human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: INTRODUCTION The purpose of this guideline is to establish clinical practice recommendations for the pharmacologic treatment of chronic insomnia in adults , when such treatment is clinical ly indicated . Unlike previous meta-analyses , which focused on broad classes of drugs , this guideline focuses on individual drugs commonly used to treat insomnia . It includes drugs that are FDA -approved for the treatment of insomnia , as well as several drugs commonly used to treat insomnia without an FDA indication for this condition . This guideline should be used in conjunction with other AASM guidelines on the evaluation and treatment of chronic insomnia in adults . METHODS The American Academy of Sleep Medicine commissioned a task force of four experts in sleep medicine . A systematic review was conducted to identify r and omized controlled trials , and the Grading of Recommendations Assessment , Development , and Evaluation ( GRADE ) process was used to assess the evidence . The task force developed recommendations and assigned strengths based on the quality of evidence , the balance of benefits and harms , and patient values and preferences . Literature review s are provided for those pharmacologic agents for which sufficient evidence was available to establish recommendations . The AASM Board of Directors approved the final recommendations . RECOMMENDATIONS The following recommendations are intended as a guideline for clinicians in choosing a specific pharmacological agent for treatment of chronic insomnia in adults , when such treatment is indicated . Under GRADE , a STRONG recommendation is one that clinicians should , under most circumstances , follow . A WEAK recommendation reflects a lower degree of certainty in the outcome and appropriateness of the patient-care strategy for all patients , but should not be construed as an indication of ineffectiveness . GRADE recommendation strengths do not refer to the magnitude of treatment effects in a particular patient , but rather , to the strength of evidence in published data . Downgrading the quality of evidence for these treatments is predictable in GRADE , due to the funding source for most pharmacological clinical trials and the attendant risk of publication bias ; the relatively small number of eligible trials for each individual agent ; and the observed heterogeneity in the data . The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient , available diagnostic tools , accessible treatment options , and re sources . We suggest that clinicians use suvorexant as a treatment for sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use eszopiclone as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use zaleplon as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use zolpidem as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use triazolam as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use temazepam as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use ramelteon as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use doxepin as a treatment for sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use trazodone as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use tiagabine as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  diphenhydramine  as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  melatonin  as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use tryptophan as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  valerian  as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) CONTEXT Multiple complex symptoms from cancer treatment can interfere with functioning . OBJECTIVES To evaluate the efficacy of an " energy and sleep enhancement " ( EASE ) intervention to relieve fatigue and sleep disturbance and improve health-related functional status . METHODS Individuals receiving chemotherapy ( CTX ) were r and omized to the EASE ( n=153 ) or a control intervention ( n=139 ) . The EASE intervention included information and behavioral skills taught by an oncology nurse in three telephone sessions . The primary outcomes of fatigue , sleep disturbance , and functional status were measured before CTX , Day 4 after first treatment ( baseline ) , and 43 - 46 or 57 - 60 days later ( follow-up ) , depending on the CTX cycle length . RESULTS The sample was primarily female ( 82 % ) and non-Hispanic white ( 89 % ) , with mean age of 53.9 years .  Fatigue and patient-reported sleep disturbance were elevated in both groups at baseline and follow-up . Actigraphy revealed that the total sleep time was almost eight hours , and sleep percent was greater than 85 % for both groups at both time points ( normal range ) . Physical functioning was diminished and at the same level as a sample with serious illness . Mental functioning was in normal range . A repeated- measures analysis of variance revealed no statistically significant group-by-time effects for fatigue , sleep disturbance , or functional status .  Unemployed individuals showed greater benefit from the EASE intervention , reporting less pain and symptom interference . CONCLUSION Potential explanations include high variability and /or floor effect for fatigue , incorrect timing of measures , insufficient amount or dose of the intervention , and confounding effects of gender . Future research should consider screening for symptom severity and tailoring interventions Though it has been shown that cancer patients report cognitive , behavioral , and physiologic responses to pain , little attention has been paid to the benefits of cognitive-behavioral therapy ( CBT ) protocol s tailored to patient characteristics . To determine whether a profile-tailored CBT treatment program was more effective than either st and ard CBT or usual care in changing outcomes for patients with cancer-related pain , 131 patients receiving treatment at four sites were r and omly assigned to st and ard CBT , profile-tailored CBT , or usual care . CBT patients attended five 50-minute treatment sessions . When compared to st and ard CBT patients , profile-tailored CBT patients experienced substantial improvement from baseline to immediately post-intervention in worst pain , least pain , less interference of pain with sleep , and less confusion . From baseline to one-month post-intervention , profile-tailored patients saw greater improvement in less interference of pain with activities , walking , relationships , and sleep ; less composite pain interference ; and less mobility and confusion symptom distress .  St and ard CBT and usual care patients experienced little change . Compared to profile-tailored CBT patients , st and ard CBT patients showed greater improvement at six-months post-intervention with less average pain , less pain now , better bowel patterns , lower summary symptom distress , better mental quality of life , and greater improvement in Karnofsky performance status ; usual care patients showed little change . More research is needed to refine the matching of cognitive-behavioral treatments to psychophysiologic patient profiles , and to determine a treatment period that does not burden those patients too fatigued to participate in a five-week program . Delivery of CBT by home visits , phone , or Internet needs to be explored further Purpose Cancer-related fatigue ( CRF ) is a disruptive symptom for many survivors . Despite promising evidence for efficacy of mindfulness-based stress reduction ( MBSR ) in reducing CRF , no trials comparing it to an active comparator for fatigued survivors have been published . The purpose of this trial was to compare MBSR to psychoeducation for CRF and associated symptoms . Methods Breast ( n = 60 ) and colorectal ( n = 11 ) cancer survivors ( stage 0–III ) with clinical ly significant CRF after completing chemotherapy and /or radiation therapy an average of 28 months prior to enrollment were r and omized to MBSR or psychoeducation/support groups ( PES ) . MBSR focused on mindfulness training ; PES focused on CRF self-management . Outcomes included CRF interference ( primary ) , CRF severity and global improvement , vitality , depression , anxiety , sleep disturbance , and pain . Outcomes were assessed at baseline ( T1 ) , post-intervention ( T2 ) , and 6-month follow-up ( T3 ) using intent-to-treat analysis . Results Between-group differences in CRF interference were not significant at any time point ; however , there was a trend favoring MBSR ( d = −0.46 , p = 0.073 ) at T2 . MBSR participants reported significantly greater improvement in vitality ( d = 0.53 , p = 0.003 ) and were more likely to report CRF as moderately to completely improved compared to the PES group ( χ2 ( 1 ) = 4.1765 , p = 0.041 ) at T2 . MBSR participants also reported significantly greater reductions in pain at T2 ( d = 0.53 , p = 0.014 ) . In addition , both MBSR and PES produced moderate-to-large and significant within-group improvements in all fatigue outcomes , depression , anxiety , and sleep at T2 and T3 compared to T1 . Conclusion MBSR and PES appear efficacious for CRF and related symptoms . Larger trials including a usual care arm are warranted . Trial Registration Clinical Trials.gov Identifier : NCT01724333 CONTEXT Information regarding sleep disturbances in the population with advanced cancer is meager . OBJECTIVES To assess the prevalence of sleep disturbances and possible correlations with associated factors in a large number of patients with advanced cancer admitted to different palliative care setting s. METHODS This was an observational study performed in different setting s of palliative care . A consecutive sample of patients with advanced cancer was prospect ively assessed for a period of six months . Epidemiological and clinical data , treatments received in the last month , Karnofsky status , Edmonton Symptom Assessment System scores , and concomitant medical treatment were recorded . Patients were administered the  Athens Insomnia Scale and  the Hospital Anxiety and Depression Scale ( HADS ) .  RESULTS A total of 820 patients were surveyed . Mean age was 69.7 years ( SD 12.7 ) , and 429 patients were males . Consistent sleep disturbances ( moderate to maximum ) were found in 60.8 % of patients . Aged patients were less likely to have sleep disturbances , whereas a poor Karnofsky level was significantly associated with sleep problems . Breast , gastrointestinal , head and neck , lung , and prostate cancers were associated with sleep problems . Patients who had a secondary school or undergraduate education had less sleep disturbances .  Hormone therapy and use of opioids and corticosteroids were positively associated with sleep disturbances , and there was a positive correlation of HADS-Anxiety and HADS-Depression scores with sleep disturbances . CONCLUSION More than 60 % of  palliative care patients have relevant sleep disturbances . Several factors associated with sleep disorders have been identified and should prompt physicians to make a careful examination and subsequent treatment of these disturbances Sleep disturbance is a very common problem for cancer patients that has largely not been addressed in the clinical intervention literature . Mindfulness meditation has demonstrated clinical benefits for a variety of patient population s in other areas of functioning . This study examined the effects of an 8-week Mindfulness-Based Stress Reduction ( MBSR ) program on the sleep quality of a heterogeneous sample of 63 cancer patients . Overall sleep disturbance was significantly reduced ( p < .001 ) and participants reported that their sleep quality had improved ( p < .001 ) . There was also a significant reduction in stress ( p < .001 ) , mood disturbance ( p = .001 ) , and fatigue ( p < .001 ) . The associations among these changes and implication s for improving quality of life of cancer patients are discussed Purpose This study aims to provide recommendations on the optimal strategies and interventions for the prevention , screening , assessment , and management of  cancer-related sleep disturbance ( insomnia and insomnia syndrome ) in adult cancer population s. Methods A systematic search of the published health literature was conducted to identify r and omized controlled trials , clinical practice guidelines , systematic review s , and other guidance documents . The Sleep Disturbance Expert Panel [ comprised of nurses , psychologists , primary care physicians , oncologists , physicians specialized in sleep disturbances , research ers , and guideline method ologists ] review ed , discussed , and approved the final version of the guideline . Health care professionals across Canada were asked to provide feedback through an external review process . Results Three clinical practice guidelines and 12 r and omized controlled trials were identified as the evidence base . Overall , despite the paucity of evidence , the evidence and expert consensus suggest that it is important to screen and assess adult cancer patients for sleep disturbances using st and ardized screening tools on a routine basis . While prevention of sleep disturbance is the desired objective , cognitive behavioral therapies are effective in improving sleep outcomes . As part of the external review with 16 health care providers , 81 % indicated that they agreed with the recommendations as written . Conclusions Sleep difficulty is a prevalent problem in cancer population s that needs greater recognition by health professionals . Prevention , screening , assessment , and treatment strategies supported by the best available evidence are critical . Recommendations and care path algorithms for practice are offered In a prospect i ve , r and om 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: INTRODUCTION The purpose of this guideline is to establish clinical practice recommendations for the pharmacologic treatment of chronic insomnia in adults , when such treatment is clinical ly indicated . Unlike previous meta-analyses , which focused on broad classes of drugs , this guideline focuses on individual drugs commonly used to treat insomnia . It includes drugs that are FDA -approved for the treatment of insomnia , as well as several drugs commonly used to treat insomnia without an FDA indication for this condition . This guideline should be used in conjunction with other AASM guidelines on the evaluation and treatment of chronic insomnia in adults . METHODS The American Academy of Sleep Medicine commissioned a task force of four experts in sleep medicine . A systematic review was conducted to identify r and omized controlled trials , and the Grading of Recommendations Assessment , Development , and Evaluation ( GRADE ) process was used to assess the evidence . The task force developed recommendations and assigned strengths based on the quality of evidence , the balance of benefits and harms , and patient values and preferences . Literature review s are provided for those pharmacologic agents for which sufficient evidence was available to establish recommendations . The AASM Board of Directors approved the final recommendations . RECOMMENDATIONS The following recommendations are intended as a guideline for clinicians in choosing a specific pharmacological agent for treatment of chronic insomnia in adults , when such treatment is indicated . Under GRADE , a STRONG recommendation is one that clinicians should , under most circumstances , follow . A WEAK recommendation reflects a lower degree of certainty in the outcome and appropriateness of the patient-care strategy for all patients , but should not be construed as an indication of ineffectiveness . GRADE recommendation strengths do not refer to the magnitude of treatment effects in a particular patient , but rather , to the strength of evidence in published data . Downgrading the quality of evidence for these treatments is predictable in GRADE , due to the funding source for most pharmacological clinical trials and the attendant risk of publication bias ; the relatively small number of eligible trials for each individual agent ; and the observed heterogeneity in the data . The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient , available diagnostic tools , accessible treatment options , and re sources . We suggest that clinicians use suvorexant as a treatment for sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use eszopiclone as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use zaleplon as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use zolpidem as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use triazolam as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use temazepam as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use ramelteon as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use doxepin as a treatment for sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use trazodone as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use tiagabine as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  diphenhydramine  as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  melatonin  as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use tryptophan as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  valerian  as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) CONTEXT Multiple complex symptoms from cancer treatment can interfere with functioning . OBJECTIVES To evaluate the efficacy of an " energy and sleep enhancement " ( EASE ) intervention to relieve fatigue and sleep disturbance and improve health-related functional status . METHODS Individuals receiving chemotherapy ( CTX ) were r and omized to the EASE ( n=153 ) or a control intervention ( n=139 ) . The EASE intervention included information and behavioral skills taught by an oncology nurse in three telephone sessions . The primary outcomes of fatigue , sleep disturbance , and functional status were measured before CTX , Day 4 after first treatment ( baseline ) , and 43 - 46 or 57 - 60 days later ( follow-up ) , depending on the CTX cycle length . RESULTS The sample was primarily female ( 82 % ) and non-Hispanic white ( 89 % ) , with mean age of 53.9 years .  Fatigue and patient-reported sleep disturbance were elevated in both groups at baseline and follow-up . Actigraphy revealed that the total sleep time was almost eight hours , and sleep percent was greater than 85 % for both groups at both time points ( normal range ) . Physical functioning was diminished and at the same level as a sample with serious illness . Mental functioning was in normal range . A repeated- measures analysis of variance revealed no statistically significant group-by-time effects for fatigue , sleep disturbance , or functional status .  Unemployed individuals showed greater benefit from the EASE intervention , reporting less pain and symptom interference . CONCLUSION Potential explanations include high variability and /or floor effect for fatigue , incorrect timing of measures , insufficient amount or dose of the intervention , and confounding effects of gender . Future research should consider screening for symptom severity and tailoring interventions Though it has been shown that cancer patients report cognitive , behavioral , and physiologic responses to pain , little attention has been paid to the benefits of cognitive-behavioral therapy ( CBT ) protocol s tailored to patient characteristics . To determine whether a profile-tailored CBT treatment program was more effective than either st and ard CBT or usual care in changing outcomes for patients with cancer-related pain , 131 patients receiving treatment at four sites were r and omly assigned to st and ard CBT , profile-tailored CBT , or usual care . CBT patients attended five 50-minute treatment sessions . When compared to st and ard CBT patients , profile-tailored CBT patients experienced substantial improvement from baseline to immediately post-intervention in worst pain , least pain , less interference of pain with sleep , and less confusion . From baseline to one-month post-intervention , profile-tailored patients saw greater improvement in less interference of pain with activities , walking , relationships , and sleep ; less composite pain interference ; and less mobility and confusion symptom distress .  St and ard CBT and usual care patients experienced little change . Compared to profile-tailored CBT patients , st and ard CBT patients showed greater improvement at six-months post-intervention with less average pain , less pain now , better bowel patterns , lower summary symptom distress , better mental quality of life , and greater improvement in Karnofsky performance status ; usual care patients showed little change . More research is needed to refine the matching of cognitive-behavioral treatments to psychophysiologic patient profiles , and to determine a treatment period that does not burden those patients too fatigued to participate in a five-week program . Delivery of CBT by home visits , phone , or Internet needs to be explored further Purpose Cancer-related fatigue ( CRF ) is a disruptive symptom for many survivors . Despite promising evidence for efficacy of mindfulness-based stress reduction ( MBSR ) in reducing CRF , no trials comparing it to an active comparator for fatigued survivors have been published . The purpose of this trial was to compare MBSR to psychoeducation for CRF and associated symptoms . Methods Breast ( n = 60 ) and colorectal ( n = 11 ) cancer survivors ( stage 0–III ) with clinical ly significant CRF after completing chemotherapy and /or radiation therapy an average of 28 months prior to enrollment were r and omized to MBSR or psychoeducation/support groups ( PES ) . MBSR focused on mindfulness training ; PES focused on CRF self-management . Outcomes included CRF interference ( primary ) , CRF severity and global improvement , vitality , depression , anxiety , sleep disturbance , and pain . Outcomes were assessed at baseline ( T1 ) , post-intervention ( T2 ) , and 6-month follow-up ( T3 ) using intent-to-treat analysis . Results Between-group differences in CRF interference were not significant at any time point ; however , there was a trend favoring MBSR ( d = −0.46 , p = 0.073 ) at T2 . MBSR participants reported significantly greater improvement in vitality ( d = 0.53 , p = 0.003 ) and were more likely to report CRF as moderately to completely improved compared to the PES group ( χ2 ( 1 ) = 4.1765 , p = 0.041 ) at T2 . MBSR participants also reported significantly greater reductions in pain at T2 ( d = 0.53 , p = 0.014 ) . In addition , both MBSR and PES produced moderate-to-large and significant within-group improvements in all fatigue outcomes , depression , anxiety , and sleep at T2 and T3 compared to T1 . Conclusion MBSR and PES appear efficacious for CRF and related symptoms . Larger trials including a usual care arm are warranted . Trial Registration Clinical Trials.gov Identifier : NCT01724333 CONTEXT Information regarding sleep disturbances in the population with advanced cancer is meager . OBJECTIVES To assess the prevalence of sleep disturbances and possible correlations with associated factors in a large number of patients with advanced cancer admitted to different palliative care setting s. METHODS This was an observational study performed in different setting s of palliative care . A consecutive sample of patients with advanced cancer was prospect ively assessed for a period of six months . Epidemiological and clinical data , treatments received in the last month , Karnofsky status , Edmonton Symptom Assessment System scores , and concomitant medical treatment were recorded . Patients were administered the  Athens Insomnia Scale and  the Hospital Anxiety and Depression Scale ( HADS ) .  RESULTS A total of 820 patients were surveyed . Mean age was 69.7 years ( SD 12.7 ) , and 429 patients were males . Consistent sleep disturbances ( moderate to maximum ) were found in 60.8 % of patients . Aged patients were less likely to have sleep disturbances , whereas a poor Karnofsky level was significantly associated with sleep problems . Breast , gastrointestinal , head and neck , lung , and prostate cancers were associated with sleep problems . Patients who had a secondary school or undergraduate education had less sleep disturbances .  Hormone therapy and use of opioids and corticosteroids were positively associated with sleep disturbances , and there was a positive correlation of HADS-Anxiety and HADS-Depression scores with sleep disturbances . CONCLUSION More than 60 % of  palliative care patients have relevant sleep disturbances . Several factors associated with sleep disorders have been identified and should prompt physicians to make a careful examination and subsequent treatment of these disturbances Sleep disturbance is a very common problem for cancer patients that has largely not been addressed in the clinical intervention literature . Mindfulness meditation has demonstrated clinical benefits for a variety of patient population s in other areas of functioning . This study examined the effects of an 8-week Mindfulness-Based Stress Reduction ( MBSR ) program on the sleep quality of a heterogeneous sample of 63 cancer patients . Overall sleep disturbance was significantly reduced ( p < .001 ) and participants reported that their sleep quality had improved ( p < .001 ) . There was also a significant reduction in stress ( p < .001 ) , mood disturbance ( p = .001 ) , and fatigue ( p < .001 ) . The associations among these changes and implication s for improving quality of life of cancer patients are discussed Purpose This study aims to provide recommendations on the optimal strategies and interventions for the prevention , screening , assessment , and management of  cancer-related sleep disturbance ( insomnia and insomnia syndrome ) in adult cancer population s. Methods A systematic search of the published health literature was conducted to identify r and omized controlled trials , clinical practice guidelines , systematic review s , and other guidance documents . The Sleep Disturbance Expert Panel [ comprised of nurses , psychologists , primary care physicians , oncologists , physicians specialized in sleep disturbances , research ers , and guideline method ologists ] review ed , discussed , and approved the final version of the guideline . Health care professionals across Canada were asked to provide feedback through an external review process . Results Three clinical practice guidelines and 12 r and omized controlled trials were identified as the evidence base . Overall , despite the paucity of evidence , the evidence and expert consensus suggest that it is important to screen and assess adult cancer patients for sleep disturbances using st and ardized screening tools on a routine basis . While prevention of sleep disturbance is the desired objective , cognitive behavioral therapies are effective in improving sleep outcomes . As part of the external review with 16 health care providers , 81 % indicated that they agreed with the recommendations as written . Conclusions Sleep difficulty is a prevalent problem in cancer population s that needs greater recognition by health professionals . Prevention , screening , assessment , and treatment strategies supported by the best available evidence are critical . Recommendations and care path algorithms for practice are offered In a prospect i ve , r and om 
    Output:
    