http://www.star-telegram.com/817/story/606891.html
http://www.star-telegram.com/817/story/608041.html
http://www.star-telegram.com/817/story/609399.html
http://www.star-telegram.com/389/story/613425.html
http://www.star-telegram.com/817/story/616014.html
http://www.star-telegram.com/817/story/618712.html
Tuesday, May 6, 2008
Saturday, April 12, 2008
Put the Fire Out!
PARABLE OF NATIONAL HEALTHCARE By Jamie and Pamela Voras
-- published on October 23, 2007http://healthcare-now.org/showstory.php?nid=542
THE PARABLE OF NATIONAL HEALTHCARE
Smoke bellows from the quiet, two story home, as the Fire Department arrives. An anxious young couple greets them, the wife clutching a crying baby.
"Thank God you're here!" says the husband. "It's just a small kitchen fire, and will only take a second to put out".
"Yes, thank goodness we're insured." adds his wife.
"We'll have this thing out in no time", the Fire Chief calmly responds, "but first we'll need to see your insurance card."
"Our insurance card?!?" says the husband,"but...it's in the filing cabinet, in the house, and the house is on fire! Can't we just worry about that later?"
"Sorry, sir, we can't do anything without proof that you have insurance."
"Oh,no, Honey", screams his wife, "I think my card is in my purse, but it's in the living room, and...well, the house is on fire!"
Shaking his head, her husband takes a deep breath and runs into the burning house. After a few minutes, he emerges, covered in ash and gasping for air, but holding the purse.
"Here, Honey, but please hurry-the fire has already jumped to the bedroom." She eventually finds the card, and hands it to the Chief.
"This will take just a minute, while we run this by the insurance company, to find out what's covered and what's not......Oops,sorry, I'm afraid we'll have to call this one in, your card isn't going through."
"Look, can't this wait? Our house is going to be ruined!"
"Listen Pal, barks the Chief - "If you're going to be rude, we can always just take care of the house on Maple Street. We KNOW they're insured, and by Blue Bell Insurance. They cover EVERYTHING!"
"I'm not being rude, it's just that this fire..."
"Hey, we finally got through. This fire has been approved to 20,000 gallons, with a 5,000 gallon deductible. Would you like to pay for that in cash or with a credit card?"
"But...we don't HAVE cash or a credit card....they're in the...house!"
"Sorry, but we're going to need that before we can proceed any further".
"I'll....I'll write you a check", says the wife, reaching for her purse as the upstairs explodes into flames.
"Thank you", says the Chief, as he writes her a receipt. "Just one more thing."
"Good grief" barks the husband. "What NOW?!?"
"How old is your wiring? Do you have fiberglass or foam insulation? Is the house pre or post 1950? Are the floors wood or tile? If it's wood, the fire is going to spread faster, you know. Now, I want to tell you that if you've had the same wiring since you bought the house, and it IS an electrical fire, you might be in trouble. Some policies don't cover a pre-existing electrical condition, and some policies don't cover wood floors, because they burn faster, so we have to ask these things, for your own benefit."
"But...my house! It's burning to the ground!"
"Yes, it is. As a matter of fact, it's getting really smokey in there. Does your policy cover oxygen for the firefighters? Some do, some don't. It's $100.00 a tank, you know. Let's see, there's 5 of us, times $100.00". Oh, and is that a 2, 3, or 4 bedroom home? Are the bathrooms upstairs, downstairs, or both? Is there a basement? An attic?..."
"Please", both the husband and wife are now frantically crying, holding on to each other, and watching everything they've worked their whole lives for disappearing into smoke.
"Okay", blasts the Fire Chief. "Let's Roll! Start the meter, Bob."
As the second story collapses, the firemen do their best to battle the blaze. They watch while the fire in the small portion that's left of their house is nearly extinguished.
"Okay-Cut the water! Cut the water!" the lead firefighter yells.
"What?!?" the astonished husband shouts..."you can't stop, the fire is nearly out. It's finally under control."
"Sorry, Sir, your policy only covers you up to 20,000 gallons, and we just reached that."
"But...my house! It's now going to be a total loss, and you could have easily saved it!"
"You should have thought of that when you bought your policy, Sir."
"Oh, how I wish that we had not-for-profit National Fire Service, like they do in Canada." sobs the wife. "Yeah, they put out a fire, no questions asked." adds the husband.
"You Liberals are all the same! Canada....Sometimes they gotta wait ten minutes for a fire truck!"
Fireman Bob chimes in with "Yeah, I don't want da government runnin' MY fire protection, just look at how day run Social Security!"
"Socialized Fire Protection?" snorts the Chief. "Not in MY America! Besides, we could never afford it."
Bob puffs up his chest "Yeah...da good old U.S.A- best Fire Protection in da world!"
The sad couple stands in horror, as they watch the chimney tumble into the ashes...."Good thing we were insured."
Jamie and Pamela Voras are the Wisconsin State Chairs for Dennis Kucinich*2008. Click here to contact Jamie and Pamela Voras and Healthcare-NOW.
-- published on October 23, 2007http://healthcare-now.org/showstory.php?nid=542
THE PARABLE OF NATIONAL HEALTHCARE
Smoke bellows from the quiet, two story home, as the Fire Department arrives. An anxious young couple greets them, the wife clutching a crying baby.
"Thank God you're here!" says the husband. "It's just a small kitchen fire, and will only take a second to put out".
"Yes, thank goodness we're insured." adds his wife.
"We'll have this thing out in no time", the Fire Chief calmly responds, "but first we'll need to see your insurance card."
"Our insurance card?!?" says the husband,"but...it's in the filing cabinet, in the house, and the house is on fire! Can't we just worry about that later?"
"Sorry, sir, we can't do anything without proof that you have insurance."
"Oh,no, Honey", screams his wife, "I think my card is in my purse, but it's in the living room, and...well, the house is on fire!"
Shaking his head, her husband takes a deep breath and runs into the burning house. After a few minutes, he emerges, covered in ash and gasping for air, but holding the purse.
"Here, Honey, but please hurry-the fire has already jumped to the bedroom." She eventually finds the card, and hands it to the Chief.
"This will take just a minute, while we run this by the insurance company, to find out what's covered and what's not......Oops,sorry, I'm afraid we'll have to call this one in, your card isn't going through."
"Look, can't this wait? Our house is going to be ruined!"
"Listen Pal, barks the Chief - "If you're going to be rude, we can always just take care of the house on Maple Street. We KNOW they're insured, and by Blue Bell Insurance. They cover EVERYTHING!"
"I'm not being rude, it's just that this fire..."
"Hey, we finally got through. This fire has been approved to 20,000 gallons, with a 5,000 gallon deductible. Would you like to pay for that in cash or with a credit card?"
"But...we don't HAVE cash or a credit card....they're in the...house!"
"Sorry, but we're going to need that before we can proceed any further".
"I'll....I'll write you a check", says the wife, reaching for her purse as the upstairs explodes into flames.
"Thank you", says the Chief, as he writes her a receipt. "Just one more thing."
"Good grief" barks the husband. "What NOW?!?"
"How old is your wiring? Do you have fiberglass or foam insulation? Is the house pre or post 1950? Are the floors wood or tile? If it's wood, the fire is going to spread faster, you know. Now, I want to tell you that if you've had the same wiring since you bought the house, and it IS an electrical fire, you might be in trouble. Some policies don't cover a pre-existing electrical condition, and some policies don't cover wood floors, because they burn faster, so we have to ask these things, for your own benefit."
"But...my house! It's burning to the ground!"
"Yes, it is. As a matter of fact, it's getting really smokey in there. Does your policy cover oxygen for the firefighters? Some do, some don't. It's $100.00 a tank, you know. Let's see, there's 5 of us, times $100.00". Oh, and is that a 2, 3, or 4 bedroom home? Are the bathrooms upstairs, downstairs, or both? Is there a basement? An attic?..."
"Please", both the husband and wife are now frantically crying, holding on to each other, and watching everything they've worked their whole lives for disappearing into smoke.
"Okay", blasts the Fire Chief. "Let's Roll! Start the meter, Bob."
As the second story collapses, the firemen do their best to battle the blaze. They watch while the fire in the small portion that's left of their house is nearly extinguished.
"Okay-Cut the water! Cut the water!" the lead firefighter yells.
"What?!?" the astonished husband shouts..."you can't stop, the fire is nearly out. It's finally under control."
"Sorry, Sir, your policy only covers you up to 20,000 gallons, and we just reached that."
"But...my house! It's now going to be a total loss, and you could have easily saved it!"
"You should have thought of that when you bought your policy, Sir."
"Oh, how I wish that we had not-for-profit National Fire Service, like they do in Canada." sobs the wife. "Yeah, they put out a fire, no questions asked." adds the husband.
"You Liberals are all the same! Canada....Sometimes they gotta wait ten minutes for a fire truck!"
Fireman Bob chimes in with "Yeah, I don't want da government runnin' MY fire protection, just look at how day run Social Security!"
"Socialized Fire Protection?" snorts the Chief. "Not in MY America! Besides, we could never afford it."
Bob puffs up his chest "Yeah...da good old U.S.A- best Fire Protection in da world!"
The sad couple stands in horror, as they watch the chimney tumble into the ashes...."Good thing we were insured."
Jamie and Pamela Voras are the Wisconsin State Chairs for Dennis Kucinich*2008. Click here to contact Jamie and Pamela Voras and Healthcare-NOW.
Did We Listen to our Infection Control Fathers and Mothers?
Here's a great post I received from a newsmail group, written by Chris Cahill, MS BS RN, Infection Prevention and Control Consultant
"As many of you know I spent about 12 years working for the California Department of Health Services (CDHS) surveying hospitals for compliance with state and federal infection control regulations and investigating outbreaks of healthcare-associated infections. What I saw in these hospitals was sickening and although I wrote many deficiencies for an unsanitary environment and other regulations and many letters to the licensing agency that I worked for, my complaints of filthy hospital environments fell on deaf ears. As I was recovering from a long overdue surgical procedure this year I dusted off a 1987 edition of Prevention and Control of Nosocomial Infections edited by Richard P. Wenzel and a 1992 edition of Hospital Infections edited by John V. Bennett MD and Philip S. Brachman MD. In the preface Bennett and Brachman commented: "Infection control staff are not always successful in influencing a change in the behavior of hospital care personnel. We must continue to emphasize the adoption of recommended procedures that will control and prevent infections and the elimination of those that are not effective and counterproductive." That was a powerful statement than and it is as true today and it was over 12 years ago. Why, after all these years and after all the published research is infection control so unsuccessful in influencing behaviors for preventing healthcare-associated infections? I believe there are several reasons each worthy of lengthy explorations. However, I shall try to highlight what I think is important. You may disagree; so be it. Several years ago the Institute for Healthcare Improvement (IHI) recommended against pre-operative shaving. What a revelation! Infection control professionals ran frantically from operating room to operating room eliminating razors. But what happened during the 30 + years between the original research that showed pre-operative shaving increased the incidence of surgical site infections (Seropian. Am J Surg. 1971;121:251) and the IHI recommendations? It is not as though hospital infection control committees came into existence just as the IHI began their campaign to reduce surgical site infections. Appropriate administration of surgical antimicrobial prophylaxis is another IHI recommendation. There has been a multitude of published research over the years showing that most prophylactic antibiotics need to be given within one hour of the surgical incision. The IHI strongly suggested the implementation of this recommendation. However it was not until the federal government dangled extra dollars that compliance with this recommendation increased. Or did it? Again where were the doctors assigned to the hospital's infection control committee all these years? Did they just come for lunch? Did they audit surgical prophylaxis? Did they tell the chiefs of the surgical services that antibiotic prophylaxis in their hospital was administered inappropriately? Why did patients have to be put at increased risk for a surgical site infection all those years when the research proved a relationship between appropriate antibiotic timing and selection and a positive surgical outcome? The topic of heated discussion today is methicillin-resistant Staphylococcus aureus (MRSA). The media and the public are driving the train leaving those of us who know something about the epidemiology of MRSA in their dust. The politicians are being lead to believe that active surveillance testing and contact precautions for all MRSA positive patients are the only answers to our transmission prevention prayers. The IHI has recommendations to prevent MRSA infection. One of the recommendations supports decontamination of the environment and equipment. "MRSA survives well in the hospital environment. Personnel who come in contact with contaminated objects or surfaces may contaminate their hands. Patients who are placed in rooms previously occupied by a patient colonized with MRSA occasionally acquire this organism, either via the hands of personnel or through their own direct contact with persisting organisms in their immediate environment. Thorough, regularly scheduled cleaning and disinfection of the environment are essential. Accordingly HICPAC (Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention (CDC)) recommendations include fastidious environmental cleaning and disinfection as a priority for all hospitals." But is this last sentence a true statement? Here is what HICPAC says: "Although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens, these surfaces generally are not directly associated with transmission of infections to either staff or patients." Further HICPAC states: "Although S. aureus has been isolated from a variety of environmental surfaces (e.g., stethoscopes, floors, charts, furniture, dry mops, and hydrotherapy tanks), the role of environmental contamination in transmission of this organism in health care appears to be minimal. This is music to a hospital administrator's ear. Who would be foolish enough not to take advantage of significantly reducing the environmental services department staffing if the CDC says clean when it looks dirty and as for discharge/transfer rooms make it look clean. The shame and blame is directed solely at the HICPAC/CDC staff who authorized the release of the recommendations and who should now voluntarily withdrawn, or with haste, revise the section of this document related to the cleaning [and disinfecting] the hospital's environment. We deserve better recommendations; it is the taxpayer's dollars that pay the experts expenses to these meetings three times each year and as a consumer of health care we deserve quality recommendations. Lastly, bathing patients seems to have been eliminated from daily nursing care. Some day there may be a machine to perform this procedure. In the 1987 edition of Prevention and Control of Nosocomial Infections, Elaine Larson comments: "it might be useful for patients at increased risk for infection... to use an antibacterial skin cleaning agent for bathing during hospitalization. Some investigators have demonstrated dramatic reductions in skin carriage of staphylococci and other skin flora when total washes with antibacterial soaps are done. This recommendation was published in 1981. (Brandberg A, Anderson J: Whole body disinfection by shower-bath with chlorhexidine soap. In Maibach H, Aly R (eds) Skin Microbiology: New York, Springer-Verlag, 1981). Some of the research published by our infection control fathers and mothers has long been forgotten, or if written into a hospital procedure it is ignored by nursing and ancillary department managers. Infection control professionals are never aware of that ignored step in a procedure until they have to cope with the deadly consequences of an outbreak of hepatitis C virus in the outpatient endoscopy center or testing hundreds of patients for bloodborne pathogens after an exposure to improperly reprocessed endoscopes or an outbreak of hepatitis B virus in diabetic long-term care patients exposed to community glucometers. We (collectively all of us who have dedicated our lives to infection prevention and control) have had little outside support along the way. The Joint Commission (JC) has been relatively mute and their surveyors, who are the patient safety watch dogs rarely find significant deficient practices. They know tracers but can not review a policy or procedure to determine if evidence-based standards (new and old) of infection prevention and control have been put into practice by patient care staff. The federal government won't spend a dime to train state inspectors to survey for infection control but they are more than willing to refuse payment to hospitals for that healthcare-associated urinary tract infection primarily caused by non-compliance with approved hospital infection control procedures. Infection control professionals are at the mercy of those with higher academic degrees and higher salaries. Infection control committee chairpersons are, for the most part relatively ineffective because they are independent consultants and depend on staff physicians for their livelihood. And anyone who interferes with a staff physician's practice, especially a surgeon might well be looking for work elsewhere. Yes, we, the experts, need to take a little trip back in time and consider what our fathers and mothers (Wenzel, Bennett, Brachman, Jarvis, Goldman, Larson and host of others) taught us about infection surveillance, prevention and control. We need to take control and we need to demand immediate better staffing to influence compliance with evidence-based standards. The public and the legislators are driving our train and right now there are no station stops. If you do not like my comments please do not respond. If you have constructive criticism I would love to hear from you." How can we contact you, Chris?
"As many of you know I spent about 12 years working for the California Department of Health Services (CDHS) surveying hospitals for compliance with state and federal infection control regulations and investigating outbreaks of healthcare-associated infections. What I saw in these hospitals was sickening and although I wrote many deficiencies for an unsanitary environment and other regulations and many letters to the licensing agency that I worked for, my complaints of filthy hospital environments fell on deaf ears. As I was recovering from a long overdue surgical procedure this year I dusted off a 1987 edition of Prevention and Control of Nosocomial Infections edited by Richard P. Wenzel and a 1992 edition of Hospital Infections edited by John V. Bennett MD and Philip S. Brachman MD. In the preface Bennett and Brachman commented: "Infection control staff are not always successful in influencing a change in the behavior of hospital care personnel. We must continue to emphasize the adoption of recommended procedures that will control and prevent infections and the elimination of those that are not effective and counterproductive." That was a powerful statement than and it is as true today and it was over 12 years ago. Why, after all these years and after all the published research is infection control so unsuccessful in influencing behaviors for preventing healthcare-associated infections? I believe there are several reasons each worthy of lengthy explorations. However, I shall try to highlight what I think is important. You may disagree; so be it. Several years ago the Institute for Healthcare Improvement (IHI) recommended against pre-operative shaving. What a revelation! Infection control professionals ran frantically from operating room to operating room eliminating razors. But what happened during the 30 + years between the original research that showed pre-operative shaving increased the incidence of surgical site infections (Seropian. Am J Surg. 1971;121:251) and the IHI recommendations? It is not as though hospital infection control committees came into existence just as the IHI began their campaign to reduce surgical site infections. Appropriate administration of surgical antimicrobial prophylaxis is another IHI recommendation. There has been a multitude of published research over the years showing that most prophylactic antibiotics need to be given within one hour of the surgical incision. The IHI strongly suggested the implementation of this recommendation. However it was not until the federal government dangled extra dollars that compliance with this recommendation increased. Or did it? Again where were the doctors assigned to the hospital's infection control committee all these years? Did they just come for lunch? Did they audit surgical prophylaxis? Did they tell the chiefs of the surgical services that antibiotic prophylaxis in their hospital was administered inappropriately? Why did patients have to be put at increased risk for a surgical site infection all those years when the research proved a relationship between appropriate antibiotic timing and selection and a positive surgical outcome? The topic of heated discussion today is methicillin-resistant Staphylococcus aureus (MRSA). The media and the public are driving the train leaving those of us who know something about the epidemiology of MRSA in their dust. The politicians are being lead to believe that active surveillance testing and contact precautions for all MRSA positive patients are the only answers to our transmission prevention prayers. The IHI has recommendations to prevent MRSA infection. One of the recommendations supports decontamination of the environment and equipment. "MRSA survives well in the hospital environment. Personnel who come in contact with contaminated objects or surfaces may contaminate their hands. Patients who are placed in rooms previously occupied by a patient colonized with MRSA occasionally acquire this organism, either via the hands of personnel or through their own direct contact with persisting organisms in their immediate environment. Thorough, regularly scheduled cleaning and disinfection of the environment are essential. Accordingly HICPAC (Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention (CDC)) recommendations include fastidious environmental cleaning and disinfection as a priority for all hospitals." But is this last sentence a true statement? Here is what HICPAC says: "Although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens, these surfaces generally are not directly associated with transmission of infections to either staff or patients." Further HICPAC states: "Although S. aureus has been isolated from a variety of environmental surfaces (e.g., stethoscopes, floors, charts, furniture, dry mops, and hydrotherapy tanks), the role of environmental contamination in transmission of this organism in health care appears to be minimal. This is music to a hospital administrator's ear. Who would be foolish enough not to take advantage of significantly reducing the environmental services department staffing if the CDC says clean when it looks dirty and as for discharge/transfer rooms make it look clean. The shame and blame is directed solely at the HICPAC/CDC staff who authorized the release of the recommendations and who should now voluntarily withdrawn, or with haste, revise the section of this document related to the cleaning [and disinfecting] the hospital's environment. We deserve better recommendations; it is the taxpayer's dollars that pay the experts expenses to these meetings three times each year and as a consumer of health care we deserve quality recommendations. Lastly, bathing patients seems to have been eliminated from daily nursing care. Some day there may be a machine to perform this procedure. In the 1987 edition of Prevention and Control of Nosocomial Infections, Elaine Larson comments: "it might be useful for patients at increased risk for infection... to use an antibacterial skin cleaning agent for bathing during hospitalization. Some investigators have demonstrated dramatic reductions in skin carriage of staphylococci and other skin flora when total washes with antibacterial soaps are done. This recommendation was published in 1981. (Brandberg A, Anderson J: Whole body disinfection by shower-bath with chlorhexidine soap. In Maibach H, Aly R (eds) Skin Microbiology: New York, Springer-Verlag, 1981). Some of the research published by our infection control fathers and mothers has long been forgotten, or if written into a hospital procedure it is ignored by nursing and ancillary department managers. Infection control professionals are never aware of that ignored step in a procedure until they have to cope with the deadly consequences of an outbreak of hepatitis C virus in the outpatient endoscopy center or testing hundreds of patients for bloodborne pathogens after an exposure to improperly reprocessed endoscopes or an outbreak of hepatitis B virus in diabetic long-term care patients exposed to community glucometers. We (collectively all of us who have dedicated our lives to infection prevention and control) have had little outside support along the way. The Joint Commission (JC) has been relatively mute and their surveyors, who are the patient safety watch dogs rarely find significant deficient practices. They know tracers but can not review a policy or procedure to determine if evidence-based standards (new and old) of infection prevention and control have been put into practice by patient care staff. The federal government won't spend a dime to train state inspectors to survey for infection control but they are more than willing to refuse payment to hospitals for that healthcare-associated urinary tract infection primarily caused by non-compliance with approved hospital infection control procedures. Infection control professionals are at the mercy of those with higher academic degrees and higher salaries. Infection control committee chairpersons are, for the most part relatively ineffective because they are independent consultants and depend on staff physicians for their livelihood. And anyone who interferes with a staff physician's practice, especially a surgeon might well be looking for work elsewhere. Yes, we, the experts, need to take a little trip back in time and consider what our fathers and mothers (Wenzel, Bennett, Brachman, Jarvis, Goldman, Larson and host of others) taught us about infection surveillance, prevention and control. We need to take control and we need to demand immediate better staffing to influence compliance with evidence-based standards. The public and the legislators are driving our train and right now there are no station stops. If you do not like my comments please do not respond. If you have constructive criticism I would love to hear from you." How can we contact you, Chris?
National Patient Safety Foundation
As a long time subscriber of the National Patient Safety Foundation Listserv, I was disheartened recently when several members recommended patients/consumers "go somewhere else" to "air our grievances" so the communication channel could be left clear for scientific research and "creative ideas." How will they get creative ideas if they refuse to listen to the "end user," the patient? Following is my last post to the National Patient Safety Foundation Listserv and I encourage all consumer advocates to boycott the NPSF or please tell me what on earth have they ever done for patients in all these years?
"Barbara, we would be happy to take our grievances elsewhere, for the love of God please tell us where to go with them. You're a manager of Quality Services, surely you're the expert on where quality concers belong. We've searched for years for the appropriate forum to voice our concerns about the human rights violations, abuse, neglect, humiliation, pain and suffering, unneccessary death, corruption and lies we've born witness to. Somebody should care. Somebody should want to hear about it and correct it, call attention to it. Our hosptial staff and leadership want us to go somewhere else. Our health departments want us to go somewhere else. Our politicians want us to go somewhere else. The AMA wants us to go somewhere else. JCAHO wants us to go away. IHI wants us to go somewhere else, they recommend the NPSF. Now NPSF members want us to go somewhere else. That pretty much leaves us with only each other and we already know what's broken in our world. We've asked you to tell us what's broken in your world and we've been met with silence. Please tell us where to go and we'll leave you behind in your peaceful eutopia."
"Barbara, we would be happy to take our grievances elsewhere, for the love of God please tell us where to go with them. You're a manager of Quality Services, surely you're the expert on where quality concers belong. We've searched for years for the appropriate forum to voice our concerns about the human rights violations, abuse, neglect, humiliation, pain and suffering, unneccessary death, corruption and lies we've born witness to. Somebody should care. Somebody should want to hear about it and correct it, call attention to it. Our hosptial staff and leadership want us to go somewhere else. Our health departments want us to go somewhere else. Our politicians want us to go somewhere else. The AMA wants us to go somewhere else. JCAHO wants us to go away. IHI wants us to go somewhere else, they recommend the NPSF. Now NPSF members want us to go somewhere else. That pretty much leaves us with only each other and we already know what's broken in our world. We've asked you to tell us what's broken in your world and we've been met with silence. Please tell us where to go and we'll leave you behind in your peaceful eutopia."
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