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Questions and Answers
What is a significant adverse effect of morphine that can develop with prolonged use?
What is a significant adverse effect of morphine that can develop with prolonged use?
- Weight gain
- Tolerance (correct)
- Increased sensitivity to pain
- Improved respiratory function
Which of the following is a contraindication for morphine use?
Which of the following is a contraindication for morphine use?
- Bronchial asthma (correct)
- Seasonal allergies
- Chronic pain
- Mild headache
What is the primary reason for limiting morphine use in patients with head injuries?
What is the primary reason for limiting morphine use in patients with head injuries?
- Respiratory depression leading to CO2 retention (correct)
- Nausea and vomiting
- Increased energy levels
- Increased tolerance
Which adverse effect is specifically associated with the gastrointestinal system when using morphine?
Which adverse effect is specifically associated with the gastrointestinal system when using morphine?
In which situation would morphine likely lead to urinary retention?
In which situation would morphine likely lead to urinary retention?
What common side effect of morphine involves a change in pupil size?
What common side effect of morphine involves a change in pupil size?
Why should morphine be used cautiously in patients with biliary colic?
Why should morphine be used cautiously in patients with biliary colic?
What condition is implicated to potentially worsen due to postural hypotension from morphine?
What condition is implicated to potentially worsen due to postural hypotension from morphine?
What is a potential consequence of morphine use in patients with hepatic damage?
What is a potential consequence of morphine use in patients with hepatic damage?
How does undiagnosed acute abdominal pain pose a risk when administering morphine?
How does undiagnosed acute abdominal pain pose a risk when administering morphine?
Which group of patients is most susceptible to respiratory depression from morphine?
Which group of patients is most susceptible to respiratory depression from morphine?
What is one of the major manifestations of acute opioid toxicity?
What is one of the major manifestations of acute opioid toxicity?
What is the recommended treatment for chronic morphine addiction?
What is the recommended treatment for chronic morphine addiction?
Which symptom is associated with sudden withdrawal from morphine?
Which symptom is associated with sudden withdrawal from morphine?
What is a significant mechanism involved in opioid withdrawal symptoms?
What is a significant mechanism involved in opioid withdrawal symptoms?
What is a critical step in the management of acute opioid toxicity?
What is a critical step in the management of acute opioid toxicity?
Morphine can lead to physical dependence within 48 hours of use.
Morphine can lead to physical dependence within 48 hours of use.
Respiratory depression from morphine is not influenced by dosage.
Respiratory depression from morphine is not influenced by dosage.
Intrathecal morphine injection is used for short-term analgesia.
Intrathecal morphine injection is used for short-term analgesia.
Morphine administration can result in increased intracranial tension.
Morphine administration can result in increased intracranial tension.
Bronchoconstriction is a known side effect of morphine particularly due to vagal stimulation.
Bronchoconstriction is a known side effect of morphine particularly due to vagal stimulation.
Morphine does not affect urinary retention in patients with an enlarged prostate.
Morphine does not affect urinary retention in patients with an enlarged prostate.
Tolerance to respiratory depression does not develop with prolonged morphine use.
Tolerance to respiratory depression does not develop with prolonged morphine use.
Nausea and vomiting are common gastrointestinal effects of morphine.
Nausea and vomiting are common gastrointestinal effects of morphine.
Morphine can mask the symptoms of appendicitis by masking acute abdominal pain.
Morphine can mask the symptoms of appendicitis by masking acute abdominal pain.
Chronic administration of opioids results in an increased endogenous production of endorphins.
Chronic administration of opioids results in an increased endogenous production of endorphins.
Infants and elderly patients exhibit a lower susceptibility to respiratory depression caused by morphine.
Infants and elderly patients exhibit a lower susceptibility to respiratory depression caused by morphine.
Following sudden withdrawal from morphine, there is an increased release of norepinephrine.
Following sudden withdrawal from morphine, there is an increased release of norepinephrine.
Opioid blockers are recommended as an initial treatment for chronic opioid toxicity.
Opioid blockers are recommended as an initial treatment for chronic opioid toxicity.
Patients with adrenal insufficiency have a normal response to morphine.
Patients with adrenal insufficiency have a normal response to morphine.
Gastric lavage is a common treatment for opioid withdrawal syndrome.
Gastric lavage is a common treatment for opioid withdrawal syndrome.
Morphine is metabolized by the liver, which contributes to its risk of hepatic encephalopathy.
Morphine is metabolized by the liver, which contributes to its risk of hepatic encephalopathy.
What effect does chronic opioid use have on endogenous opioid production?
What effect does chronic opioid use have on endogenous opioid production?
How does morphine impact patients with undiagnosed acute abdominal pain?
How does morphine impact patients with undiagnosed acute abdominal pain?
What therapy is recommended for managing chronic morphine addiction?
What therapy is recommended for managing chronic morphine addiction?
Identify a significant risk associated with morphine in infants and the elderly.
Identify a significant risk associated with morphine in infants and the elderly.
What are the initial symptoms of sudden withdrawal from morphine?
What are the initial symptoms of sudden withdrawal from morphine?
What critical intervention is necessary for acute opioid toxicity?
What critical intervention is necessary for acute opioid toxicity?
Explain the mechanism behind rebound norepinephrine release during opioid withdrawal.
Explain the mechanism behind rebound norepinephrine release during opioid withdrawal.
What is a potential consequence of morphine use in patients with hepatic damage?
What is a potential consequence of morphine use in patients with hepatic damage?
How does the route of administration affect the dosage of morphine in acute myocardial infarction?
How does the route of administration affect the dosage of morphine in acute myocardial infarction?
Identify a potential risk associated with the use of morphine in patients with head injuries.
Identify a potential risk associated with the use of morphine in patients with head injuries.
What is the significance of tolerance in morphine treatment concerning its analgesic effects?
What is the significance of tolerance in morphine treatment concerning its analgesic effects?
Explain how morphine administration can affect patients with gallstones.
Explain how morphine administration can affect patients with gallstones.
What common ocular symptom is seen in patients dependent on morphine?
What common ocular symptom is seen in patients dependent on morphine?
What precautions should be taken when administering morphine to patients with respiratory conditions?
What precautions should be taken when administering morphine to patients with respiratory conditions?
How might morphine influence urinary function in male patients with enlarged prostates?
How might morphine influence urinary function in male patients with enlarged prostates?
Describe one major adverse effect of morphine on the central nervous system.
Describe one major adverse effect of morphine on the central nervous system.
In acute myocardial infarction, morphine is administered at a dose of ______ mg intravenously.
In acute myocardial infarction, morphine is administered at a dose of ______ mg intravenously.
One of the significant adverse effects of morphine is respiratory ______, which is dose-dependent.
One of the significant adverse effects of morphine is respiratory ______, which is dose-dependent.
Morphine can lead to ______ tension due to its effects on the central nervous system.
Morphine can lead to ______ tension due to its effects on the central nervous system.
Patients with an enlarged prostate may experience urinary ______ as a side effect of morphine.
Patients with an enlarged prostate may experience urinary ______ as a side effect of morphine.
Morphine causes bronchoconstriction, which is particularly due to ______ stimulation.
Morphine causes bronchoconstriction, which is particularly due to ______ stimulation.
Effective pain relief in critically ill patients can be achieved through intrathecal injection of ______ morphine.
Effective pain relief in critically ill patients can be achieved through intrathecal injection of ______ morphine.
One contraindication for morphine use is ______ injury due to the risk of respiratory depression.
One contraindication for morphine use is ______ injury due to the risk of respiratory depression.
Postural hypotension can be caused by morphine, which may lead to ______ effects in patients.
Postural hypotension can be caused by morphine, which may lead to ______ effects in patients.
Chronic administration of opioids decreases endogenous production of ______.
Chronic administration of opioids decreases endogenous production of ______.
Infants and elderly patients are more susceptible to respiratory ______.
Infants and elderly patients are more susceptible to respiratory ______.
Morphine can mask the symptoms of appendicitis by masking acute abdominal ______.
Morphine can mask the symptoms of appendicitis by masking acute abdominal ______.
Sudden withdrawal from morphine can lead to symptoms such as irritability, nervousness, and ______.
Sudden withdrawal from morphine can lead to symptoms such as irritability, nervousness, and ______.
Acute opioid toxicity may manifest as coma with depressed respiration, miosis, and ______.
Acute opioid toxicity may manifest as coma with depressed respiration, miosis, and ______.
Treatment for chronic morphine addiction may involve gradual withdrawal with substitution by ______.
Treatment for chronic morphine addiction may involve gradual withdrawal with substitution by ______.
Opioid blockers can be used in the management of acute ______ toxicity.
Opioid blockers can be used in the management of acute ______ toxicity.
Morphine increases the risk of hepatic encephalopathy due to marked CNS ______.
Morphine increases the risk of hepatic encephalopathy due to marked CNS ______.
Match the following routes of morphine administration with their effects:
Match the following routes of morphine administration with their effects:
Match the major adverse effects of morphine with their descriptions:
Match the major adverse effects of morphine with their descriptions:
Match the contraindications of morphine with their implications:
Match the contraindications of morphine with their implications:
Match the following adverse gastrointestinal effects with their characteristics:
Match the following adverse gastrointestinal effects with their characteristics:
Match the physiological effects of morphine with their systems affected:
Match the physiological effects of morphine with their systems affected:
Match the onset timeframes for morphological effects with their corresponding conditions:
Match the onset timeframes for morphological effects with their corresponding conditions:
Match the morphine side effects with their specific characteristics:
Match the morphine side effects with their specific characteristics:
Match the following morphine preparations with their usage scenarios:
Match the following morphine preparations with their usage scenarios:
Match the following conditions with their respective implications when using morphine:
Match the following conditions with their respective implications when using morphine:
Match the following symptoms with their associated conditions:
Match the following symptoms with their associated conditions:
Match the following treatment methods with their corresponding indications:
Match the following treatment methods with their corresponding indications:
Match the following neurochemical changes to their relevant situations involving opioids:
Match the following neurochemical changes to their relevant situations involving opioids:
Match the following withdrawal symptoms with their onset timings:
Match the following withdrawal symptoms with their onset timings:
Match the following characteristics with their associated groups affected by opioids:
Match the following characteristics with their associated groups affected by opioids:
Match the following opioid effects with their related complications:
Match the following opioid effects with their related complications:
Match the following conditions with the appropriate need for caution regarding morphine use:
Match the following conditions with the appropriate need for caution regarding morphine use:
Study Notes
Morphine Sulfate Preparations and Doses
- Administered as 10 mg subcutaneously or intramuscularly; 5 mg intravenous in acute myocardial infarction.
- Intrathecal (epidural) injection provides long-lasting analgesia, particularly beneficial for critically ill patients prone to respiratory depression.
- Available in sustained release formulations and transdermal patches.
Adverse Effects
-
CNS Effects
- Prolonged use can lead to tolerance and physical dependence; physical dependence may develop within 24 hours with use every 4 hours.
- Tolerance develops for analgesia and euphoria but not for respiratory depression.
- Increased intracranial tension and dose-dependent respiratory depression are notable risks.
-
Respiratory System
- Bronchoconstriction is a potential adverse effect.
-
Cardiovascular System
- May cause postural hypotension.
-
Gastrointestinal Tract
- Common effects include nausea, vomiting, constipation, increased biliary tract pressure, and potential biliary colic.
-
Genitourinary System
- Urinary retention can occur especially in patients with enlarged prostates; may prolong labor.
-
Ocular Effects
- Miosis is a consistent sign of morphine addiction.
Contraindications and Precautions
- Contraindicated in head injuries and conditions with increased intracranial pressure due to risk of respiratory depression and CO2 retention.
- Not suitable for patients with bronchial asthma because it can induce bronchoconstriction, respiratory depression, and histamine release.
- Use caution in patients with biliary colic or gallstones as morphine can increase biliary pressure.
- Patients with senile enlarged prostate may experience urinary urgency and difficulty urinating due to increased detrusor muscle tone.
- Hypotension risks due to the potential for postural hypotension.
- Contraindicated in hepatic damage due to metabolic processing in the liver and increased CNS depression.
- Patients with hypothyroidism or adrenal insufficiency may have exaggerated responses to morphine.
- Should not be used in cases of undiagnosed acute abdominal pain as it can mask symptoms and delay diagnosis.
- Infants and elderly individuals are at greater risk for respiratory depression.
Chronic Opioid Toxicity
- Symptoms include behavioral changes, constipation, itching, and miosis.
- Sudden withdrawal may lead to irritability, nervousness, tremors, hypertension, and muscle cramps starting 6-10 hours after the last dose, peaking at 48 hours and subsiding over 5-10 days.
- Mechanism involves chronic opioid use decreasing endogenous endorphin and norepinephrine levels, leading to withdrawal symptoms due to sudden deficiency of endogenous opioids.
Treatment of Chronic Morphine Addiction
- Should include gradual withdrawal of morphine, substituted with methadone, followed by a gradual tapering off methadone.
- Clonidine can be used to stimulate central alpha-2 receptors, reducing norepinephrine release.
- Sedatives like diazepam may aid in managing symptoms during withdrawal.
Acute Opioid Toxicity
- Signs include coma, depressed respiration, miosis, and shock; death typically results from respiratory depression.
- Treatment involves gastric lavage, ensuring a patent airway, and providing artificial respiration as necessary.
Morphine Sulfate Preparations and Doses
- Administered as 10 mg subcutaneously or intramuscularly; 5 mg intravenous in acute myocardial infarction.
- Intrathecal (epidural) injection provides long-lasting analgesia, particularly beneficial for critically ill patients prone to respiratory depression.
- Available in sustained release formulations and transdermal patches.
Adverse Effects
-
CNS Effects
- Prolonged use can lead to tolerance and physical dependence; physical dependence may develop within 24 hours with use every 4 hours.
- Tolerance develops for analgesia and euphoria but not for respiratory depression.
- Increased intracranial tension and dose-dependent respiratory depression are notable risks.
-
Respiratory System
- Bronchoconstriction is a potential adverse effect.
-
Cardiovascular System
- May cause postural hypotension.
-
Gastrointestinal Tract
- Common effects include nausea, vomiting, constipation, increased biliary tract pressure, and potential biliary colic.
-
Genitourinary System
- Urinary retention can occur especially in patients with enlarged prostates; may prolong labor.
-
Ocular Effects
- Miosis is a consistent sign of morphine addiction.
Contraindications and Precautions
- Contraindicated in head injuries and conditions with increased intracranial pressure due to risk of respiratory depression and CO2 retention.
- Not suitable for patients with bronchial asthma because it can induce bronchoconstriction, respiratory depression, and histamine release.
- Use caution in patients with biliary colic or gallstones as morphine can increase biliary pressure.
- Patients with senile enlarged prostate may experience urinary urgency and difficulty urinating due to increased detrusor muscle tone.
- Hypotension risks due to the potential for postural hypotension.
- Contraindicated in hepatic damage due to metabolic processing in the liver and increased CNS depression.
- Patients with hypothyroidism or adrenal insufficiency may have exaggerated responses to morphine.
- Should not be used in cases of undiagnosed acute abdominal pain as it can mask symptoms and delay diagnosis.
- Infants and elderly individuals are at greater risk for respiratory depression.
Chronic Opioid Toxicity
- Symptoms include behavioral changes, constipation, itching, and miosis.
- Sudden withdrawal may lead to irritability, nervousness, tremors, hypertension, and muscle cramps starting 6-10 hours after the last dose, peaking at 48 hours and subsiding over 5-10 days.
- Mechanism involves chronic opioid use decreasing endogenous endorphin and norepinephrine levels, leading to withdrawal symptoms due to sudden deficiency of endogenous opioids.
Treatment of Chronic Morphine Addiction
- Should include gradual withdrawal of morphine, substituted with methadone, followed by a gradual tapering off methadone.
- Clonidine can be used to stimulate central alpha-2 receptors, reducing norepinephrine release.
- Sedatives like diazepam may aid in managing symptoms during withdrawal.
Acute Opioid Toxicity
- Signs include coma, depressed respiration, miosis, and shock; death typically results from respiratory depression.
- Treatment involves gastric lavage, ensuring a patent airway, and providing artificial respiration as necessary.
Morphine Sulfate Preparations and Doses
- Administered as 10 mg subcutaneously or intramuscularly; 5 mg intravenous in acute myocardial infarction.
- Intrathecal (epidural) injection provides long-lasting analgesia, particularly beneficial for critically ill patients prone to respiratory depression.
- Available in sustained release formulations and transdermal patches.
Adverse Effects
-
CNS Effects
- Prolonged use can lead to tolerance and physical dependence; physical dependence may develop within 24 hours with use every 4 hours.
- Tolerance develops for analgesia and euphoria but not for respiratory depression.
- Increased intracranial tension and dose-dependent respiratory depression are notable risks.
-
Respiratory System
- Bronchoconstriction is a potential adverse effect.
-
Cardiovascular System
- May cause postural hypotension.
-
Gastrointestinal Tract
- Common effects include nausea, vomiting, constipation, increased biliary tract pressure, and potential biliary colic.
-
Genitourinary System
- Urinary retention can occur especially in patients with enlarged prostates; may prolong labor.
-
Ocular Effects
- Miosis is a consistent sign of morphine addiction.
Contraindications and Precautions
- Contraindicated in head injuries and conditions with increased intracranial pressure due to risk of respiratory depression and CO2 retention.
- Not suitable for patients with bronchial asthma because it can induce bronchoconstriction, respiratory depression, and histamine release.
- Use caution in patients with biliary colic or gallstones as morphine can increase biliary pressure.
- Patients with senile enlarged prostate may experience urinary urgency and difficulty urinating due to increased detrusor muscle tone.
- Hypotension risks due to the potential for postural hypotension.
- Contraindicated in hepatic damage due to metabolic processing in the liver and increased CNS depression.
- Patients with hypothyroidism or adrenal insufficiency may have exaggerated responses to morphine.
- Should not be used in cases of undiagnosed acute abdominal pain as it can mask symptoms and delay diagnosis.
- Infants and elderly individuals are at greater risk for respiratory depression.
Chronic Opioid Toxicity
- Symptoms include behavioral changes, constipation, itching, and miosis.
- Sudden withdrawal may lead to irritability, nervousness, tremors, hypertension, and muscle cramps starting 6-10 hours after the last dose, peaking at 48 hours and subsiding over 5-10 days.
- Mechanism involves chronic opioid use decreasing endogenous endorphin and norepinephrine levels, leading to withdrawal symptoms due to sudden deficiency of endogenous opioids.
Treatment of Chronic Morphine Addiction
- Should include gradual withdrawal of morphine, substituted with methadone, followed by a gradual tapering off methadone.
- Clonidine can be used to stimulate central alpha-2 receptors, reducing norepinephrine release.
- Sedatives like diazepam may aid in managing symptoms during withdrawal.
Acute Opioid Toxicity
- Signs include coma, depressed respiration, miosis, and shock; death typically results from respiratory depression.
- Treatment involves gastric lavage, ensuring a patent airway, and providing artificial respiration as necessary.
Morphine Sulfate Preparations and Doses
- Administered as 10 mg subcutaneously or intramuscularly; 5 mg intravenous in acute myocardial infarction.
- Intrathecal (epidural) injection provides long-lasting analgesia, particularly beneficial for critically ill patients prone to respiratory depression.
- Available in sustained release formulations and transdermal patches.
Adverse Effects
-
CNS Effects
- Prolonged use can lead to tolerance and physical dependence; physical dependence may develop within 24 hours with use every 4 hours.
- Tolerance develops for analgesia and euphoria but not for respiratory depression.
- Increased intracranial tension and dose-dependent respiratory depression are notable risks.
-
Respiratory System
- Bronchoconstriction is a potential adverse effect.
-
Cardiovascular System
- May cause postural hypotension.
-
Gastrointestinal Tract
- Common effects include nausea, vomiting, constipation, increased biliary tract pressure, and potential biliary colic.
-
Genitourinary System
- Urinary retention can occur especially in patients with enlarged prostates; may prolong labor.
-
Ocular Effects
- Miosis is a consistent sign of morphine addiction.
Contraindications and Precautions
- Contraindicated in head injuries and conditions with increased intracranial pressure due to risk of respiratory depression and CO2 retention.
- Not suitable for patients with bronchial asthma because it can induce bronchoconstriction, respiratory depression, and histamine release.
- Use caution in patients with biliary colic or gallstones as morphine can increase biliary pressure.
- Patients with senile enlarged prostate may experience urinary urgency and difficulty urinating due to increased detrusor muscle tone.
- Hypotension risks due to the potential for postural hypotension.
- Contraindicated in hepatic damage due to metabolic processing in the liver and increased CNS depression.
- Patients with hypothyroidism or adrenal insufficiency may have exaggerated responses to morphine.
- Should not be used in cases of undiagnosed acute abdominal pain as it can mask symptoms and delay diagnosis.
- Infants and elderly individuals are at greater risk for respiratory depression.
Chronic Opioid Toxicity
- Symptoms include behavioral changes, constipation, itching, and miosis.
- Sudden withdrawal may lead to irritability, nervousness, tremors, hypertension, and muscle cramps starting 6-10 hours after the last dose, peaking at 48 hours and subsiding over 5-10 days.
- Mechanism involves chronic opioid use decreasing endogenous endorphin and norepinephrine levels, leading to withdrawal symptoms due to sudden deficiency of endogenous opioids.
Treatment of Chronic Morphine Addiction
- Should include gradual withdrawal of morphine, substituted with methadone, followed by a gradual tapering off methadone.
- Clonidine can be used to stimulate central alpha-2 receptors, reducing norepinephrine release.
- Sedatives like diazepam may aid in managing symptoms during withdrawal.
Acute Opioid Toxicity
- Signs include coma, depressed respiration, miosis, and shock; death typically results from respiratory depression.
- Treatment involves gastric lavage, ensuring a patent airway, and providing artificial respiration as necessary.
Morphine Sulfate Preparations and Doses
- Administered as 10 mg subcutaneously or intramuscularly; 5 mg intravenous in acute myocardial infarction.
- Intrathecal (epidural) injection provides long-lasting analgesia, particularly beneficial for critically ill patients prone to respiratory depression.
- Available in sustained release formulations and transdermal patches.
Adverse Effects
-
CNS Effects
- Prolonged use can lead to tolerance and physical dependence; physical dependence may develop within 24 hours with use every 4 hours.
- Tolerance develops for analgesia and euphoria but not for respiratory depression.
- Increased intracranial tension and dose-dependent respiratory depression are notable risks.
-
Respiratory System
- Bronchoconstriction is a potential adverse effect.
-
Cardiovascular System
- May cause postural hypotension.
-
Gastrointestinal Tract
- Common effects include nausea, vomiting, constipation, increased biliary tract pressure, and potential biliary colic.
-
Genitourinary System
- Urinary retention can occur especially in patients with enlarged prostates; may prolong labor.
-
Ocular Effects
- Miosis is a consistent sign of morphine addiction.
Contraindications and Precautions
- Contraindicated in head injuries and conditions with increased intracranial pressure due to risk of respiratory depression and CO2 retention.
- Not suitable for patients with bronchial asthma because it can induce bronchoconstriction, respiratory depression, and histamine release.
- Use caution in patients with biliary colic or gallstones as morphine can increase biliary pressure.
- Patients with senile enlarged prostate may experience urinary urgency and difficulty urinating due to increased detrusor muscle tone.
- Hypotension risks due to the potential for postural hypotension.
- Contraindicated in hepatic damage due to metabolic processing in the liver and increased CNS depression.
- Patients with hypothyroidism or adrenal insufficiency may have exaggerated responses to morphine.
- Should not be used in cases of undiagnosed acute abdominal pain as it can mask symptoms and delay diagnosis.
- Infants and elderly individuals are at greater risk for respiratory depression.
Chronic Opioid Toxicity
- Symptoms include behavioral changes, constipation, itching, and miosis.
- Sudden withdrawal may lead to irritability, nervousness, tremors, hypertension, and muscle cramps starting 6-10 hours after the last dose, peaking at 48 hours and subsiding over 5-10 days.
- Mechanism involves chronic opioid use decreasing endogenous endorphin and norepinephrine levels, leading to withdrawal symptoms due to sudden deficiency of endogenous opioids.
Treatment of Chronic Morphine Addiction
- Should include gradual withdrawal of morphine, substituted with methadone, followed by a gradual tapering off methadone.
- Clonidine can be used to stimulate central alpha-2 receptors, reducing norepinephrine release.
- Sedatives like diazepam may aid in managing symptoms during withdrawal.
Acute Opioid Toxicity
- Signs include coma, depressed respiration, miosis, and shock; death typically results from respiratory depression.
- Treatment involves gastric lavage, ensuring a patent airway, and providing artificial respiration as necessary.
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Description
This quiz covers the preparations, dosing guidelines, and adverse effects of morphine sulphate. It includes details on different administration routes such as subcutaneous, intravenous, and epidural injections, as well as the implications of prolonged use. Test your knowledge on morphine management in acute settings.
