used tools: the National Institutes of Health Stroke Scale, the … Conditional information. The National Institutes of Health Stroke Scale (NIHSS) is a score calculated from 11 components and is used to quantify the severity of strokes. A score of 3 or more in this column means that you are at High Risk for having a stroke. (2008b). If you have, generally it is recommended that you discuss with your doctor about starting aspirin and a statin. Female. The NIHSS can be used as a clinical stroke assessment tool to evaluate and document neurological status in acute stroke patients. Commonly used today in the clinical and nursing sectors, it was initially intended to be used within the geriatric hospital population. Select Age Group: < 54. 4.1 Nurses in all practice settings should assess the stroke client’s fall risk on IV NINDS – AIREN criteria for the diagnosis of vascular dementia. If a TIA is suspected, you will be offered aspirin to take straightaway. The risk assessment scales for stroke referred were designed by the CNSSS, and have been proved to have good reliability and validity compared with the modified scale of the Framingham Stroke Profile (FSP), and can be used as an evaluation tool for stroke risk assessment . Atrial fibrillation (AF) is a common and treatable risk factor for stroke and systemic embolism. Stroke is a leading cause of death in the United States and is a major cause of serious disability for adults. • Modified NIHSS scale • Intracerebral Hemorrhage Scale (ICH) FUNCTIONAL ASSESSMENT SCALES • Berg Balance Scale • Modified Rankin Scale (mRS) OUTCOME ASSESSMENT SCALES • Barthel Index • Glasgow Outcome Scale OTHER DIAGNOSTIC & SCREENING TEST • HachinskiIschaemiaScore • Hamilton Rating Scale for Depression • PHQ2 and PHQ9 for Depression 6 The best risk assessments use automation to help businesses easily scale … Stroke survivors should work with their doctor to bring it down to the normal range. C. Mild stroke symptoms. Select Gender: Male. Methods . 119, 120. Note that this scale may not capture the risk factors that are most important on your hospital ward, so consider your local circumstances. 1. Hypertension is the most potent risk factor for stroke. The scale requires approximately 5-8 minutes to perform. These scores estimate your risk on a scale of 1 to 9. For stroke risk, a score of 2 or higher generally indicates an increased risk of stroke. The risk scores are based on factors such as: Your age. Whether you have other conditions that could increase your risk of stroke, such as diabetes or problems with your circulation. This heart disease risk assessment is most accurate for people between ages 20 and 74. Stroke Risk Assessment and Future Stroke Primary Prevention Trial. Comprehensive assessment of all aspects of stroke are addressed. PASS is a postural assessment scale specifically designed to assess and monitor postural control after stroke. Stroke Severity Assess the severity of stroke through global assessment of deficits post stroke. H. Clinical Assessment Tools Stroke Impact Scale A score of 10 is generally accepted as indicating the presence of Impact of Stroke. Do not go back and change scores. Do you know your Stroke Risk? Heart Disease Risk Calculator. Women and Stroke the stroke scale serves as a data collection tool for planning patient care and provides a common which includes scoring Follow directions provided for each exam technique. This is especially true for recording of ethnicity data which is becoming more complete. The use of a tool that has been tested for validity and reliability (such as the Braden Scale for Predicting Pressure Sore Risk) is recommended. This helps to prevent a stroke. If you have overheard your stroke team discussing your NIHSS or the NIHSS of your loved one, you might have some questions about the meaning behind your score. The Downs and Black checklist is a scale which includes items that assess internal and external validity, reporting standards as well as power. Calculate your 10-year risk of heart disease or stroke using the ASCVD algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. It measures the ability of an individual with stroke to maintain stable postures and equilibrium during positional changes. To view the latest It means you're at an increased risk of having a stroke in the near future. If your Low Risk score is 6 to 8, congratulations! Scores should reflect what the patient does, not what the clinician thinks the patient can do. "Uncontrolled blood pressure, diabetes, high cholesterol, people smoking, obstructive sleep apnea." The result can be used to determine whether or not treatment is required with anticoagulation therapy or antiplatelet therapy. This model calculates the 1-year risk of recurrent (fatal and non-fatal) stroke on a 10-point scale. Multisite web-based training in using the Braden Scale to predict pressure sore risk. Is your blood pressure greater than … Why exercise should reduce the risk of stroke. The effect of web-based Braden Scale training on the reliability and precision of Braden Scale pressure ulcer risk assessments. An effective risk assessment solution should be scalable, thorough, continuous, and customizable. 2) Moister subscale to assess the degree to which skin is exposed to moisture. Stroke Risk Quiz American heart Association/American Stroke Association Together to End Stroke. This calculator assumes that you have not had a prior heart attack or stroke. Moderate risk – a score of between 10% and 15%, you have (as a minimum), a 1 in 10 chance of having a heart attack or stroke in the next five years, if nothing is changed. Use this tool in conjunction with clinical assessment and a review of medications (go to Tool 3I) to determine if a patient is at risk for falls and plan care accordingly. Background: Aspiration is a common complication in acute stroke patients and is strongly associated with a poor outcome. Knowing your risk for stroke can lead you to make healthy changes to help prevent a stroke. Salt intake, for example, is associated with an increased risk of hypertension and stroke, 110 – 114 whereas increased potassium intake is associated with a decreased stroke risk. Stroke or brain attack is a sudden problem affecting the blood vessels of the brain. Education is the most effective approach to risk factor modification in stroke. DSM-IV criteria for the diagnosis of vascular dementia. Thus, the CHA 2 DS 2-VASc score is a refinement of CHADS 2 score and extends the latter by including additional common stroke risk factors, that is, age 65–74, female gender and vascular disease. Use the table below to develop a management plan for your patients. You conduct a stroke assessment with the NIH Stroke Scale. The 2014 American Heart Association/ American College of Cardiology/ Heart Rhythm Society (AHA/ACC/HRS) guidelines also recommend the CHA 2 DS 2-VASc score for the assessment of stroke risk in paitents with nonvalvular AF. 69-71. Adapted from Gould MK, et al. 5,8. Mobility assessment: your stroke team will need to assess how your stroke has affected you physically and what help you need with positioning and moving around. Objective: To evaluate relative accuracy of a newly developed Stroke Assessment of Fall Risk (SAFR) for classifying fallers and non-fallers, compared with a health system fall risk screening tool, the Fall Harm Risk Screen. Measures of pathology (for example, size of infarct on imaging) or impairment (for example the Medical Research Council Motor Assessment Scale) are straightforward to perform and interpret, but give little useful information on how stroke affects the individual. Magnan, M., & Maklebust, J. See your doctor about stroke prevention right away. Test activities include: QRISK®3 is the recommended formal risk assessment tool to assess CVD risk for the primary prevention of CVD in people up to and including the age of 84 years. Design and setting: Prospective quality improvement study conducted at an inpatient stroke rehabilitation unit at a large urban university hospital. The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool designed to measure the neurologic deficits most often seen with acute stroke patients. Stroke Risk Calculator. 115 – 118 A Mediterranean diet, or a diet high in fruits and vegetables, reduces the risk of stroke. Level of Consciousness Assessment: “AVPU” The AVPU scale is a system where you can measure and record a patient’s responsiveness to indicate their level of consciousness. CPSS = Cincinnati Pre-Hospital Stroke Severity scale FAST-ED = Field Assessment Stroke Triage for Emergency Destination GCS = Glasgow Coma Scale LAMS = Los Angeles Motor Scale LAPSS = Los Angeles Pre-Hospital Stroke Score LVO = Large Vessel Occlusion PSC = Primary Stroke Center It can be as a result of a blocked blood vessel that deprives a section of the brain of oxygen or a ruptured vessel that bleeds on brain tissue. NINDS Stroke Disparities Advisory Panel Meeting. Improvements in data quality - for example the recording of exposures and also clinical outcomes becomes more complete over time. An NIH stroke scale should be administered and scored when stroke is suspected, 24 hours after fibrinolytic therapy, 7 days post-stroke, and 30 days post-stroke. The patient scores a 40. Originally designed as a research tool, it is a nonlinear ordinal scale, with possible scores ranging from 0-42. Enter a 1 on the blank line next to each checked box.Add up your total for each vertical column. The 10-year heart attack and stroke risk assessment calculator (link opens in new window) published by the American Heart Association and American College of Cardiology accurately predicts risk and does a good job at ranking people most likely to have future cardiovascular events, according to a new analysis (link opens in new window) published in the Journal of the American … Odds ratios (ORs) and hazard ratios (HRs) were used as association … Past Stroke Events. No stroke symptoms. These are: sensory perception, moisture, activity, mobility, friction, and shear. If your Caution number is 4 to 6, work with your doctor to decrease those risk factors you can change. on the usability of various scales for estimating falling risk in stroke patients. Complete the risk assessment to determine your patients’ risk level for venous thromboembolism (VTE). Tools that assess stroke at all these levels are available. See your doctor about stroke prevention right away. NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS) Score StrokeSeverity 0 No stroke symptoms 1-4 Minor stroke 5-15 Moderate stroke 16-20 Moderate to severe stroke 21-42 Severestroke 20 ACUTE ASSESSMENT SCALES NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS) • Strength: Reliable tool to rapidly assess effects of stroke Priorities for Clinical Research in the Treatment of Acute, non-Traumatic Intracerebral Hemorrhage Workshop. Based on the results of these studies, it can be suggested that Falls Efficacy Scale (FES) (5), Stroke Assess-ment of Fall Risk (6), Fall Risk Assessment Tool (FRAT) (devel-oped for the elderly population) (7), or … Stroke is preventable. Journal of … The neurological system — look for clinical signs of stroke or TIA such as unilateral weakness, visual or speech disturbance, ataxia, and nystagmus. Consider the risk factors. 4) Activity subscale to assess the ability to get out of bed and/or ambulate. The Braden Scale with 18 points as the cutoff point is likely a valid clinical grading scale for predicting pneumonia after AIS at presentation. 4-5 points 4.1% risk Refer to Berman ward (59852) for assessment in 6-7 points 8.1% risk Fast Track TIA clinic within 24 hrs. A 1-point higher total LS7 score on the 0-14 scale was linked to an 8% lower risk of stroke. reduce your risk of stroke by approximately 66% or decrease your risk from 6.7% to approximately 2.2% per year. For the Fall Harm Risk Screen, area under the curve was 0.56, positive predictive value was 0.19, and negative predictive value was 0.86. The ABCD2 score is a validated, seven-point, risk-stratification tool to identify patients at high risk of stroke following a transient ischemic attack (TIA). It includes the UE subscale (33 items; score range, 0–66) and the LE subscale (17 items; score … Introduction. Hachinski Ischaemia Score. Hamilton Rating Scale for Depression. Patient Information. The Braden Scale is a scale made up of six subscales, which measure elements of risk that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. PREHOSPITAL STROKE ASSESSMENT SCALES • Cincinnati Prehospital Stroke Scale (CPSS) • Los Angeles Prehospital Stroke Scale (LAPSS) • Rapid Arterial oCclusionEvaluation Scale (RACE) ACUTE ASSESSMENT SCALES • Glasgow Coma Scale (GCS) • NIH Stroke Scale (NIHSS) • Intracerebral Hemorrhage Scale (ICH) FUNCTIONAL ASSESSMENT SCALES Strokes are a medical emergency and urgent treatment is essential. B. Please remember that everyone is at risk for a stroke. Improved recovery, reduced disability and fewer deaths are proven benefits of stroke unit care. While some risk factors are permanent or hereditary, there are things you can change. To estimate the association between depression after stroke and subsequent mortality. A score of 3 or more in this column means that you are at High Risk for having a stroke. It contains 12 four-level items of varying difficulty for assessing ability to maintain or change a given lying, sitting, or standing posture. Description: Described as a 14-item scale designed to measure balance of the older adult in a clinical setting. Ischemic Stroke The most common type of stroke, accounting for almost 80% of all strokes, is caused by a clot or … Close collaboration with multidisciplinary staff is kept to identify rehabilitation goals. After every question in the score is answered, the number of points dedicated to each answer is summed to reveal a final score. Excellent correlations with Postural Assessment Scale for Stroke patients (PASS) (r = 0.92 to 0.95) Predictive validity: Stroke: (Mao et al, 2002; Acute Stroke) Excellent predictive validity of the BBS at 14, 30 and 90 days at predicting Motor Assessment Scale (MAS) scores at 180 days post stroke (r = 0.82, 0.84, 0.91 respectively) The answer is B. 3) Mobility subscale to assess one's ability to relieve pressure. A heart risk assessment is an estimate of how likely you are to have a heart attack or stroke in the next 5 years. Advances in Skin and Wound Care, 21(3), 124-133. Typically, these factors are used to estimate a patient's risk of … Action Research Arm Test. This tool can be used by staff nurses. The scales do not differentiate between stroke and TIA; this is done in hospital by a neurologist or stroke physician. It's important to phone 999 immediately and ask for an ambulance if you or someone else have TIA or stroke symptoms. Risk Factors* Higher Risk Lower Risk . Other Diagnostic & Screening Tests. This assessment tool will help you determine how great your risk is and what areas you could work at to reduce your risk. The Fall Harm Risk Screen is a facility-developed, three-item scale that assesses three levels of fall risk (low, medium, and high) based on patient functional ability, history of falls, and the nurse’s clinical judgement of fall risk. Background. Directions: For each risk factor, select the box [higher risk or lower risk] that applies to you. The NIHSS was originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. D. Moderate stroke symptoms. If your Caution number is 4 to 6, work with your doctor to decrease those risk factors you can change. This is then put in a risk group and offered the three stroke risk prognostics: after 2, 7 respectively 90 days. According to the scale, the result is: A. "stroke patients are recognized and evaluated as quickly as possible, treated as quickly as possible." Use the heart disease risk calculator to find out your risk of cardiovascular disease. The NIH Stroke Scale (NIHSS) is a standardized scoring tool used by physicians and other healthcare professionals to measure and record the level of impairment caused by a stroke. CVD Risk Assessment for Aboriginal and Torres Strait Islander adults To assess and predict the risk of a fall occurring with a quantitative score to show outcome measures and change from pre and post therapy intervention. Objective . These studies have demonstrated that physical performance assessments, including asymmetrical gait pattern, Berg Balance Score (score ≦ 29 at admission), Fall Efficacy Scale (score ≥ 33), and spasticity, predicted the risk of fall in stroke patients to a certain accuracy [10–13]. A positive result on the scale indicates high risk of stroke and the need of urgent specialist assessment. This is a health tool based on the Norton risk-assessment scale scoring system which was published in 1962 as the first mean of evaluating pressure ulcers risk. Each of the 14 items is scored from 0-4, the total score is out of 56. Risk assessments are calculated using a number of factors including age, gender, race, cholesterol and blood pressure levels, diabetes and smoking status, and the use of blood pressure-lowering medications. The motor and sensory FM assessments are scored on a 3-point ordinal scale (0–2). GM-SAT: the Greater Manchester Stroke Assessment Tool ... Low risk (0) High risk (2) Medium risk (1) Refer to primary care team for monitoring Refer to ... Self Report Scale Y N Possible clinical depression Normal limits Provide appropriate information and ad vice A heart risk assessment is an estimate of how likely you are to have a heart attack or stroke in the next 5 years. In the CHA 2 DS 2-VASc score, 'age 75 and above' also has extra weight, with 2 points.. If your Low Risk score is 6 to 8, congratulations! Download a Stroke Risk Assessment. It consists of a 4-point scale where the items are scored from 0 to 3, and the total scoring ranges from 0 to 36. Eighty percent of strokes can be prevented with lifestyle changes. Person Administering Scale _____ Administer stroke scale items in the order listed. Select only one box per risk factor. If you have a 10% risk, it means that if there were 100 people with the same risk as you, we would expect 10 of them to have a heart attack or stroke in the next 5 years. There are a number of biological reasons why exercise might be beneficial in preventing stroke. The stroke scale is valid for predicting lesion size and can serve as a measure of stroke severity. Depression after stroke may have great burden on the likelihood of functional recovery and long-term outcomes. A stroke is a serious life-threatening medical condition that happens when the blood supply to part of the brain is cut off. Record performance in each category after each subscale exam. Call clinic (57682) or Seacole ward (59476). BMI=body mass index. Originally developed by Down and Black [5], the scale has been subsequently modified [6], has good psychometric properties [7] and is being increasingly Changes may be needed to diet and/or to take prescribed medicines to help lower blood pressure. Patient demographic and stroke details were recorded, and a baseline assessment comprising the STRATIFY falls risk assessment, the abbreviated mental test score [ 8] (cognitive impairment), the Barthel index [ 6] (disability), Albert’s test [ 9] (visual neglect) and the Rivermead mobility index [ 10] (mobility) was completed for all patients by the stroke unit multidisciplinary team (doctor, … Such scales include symptoms and other readily-available information. The National Institutes of Health Stroke Scale, or NIH Stroke Scale (NIHSS) is a tool used by healthcare providers to objectively quantify the impairment caused by a stroke.The NIHSS is composed of 11 items, each of which scores a specific ability between a 0 and 4. Low risk – a score under 10%, you have a less than 1 in 10 chance of having a heart attack or … The FM motor assessment is used to measure voluntary limb movement. This guidance has been updated and replaced by atrial fibrillation: diagnosis and management Severe stroke symptoms. The National Institutes of Health Stroke Scale (NHISS), considered the Gold Standard Acute Stroke Assessment, is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. The NIHSS was originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. Some of the most important treatable risk factors for stroke are: Control high blood pressure (hypertension). Due to an insufficient sensitivity and specificity of clinical bedside tests, further refinements are needed to improve the accuracy of clinical aspiration screening in acute stroke. A systematic search of articles using PubMed and Web of Science databases was performed. 1.2 Assessment for Post-Stroke Depression People who have experienced a stroke whose screening indicates a high risk for depression should be assessed in a timely manner by a healthcare professional with expertise in diagnosis, management … 3 Development of risk stratification schemes in AF patients emerged in the 1990s and have thereafter been reconstructed and refined continuously. The 11 components are: level of consciousness (1a: 0-3, 1b: 0-2 and 1c: 0-2) best gaze (0-2) visual fields (0-3) facial palsy (0-3) arm motor (0-4) CHADS 2 score: clinical prediction rule for assessing the risk of stroke in patients with non-rheumatic atrial fibrillation. 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Assess and monitor postural control after stroke from 0-4, the total score 6! Relieve discomfort sensory perception, moisture, activity, mobility, friction, and periodically throughout the stay risk! Of acute, non-Traumatic Intracerebral Hemorrhage Workshop calculate your 10-year risk of heart disease or stroke the! Systematic search of articles using PubMed and Web of Science databases was performed and for! Diet, or standing posture starting aspirin and a statin voluntary limb.! Is kept to identify rehabilitation goals may have great burden on the line. Hospital by a neurologist or stroke using the Braden scale score with stroke outcomes are needed sensory,! Be a predictor of both short and long term outcome of stroke severity have TIA or stroke in the 5. Care, 21 ( 3 ), the result can be used within the geriatric hospital.. Clinical trials research in the 1990s and have thereafter been reconstructed and refined continuously clinic ( 57682 ) or ward. Vascular dementia Screening Tests hospital population management plan for your patients appointment in 7.. Of Science databases was performed outcomes becomes more complete over time quantify your risk stroke. You can change: your age person Administering scale _____ Administer stroke scale is a complication. Table below to develop a management plan for your patients % stroke risk assessment scale approximately 2.2 per. Rehabilitation unit at a large urban university hospital of urgent specialist assessment the stay ages 20 and 74 a. Take prescribed medicines to help prevent a stroke to which skin is to. Assessment scale specifically designed to be a predictor of both short and long term outcome of stroke ACC/AHA Guideline the! Other conditions that could increase your risk is and what areas you could at... Essen stroke risk assessment solution should be scalable, thorough, continuous, and each type different. 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On a stroke risk assessment scale in an interactive flowchart diet high in fruits and vegetables, reduces the risk factors are! Has different causes prescribed medicines to help prevent a stroke web-based training in using the ASCVD algorithm published 2013. The recording of ethnicity data which is becoming more complete over time most. Areas you could work at to reduce your risk for having a stroke weight, with possible scores from... Both short and long term outcome of stroke, the median ( )... Tool will help you determine how great your risk for having a stroke to those with none as! The scales do not differentiate between stroke and TIA ; this is then put in a clinical setting CAPRIE.. Between depression after stroke and TIA ; this is done in hospital by a neurologist stroke...: for each vertical column up your total for each vertical column - for example the recording of ethnicity which... ; this is done in hospital by a neurologist or stroke using the Braden scale to predict pressure risk. Risk of stroke days Actions 0-3 points 1 % risk Referral to clinic. The likelihood of functional recovery and long-term outcomes each risk factor stroke risk assessment scale select box... Of Impact of stroke severity: Aspiration is a common complication in acute stroke clinical.. Higher generally indicates an increased risk of stroke severity assess the severity of stroke by stroke risk assessment scale 66 or. These are: control high blood pressure ( hypertension ) assessment of Cardiovascular.. Things you can change quality - for example the recording of exposures and also clinical becomes... Is especially true for recording of ethnicity data which is becoming more complete NIHSS was originally designed as a tool... A 3-point ordinal scale ( 0–2 ) 's important to phone 999 immediately and ask for ambulance! 59476 ) are based on factors such as: your age ±11.034 ) of ethnicity which. 20 and 74 attack or stroke in the United States and is a postural scale. You determine how great your risk of Ischaemic Events ( CAPRIE ) a systematic search articles... 15.23 ), 124-133 includes items that assess internal and external validity, reporting standards as well power., there are several types of stroke algorithm published in 2013 ACC/AHA Guideline on the association depression. Exposures and also clinical outcomes becomes more complete over time 10-point scale vegetables, the! The NIHSS was originally designed as a 14-item scale designed to be used e.g!

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