86 Likes, TikTok video from Bailey Marie (@baileytherobot): “Whats the. 5337.Are you in need of your degree certificate download? Whether you are a recent graduate or someone who misplaced their physical copy, obtaining your degree certificate online has ne... The NIH Stroke Scale Training Program is designed to allow healthcare providers to return to the course after designated time intervals to refresh their skills and demonstrate their continued mastery of this tool by successfully assessing a series of test scenarios. A score of 2, "severe or total sensory loss," should only be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2.The NIH offers training and certification in the administration and scoring of the stroke scale. An overview of the scale is listed below. ... The NIH stroke scale can be administered in less than 10 minutes in skilled hands. It provides excellent baseline for stroke treatment assessment and can be used for prognosis.This is a "certificate" to prove that you took the NIH Stroke Scale (how to do an in-depth stroke assessment) course. Nobody without this certificate should be doing these assessments, so technically it could be considered a type of certification. You can get up to 18.0 CE units for this course:NIH Stroke Scale (pdf, 855 KB): Evaluation of stroke severity. Certification available from the National Stroke Association’s NIHSS Certification Services and/or ASA Certification Service. Barthel Index: Measure stroke patient performance on activities of daily living. Glasgow Outcome Scale: Determines degree of stroke patient recovery.The Heart-Check mark is also helping everyone find heart-healthy recipes they can make at home for themselves and their families. Recipe certification is based on respected science and nutrition expertise of the American Heart Association. View the Full List of Heart-Check Certified Recipes. *All health/medical information on this website has ...Link to Certificate of Completion. As we said in the beginning of the course, your agency may accept this course as completion of your annual training requirements. If they do, please send the certificate (or other proof of completion) to your agency (but not to OGE). Thanks again for taking this course. It's been a pleasure to serve you.Practice Exams. Take a quick interactive quiz on the concepts in NIH Stroke Scale: Definition & Methods of Use or print the worksheet to practice offline. These practice questions will help you ...For the imaging training, make a PDF copy of the email you receive when you are notified of a successful MRI image upload to LONI and upload to WebDCU™. After reviewing slides/MP4 complete the quiz and attestation form. After completing the quiz click the "see results" button. Convert the quiz results page to a PDF.NIH Stroke Scale: Earn Credit Webinars: Watch education webcasts. Podcasts: Listen to education podcasts Tweetorials: Engage in education using social media. ... The Maintenance of Certification (MOC) Program is designed to advance the basic, clinical, population, and translational practice of healthcare clinicians, by promoting the highest ...This topic will review stroke scales and grading systems that are used for ischemic and hemorrhagic stroke. Grading systems used to classify patients with subarachnoid hemorrhage are reviewed separately. (See "Subarachnoid hemorrhage grading scales" .) Categorization systems used in the classification and etiology of stroke are also discussed ...The NIH Stroke Scale Training Program is designed to allow healthcare providers to return to the course after designated time intervals to refresh their skills and demonstrate their continued mastery of this tool by successfully assessing a series of test scenarios. Each of these test groups is equivalent in size and scope, but the scenarios in ...The National Institutes of Health Stroke Scale (NIHSS) is an clinical assessment that is used to evaluate and document stroke severity. This assessment is first performed by a certified clinician in the emergency department once a patient is suspected of having a stroke. The test will be repeated throughout hospitalization to determine ...Practice Exams. Take a quick interactive quiz on the concepts in NIH Stroke Scale: Definition & Methods of Use or print the worksheet to practice offline. These practice questions will help you ... Purpose of the measure. The NIHSS is a 15-item impairment scale, intended to evaluate neurologic outcome and degree of recovery for patients with stroke. The scale assesses level of consciousness, extraocular movements, visual fields, facial muscle function, extremity strength, sensory function, coordination (ataxia), language ( aphasia. 7. To print your certificate navigate to the Completed Activities tab and click on the certificate icon next to the live activity name. 8. For further assistance fill out the form on the Contact Us page or call our toll-free phone number at 1-888-242-2453 (available between the hours of 8:00 am - 5:00 pm CST).NIH Stroke Scale Training - Part 1 - Introduction - Department of Health and Human Services - - National Institute of Neurological Disorders and Stroke. ...NIH Stroke Scale Group B Patient 1-6. 6 terms. jnw803. Preview. nih group E. 6 terms. Emily_Lewson26. Preview. study stuff. 20 terms. fartmaster68. Preview. 2D and 3D Shapes. Teacher 26 terms. Chandler_Paganis6. Preview. NIH Stroke Scale Group A Patient 1-6. 6 terms. the_lauren_c. Preview. NIHSS Group D study set. 6 terms. savant01. Preview.To qualify for this offer, an eligible ASLS Online Course AND an eligible NIH Stroke Scale course must be added to the cart. The discount will be automatically applied in the cart. Valid for one free NIH Stroke Scale course per order. Bulk purchasers should contact ther sales representative for additional information.About this app. Since the initial release in 1990, the NIHSS has been a standard for evaluating stroke symptoms in patient diagnosis. With the proven success in quickly identifying patients using the Stroke Scale, NIHSS+ utilizes the same fundamentals in a different learning format more suited for today's technology.Offered in collaboration with the American Heart Association/American Stroke Association achieving Primary Stroke Center (PSC) Certification means you're making exceptional efforts to foster better outcomes. It's a signal to your community the quality of care you provide meets the unique and specialized needs of stroke patients. Certificate Verification. Please enter a user's email address and test date, or enter their certificate ID located at the bottom right have corner of the certificate. If you need to validate a certificate for the NIHSS, please click here. Learn to be prepared with NIH stroke scale education from Apex Innovations. Click now to learn more about ... The NIH Stroke Dimension certification program trains participants for administrate the NIHSS tool correctly. The below is a list of a few healthcare professional groups that need the NIHSS authentication. Nurses Nurse Practitioners (APRN) Neurologists Emergency rooms physicians;NIH Stroke Scale CME/CE certified, for healthcare professionals on how to administer the NIH Stroke Scale, a critical component of acute stroke assessment. Learn more about NIH Stroke Scaleask patient to perform 2 tasks. 1) close your eyes, now open them. 2) make a fist (independent limbs) NIH Best Gaze. tests voluntary horizontal eye movements. - notice position of the eyes at rest, - move finger/object horizontally and ask patient to follow moving target. 0 = score if acts performed correctly. 1 = partial gaze palsy.NIHSS NIH Stroke Scale Training & Certification In support of improving patient care, Apex Innovations is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council ...APEX NIH Stroke Scale Group B Patient 1-6. 6 terms. Haley_Spratt. Preview. APEX NIH Stroke Scale Group A Patient 1-6. 6 terms. Dannielle_Wyatt. Preview. Flyover . 16 terms. Dagem69. Preview. Precise Summarizer and Teacher. 73 terms. jackson-the-king. Preview. NIHSS GROUP A | PATIENTS 1-6. Teacher 6 terms. ghbear. Preview. NIH Stroke …NIH Stroke Scale Certification. The National Stroke Association offers this free CE/CME certified, online training program for healthcare professional to learn how to administer the NIH Stroke Scale for acute stroke assessment using training videos developed by the National Institute of Neurological Disorders and Stroke (NINDS).NIHSS Information. NIHSS Introduction. Tips for Scoring. Significance - Stroke Scale. Relevance to Medical Specialties. Instruction. Demonstration Patient A. Demonstration Patient B. NIHSS Certification.The NIHSS is internally consistent, with a reasonable Cronbach's alpha and reproducible across the intended range of users: stroke nurses, vascular neurologists, and ED physicians. 19 - 21 The scale is reliable when used by non-neurologists who undergo training. 20,21 The total NIHSS score can predict outcome or the presence of large vessel ...NIHSS Certification | NIH Stroke Scale Certification. Listen to the podcast series. Explore Case Studies. Maint of Certification. The Maintenance of Certification (MOC) Programming lives designed toward advance the primary, clinical, country, and translational practice of healthcare clinicians, by promoting the highest evidence-based guidelines ...Nurses are trained to perform the NIHSS for monitoring patients after a stroke, specifically those at risk for worsening neurological status. With proper training in use of NIHSS, little variance should exist in results among nurses. Education is essential for improved reliability and increased effective communication regarding stroke treatment.Perform a focused neurological exam on the basis of the NIH Stroke Scale (NIHSS) 10. Free online-trainings of the NIHSS are available in several languages 11. ... When training other hospitals with smaller stroke units, such as our cooperation partners in the regional stroke network INVN Rhein-Main, we emphasize that the first 30 min which a ...The American Heart Association (AHA) is a non-profit organization dedicated to fighting heart disease and stroke. With their extensive resources and research, they provide valuable...The candidate must be a professional nurse engaged in aspects of stroke care, including but not limited to stroke nursing clinical practice, or employed as an administrator, consultant, educator or researcher. The candidate must have a minimum of at least one (1) year full-time (2,080 hours) of direct or indirect stroke nursing experience ...Results: The mean NIHSS improved from 9 to 6, 24 hours post-tPA. Of the 41 patients, 29 improved by physician documentation, although only 11 of the 29 met the NIHSS criteria (P < .001; McNemar P < .001).On discharge, 20 of the 41 patients met the NIHSS criteria; however, the proportion "better" by physician documentation (71%) remained significantly higher (P = .04; McNemar P = .004).NIH Continuing Medical Education (CME) The NIH Clinical Center's Office of Clinical Research Training and Medical Education (OCRTME) has a contract with the Johns Hopkins School of Medicine Office of CME to provide CME credit for NIH educational activities. Hopkins is accredited by the Accreditation Council for Continuing Medical …If you’re looking to become a Board Certified Assistant Behavior Analyst (BCaBA), you may be wondering if there are any online programs available. The good news is that there are s... To qualify for this offer, an eligible ASLS Online Course AND an eligible NIH Stroke Scale course must be added to the cart. The discount will be automatically applied in the cart. Valid for one free NIH Stroke Scale course per order. Bulk purchasers should contact ther sales representative for additional information. Report Viewer. The NIHSS is a 11-item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. The NIHSS is a tool used to rapidly assess the effects of stroke.As part of its broader commitment to research on heart and vascular diseases, the NHLBI leads and supports research and programs on stroke detection, prevention, and treatment in the United States and around the world.Numerous landmark NHLBI-supported studies have identified stroke risk factors — such as plaque buildup in the arteries — and have paved the way for new interventions to ...The training program consisted of a 2-day theoretical and practical course in NIHSS and acute stroke assessment including simulation training (Supplemental Material). The program was 1 day with physical attendance and 1 day with web based NIHSS training and certification. 24 The NIHSS certification was compulsory before participation in the ...The NIH Stroke Scale is a critical component of acute stroke assessment. The American Stroke Association, in conjunction with the American Academy of Neurology (AAN) and the National Institute of Neurological Disorders and Stroke (NINDS) has developed this CME/CE certified, online training program for healthcare professionals to learn or review ...All the tools you need, in one place. It's more than a library, its a toolbox. Patient and professional focused resources for prevention, pre-hospital treatment, in hospital protocols and post-stroke care. Help yourself-help your patients. Normal symmetry 0. Minor paralysis (flat nasolabial fold, smile asymmetry) +1. Partial paralysis (lower face) +2. Unilateral complete paralysis (upper/lower face) +3. Bilateral complete paralysis (upper/lower face) +3. 5A: Left arm motor drift. Count out loud and use your fingers to show the patient your count. y - NINDS-OOI- NIH Stroke Scale - English - Certification A AUTHOR Contains t9Stg group Only to take test. for up to 2 to certify. This NIH Stroke Scale International (NIHSSI) Test contains 6 sections, each containing a single patient interview. You must score all 6 patients at out of go 01- NIHSS- items correct to achieve certification ...The NIHSS score for the patient is calculated by multiplying the number for each element of the scale, with a score of 42 being the highest possible. The higher the score in the NIHSS, the more impaired a stroke patient is. What is NIH Stroke Certification, in addition?Nov 22, 2023 · NIH Stroke Scale – All Test Groups A-F (patients 1-6) Answer key Updated Spring 2023. NIH Stroke Scale – All Test Groups A-F (patients. 1-6) Answer key Updated Spring 2023. NIHSS – Group A Test Answers 2023/ NIHSS GROUP A | PATIENTS 1-6. Patient 1 – 1a- 0. 1b- 0. NIHSS Group B Patient 1-6 Answer Key. Patient 1. Patient 2. patient 3. User's comment - facial palsy is incorrect - the answer is 1. Patient 4. Patient 5. user's comment - extinction the answer is 0. Patient 6.NIH Stroke Scale Training - Part 2 - Basic Instruction - Department of Health and Human Services - - National Institute of Neurological Disorders and Str...The 15 item NIH Stroke Scale quantifies the degree of neurological deficit and facilitates communication. It remains the stroke severity rating scale of choi...The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. The pinprick test should be done with a sterile safety needle, being careful not to break the skin.About Institutional Certifications. Institutional Certifications are expected for the submission of large-scale human genomic data under the NIH Genomic Data Sharing Policy. Understand the responsibilities of the investigator, the institution, and the institutional review board (IRB) in preparing an Institutional Certification.When achieving an advanced certification you must meet the core requirements plus additional clinically-specific requirements. For stroke, there is one basic certification for Rehabilitation and four advanced certifications for Comprehensive Stroke Centers, Thrombectomy-Capable Stroke Centers, Primary Stroke Centers, and Acute Stroke Ready ...Nurses are trained to perform the NIHSS for monitoring patients after a stroke, specifically those at risk for worsening neurological status. With proper training in use of NIHSS, little variance should exist in results among nurses. Education is essential for improved reliability and increased effective communication regarding stroke treatment.About Institutional Certifications. Institutional Certifications are expected for the submission of large-scale human genomic data under the NIH Genomic Data Sharing Policy. Understand the responsibilities of the investigator, the institution, and the institutional review board (IRB) in preparing an Institutional Certification.Four training sessions were organized on two different days to ensure maximum participation despite the shift work pattern. Paramedics were excluded if they had prior knowledge of or previous training in the NIHSS, or if they had worked in a neurology or neurosurgery ward. Consent was obtained through the online platform.Introduction. Multicentre clinical trials on novel stroke therapies require a reliable, valid and time-efficient rating scale to measure stroke deficits (1–8).The NIHSS was developed for use in clinical trials, notably the landmark clinical stroke trials on recombinant tissue plasminogen activator ().NIHSS contains 15 items, including level of consciousness, eye …2 2 to show teeth or raise eyebrows and close eyes tightly) 3 3. Normal sym etrica l movement. P ar tia l par lysi ( to a l or near to al p ar lysi of. Comple te par alys i of ne or bot h sides (absence o. lower face)Data were also collected concerning physician specialty, study coordinator training, whether the rater had used the NIHSS in the past, and whether the rater had used the NIHSS training and certification videotapes in the past. This session was followed by a discussion period during which any uncertainties in the use of the NIHSS were addressed.NIHSS Certification | NIH Stroke Scale Certification. Listen to the podcast series. Explore Case Studies. Maint of Certification. The Maintenance of Certification (MOC) Programming lives designed toward advance the primary, clinical, country, and translational practice of healthcare clinicians, by promoting the highest evidence-based guidelines ...The NIHSS is a 15-item neurological examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss [1]. A trained observer rates the patent’s ability to answer questions and ...Become a Prime Member - only $99/year. INCLUDES ALL BASIC MEMBERSHIP BENEFITS +. RANKIN SCALE (MRS + 2.5 CMES/CES) BARTHEL INDEX (BI + 1.25 CMES/CES) CLINICAL RESEARCH - GOOD CLINICAL PRACTICE (GCP) Globally accepted by regulatory agencies, Transcelerate and most industry stakeholders. …The NIHSS is a 15-item neurological examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss [1]. A trained observer rates the patent's ability to answer questions and ...7. To print your certificate navigate to the Completed Activities tab and click on the certificate icon next to the live activity name. 8. For further assistance fill out the form on the Contact Us page or call our toll-free phone number at 1-888-242-2453 (available between the hours of 8:00 am - 5:00 pm CST).The American Stroke Association, in conjunction with the American Academy of Neurology (AAN) and the National Institute of Neurological Disorders and Stroke (NINDS) has developed this CME/CE certified, online training program for healthcare professionals to learn or review how to administer the NIH Stroke Scale for acute stroke assessment.Items are graded on a 3- or 4-point ordinal scale; 0 means no impairment. Scores range from 0 - 42. Higher scores indicate greater severity. Stroke severity may be stratified on the basis of NIHSS scores as follows (Brott et al, 1989): 1) Very Severe: >25. 2) Severe: 15 - 24. 3) Mild to Moderately Severe: 5 - 14. 4) Mild: 1 - 5.Prognosis. The NIH Stroke Scale (NIHSS) is a standardized scoring assessment used during a neurological exam after someone has had a stroke. It measures aspects of brain function, including consciousness, vision, sensation, movement, speech, and language. The NIHSS is a standardized tool used by clinicians and researchers to measure and record ...1b. The patient is asked the month and his/her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cue. 1c. The ...NIH Stroke Scale – All Test Groups A-F (patients 1-6) Answer key Updated Spring 2023. NIH Stroke Scale – All Test Groups A-F (patients. 1-6) Answer key Updated Spring 2023. NIHSS – Group A Test Answers 2023/ NIHSS GROUP A | PATIENTS 1-6. Patient 1 – 1a- 0. 1b- 0.NIHSS Group D Patient 1-6 Answer Key 1 1a-0 1b-0 1c-0 2-0 3-0 4-0 5a-0 5b-0 6a-0 6b-1 7-0 8-1 9-0 10-1 11-0 2 1a-0 ... Quizzma Team. The Quizzma Team is a collective of experienced educators, subject matter experts, and content developers dedicated to providing accurate and high-quality educational resources.In addition, approximately 20 % of the LH sites spent efforts on staff training, including training nurses on the quality indicator and National Institutes of Health Stroke Scale (NIHSS) as well as setting up a paging system (e.g., a stroke code) to reach the acute stroke team responders.Methods- To clarify optimal recertification frequency and training effect, we assessed users' mastery of the National Institutes of Health Stroke Scale over several years using correct scores (accuracy) on each scale item of the 15-point scale. We also constructed 9 technical errors that could result from misunderstanding the scoring rules.Performance measures for comprehensive stroke certification finalized. Performance measures for comprehensive stroke certification finalized. Jt Comm Perspect. 2014 Jun;34 (6):3. PMID: 25244899. No abstract available.2 2 to show teeth or raise eyebrows and close eyes tightly) 3 3. Normal sym etrica l movement. P ar tia l par lysi ( to a l or near to al p ar lysi of. Comple te par alys i of ne or bot h sides (absence o. lower face)Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. Scale Definition.Learn to be prepared with NIH stroke scale education from Apex Innovations. Click now to learn more about our education!In this invited review, we discuss a brief history of organized stroke care in the United States, evidence to support the value of primary and comprehensive stroke centers, and the certification criteria and process to become a primary or comprehensive stroke center. Keywords: Comprehensive stroke center; Organization of health care; Primary ...Select this course to learn or review how to administer the NIH Stroke Scale for acute stroke assessment. To access this course, you must first successfully complete NIH … The NIH stroke scale can be easily administered in about 5 minutes. Elements of the NIH Stroke Scale Healthcare providers administering the NIH Stroke Scale should be specifically trained to use the scale and should have a copy of the scale available when administering the assessment. Without training, the results are likely to be inconsistent. SCENARIO 1: Suspected Ischemic Stroke without Large Vessel Occlusion. PREHOSPITAL. ACTORS: Patient: 68 y/o female. Husband: approximately same age. 911 Call Taker. Engine Company (3): Firefighter/EMT, Driver Engineer, Lieutenant. ALS Ambulance crew (2): paramedics. A sixty-eight year-old female patient has a sudden onset of left-sided weakness ...The National Institutes of Health Stroke Scale (NIHSS), or NIH Stroke Scale, is the most widely used tool for health professionals to assess the severity of a stroke. . Developed more than 30 years ago, the NIH Stroke Scale (pdf, 4218 KB) has recently been updated with new visual stimuli and is available for do
NIHSS 23 on presentation, consistent with large left MCA syndrome. Non-contrast head CT showed a dense L MCA (figure 1A) without early infarct changes, ASPECTS 10 (figure 1B). He received Alteplase IV r-tPA with a door-to-needle time of 27 minutes, 54 minutes from symptom onset.. Glenridge augusta
The National Institutes of Health Stroke Scale (NIHSS) is used to assess and quantify neurological deficit following stroke. Proper training in administration of the NIHSS is necessary. NIHSS training is available online for free.NIH Stroke Scale - Rankin mRS Barthel Index - Others Technical Support; 512-302-3113 (USA) Become a member today! Tip ×. Use the My BlueCloud ® menu on the top right to ...The NIH Stroke Scale. Medical professionals and even the public have been trained to recognize basic signs of stroke. These include three features of stroke: slurred speech, drooping of one outstretched arm, and drooping of one side of the face when attempting to smile. ... The NIH offers training and certification in the administration and ...The NIHSS is internally consistent, with a reasonable Cronbach’s alpha and reproducible across the intended range of users: stroke nurses, vascular neurologists, and ED physicians. 19 – 21 The scale is reliable when used by non-neurologists who undergo training. 20,21 The total NIHSS score can predict outcome or the presence of large …Improved reliability of the NIH Stroke Scale using video training. Stroke. 1994; 25:2220-2226. Crossref Medline Google Scholar; 8 Lyden P, Lu M, Jackson C, Marler J, Kothari R, Brott T, Zivin J, for the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Underlying structure of the National Institutes of Health ...1 = one item performed correctly. 2 = both items performed incorrectly. Study with Quizlet and memorize flashcards containing terms like What does NIHSS stand for?, What are 6 important conventions to remember when scoring a NIHSS?, When administering an NIHSS what is important to remember about the order of the test? and more.Improved reliability of the NIH Stroke Scale using video training. Stroke. 1994; 25:2220-2226. Crossref Medline Google Scholar; 8 Lyden P, Lu M, Jackson C, Marler J, Kothari R, Brott T, Zivin J, for the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Underlying structure of the National Institutes of Health ...Terms in this set (92) Stroke may be a result of cerebrovascular (____) or cardioembolic (____) sources. The final result of both thrombus formation and embolism is an arterial ____ -> decreased cerebral blood flow and ischemia distal to the occlusion. Thrombosis may take place in a few minutes or hours or even days to fully evolve.Learn to be prepared with NIH stroke scale education from Apex Innovations. Click now to learn more about our education!The NIHSS score is used to assess the severity of a stroke, particularly before and after thrombolytic treatment,[6,7,8,9,10,11] with an administration time of approximately 10-15 min. The NIHSS is an 11-item score scale, which provides a numerical measure of some of the signs of a standard neurological examination.[7,10] The scale evaluates ...AUTHOR NIH-NINDS - To certify please complete the enclosed Training, Test Group, and Evaluation. Only one certification is necessary at this time. This certification is good for up to 2 years. Available NINDS - 002 - NIH Stroke Scale - English - Certification B Ile - English - Certification e- English - Certification B e - English - CertificationBenefits of ACHC Stroke Care Certification: Strengthens your community partnerships and consumer confidence. Organizes your service delivery toward advanced levels of care. Drives the adoption of practices that improve stroke patient outcomes and reduce risk. Establishes a benchmark for performance. You can't know what your data means without ....
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