Newly diagnosed patients and those requiring stem cell transplant require extensive testing to determine their ability to tolerate the planned treatment. The diagnostic tests are designed to evaluate the health of the patient’s major organs, namely the heart, lungs, liver and kidneys. These are usually simple tests and are not particularly invasive.
Patients whose treatment involves chemotherapy or a transplant will require other procedures such as Hickman® line insertion, bone marrow examination and transfusions.
Your BMT doctor will discuss the tests and procedures in detail with you. With the information provided on this site, we hope that you will find it less stressful and frightening.
The following are common procedures you may undergo.
Apheresis (a-fair-ee-sis) is a procedure in which the components of whole blood – red cells, white cells, and plasma – are separated into layers using a machine called a Cell Separator. This procedure is used to collect blood stem cells from donors or autologous transplant patients.
In the apheresis procedure, whole blood is removed from the body through an intravenous line and enters the machine where the components of the blood are separated. The cell separator machine can be adjusted so that one of the layers is removed and/or replaced. Then the blood components are returned to the body through a different intravenous line.
Sometimes the blood is removed from an arm vein on one side and returned to the body through an arm vein on the opposite side. However, this may not be technically possible if the patient’s veins are small, or if the patient is very unwell. In this situation, a St. Paul’s Catheter (a rigid intravenous catheter) may be inserted into a large vein in the neck or groin to allow for repeated apheresis procedures.
Apheresis usually produces some mild side effects due to lowering of the blood calcium level as a result of the anticoagulant used in the cell separator. Low calcium levels can cause light-headedness, nausea, muscle cramping and tingling of the lips and hands/feet. These symptoms are usually managed with oral or intravenous calcium replacement. Occasionally, the apheresis procedure can reduce the blood pressure, but this is uncommon except when a patient has other health problems, such as heart disease. A nurse and doctor will be present during the procedure to monitor you.
When you are an inpatient, each morning and sometimes more times during the day, routine blood samples will be taken from you through your Hickman® line. It does not hurt to have blood taken from a Hickman® line. If you do not have a Hickman® line, blood will be taken from a vein in the hand or arm. If you are an outpatient, you will likely have blood samples drawn at most of your appointments in the Outpatient Daycare Unit. Patient progress is watched carefully and treatment is changed as needed, according to the results of the blood tests.
In addition to the routine blood work, blood cultures are often performed on BMT patients. This test is performed regularly as BMT patients are at risk of infection. Tests may be performed on the Inpatient Unit (T15) and in the Leukemia/BMT Day Care Outpatient Unit. Blood cultures are also routinely done if the patient’s temperature is higher than 38°C, with 37°C being normal temperature.
This blood sample can be taken from a Hickman® line, or a vein in the arm or hand. The sample is sent to a lab, where it is kept under special conditions to see if any bacteria or other organisms grow. No special preparation is needed for this blood test.
Blood Product Transfusion
There are many different products made from human blood that can be transfused:
- Red Blood Cells: The function of the red cells is to carry the oxygen to the vital organs to allow for survival. At present, there is no proven substitute for red blood cells. A red cell transfusion may be necessary to prevent damage to vital organs due to lack of oxygen.
- Platelets: Platelets are small cells needed to prevent or stop bleeding. These sticky little cells are needed to start blood clotting at the site of injury. Platelet transfusions may be required for patients who have a low number of platelets or whose platelets do not work properly.
- Plasma: Plasma contains many substances including the proteins that help blood to clot.
- Albumin: Albumin is a protein from plasma than can be used to replace fluid that has been lost.
- Immunoglobulin Preparations: Immunoglobulins are proteins that help fight infection. They may be given to patients with low immunoglobulin levels, or patients experiencing recurrent infections.
Whole blood is collected by Canadian Blood Services from volunteer donors. All potential donors are screened by a written questionnaire and interviewed by a nurse. This donated blood is processed into its separate components and tested for:
- Hepatitis B
- Hepatitis C
- Human Immunodeficiency Virus (HIV 1 and 2, the AIDS viruses)
- Human T Cell Lymphotropic Virus 1 and 2 (HTLV-1 and 2)
- West Nile Virus
If blood is found to have any of these infections, it is disposed of and never used. Blood is never collected from an infected donor again. However, you need to be aware that blood can never be guaranteed to be 100% safe and there remains a theoretical risk of 1 in 1,000,000 risk of HIV transmission as well as a 1 in 250,000 risk of Hepatitis B or C transmission despite appropriate screening.
Everything possible is done to reduce the risks associated with blood transfusions; however, you should be aware of the possible risks:
- Viral infections: Although blood products are tested for infections of known viruses, it is still possible to become infected. It is possible for a donor to carry a virus and not feel sick or to be infected but only feel sick several days later. The risks are decreasing because screening tests are improving all the time. You can get more information about the risks from your doctor.
- Allergic reactions: You might feel itchy or get a rash with transfusions. However, these reactions are easily treated with antihistamines and anti-inflammatories. Rarely, allergic reactions may be severe and produce shortness of breath or throat swelling.
- Fever: A reaction may occur from substances in the donor blood, which may result in a fever. This response occurs during or shortly after the transfusion has been completed. The fever may or may not require treatment. The symptoms may consist of feeling cold or chills, followed by a rapid rise in body temperature (fever). If you have had a history of fever reactions with prior transfusions, you should tell the doctor.
- Hemolytic reactions: This rare reaction occurs when antibodies in the patient’s blood react against the donor red cells, destroying them. This is called hemolysis and can result in kidney failure. To ensure that the correct blood is given to prevent this reaction, careful blood testing, processing and administering procedures are required.
- Iron Overload: If blood product transfusion is required for an extended period of time, it is possible for the body to accumulate too much iron. This could lead to problems with liver or heart function. Once patients no longer require transfusions, blood may have to be removed from the body as medical therapy to remove iron. This procedures is called a phlebotomy. If patients with iron overload are still requiring transfusion, a drug (Desferal) can be prescribed to assist in iron excretion from the body.
- Previous reactions: You should let the doctor know if you have had a reaction from blood transfusions in the past, so that steps can be taken to prevent it from recurring.
A blood sample is taken from you and sent to the hospital laboratory. Tests are performed to ensure the donor blood is compatible with the patient’s blood. This process is called cross-matching. The donor blood is then labelled with your name and you will receive only that blood.
The blood, or blood product, is given to you through your Hickman® line or a needle in a vein in the arm. During the transfusion, the nurse will take your temperature, blood pressure and pulse. The blood transfusion can take from 30 minutes to a few hours to complete.
Family members sometimes ask if they can donate blood for a loved one. This is called a directed donation. In general, directed donations are not done but may be possible in special situations; for example, if the patient has a very rare blood type, or in some cases, a parent may donate for their child when the parent’s and the child’s blood match.
It is important to remember that directed donations are not generally available. This is because directed donations have not been shown to be safer than volunteer blood donations.
In order that staff know your wishes with regard to receiving blood or blood products, it is required that you sign the relevant consent forms:
- If you are likely to need blood and/or blood products, you will be asked to complete a consent form on each admission to hospital or at the beginning of each course of treatment.
- If you choose to refuse blood and/or blood products, you must complete a Refusal To Accept Form for each admission and/or each course of treatment.
- If you refuse to receive blood and/or blood products at any time, you must carry an Advance Directive or other written instruction advising the medical staff.
If you or your families need more information, please talk to your doctor. The medical staff at the hospital’s blood bank can also help.
Bone Marrow Aspirate & Biopsy
A bone marrow aspirate and biopsy is a procedure in which a small sample of bone marrow and bone are collected. Bone marrow aspirates and biopsies are done to diagnose your disease and to determine the effectiveness of your treatment.
The aspirate and biopsy are performed either in the BMT Inpatient Unit or the BMT Day Care Outpatient Unit. The doctor or nurse practitioner performs the procedure with the assistance of a laboratory technician. You can eat and drink before the test, but should empty your bladder before the procedure as it takes about 15-20 minutes and you must lie flat for half an hour before resuming normal activities.
A pre-medication may be given to help you relax during the procedure. The aspirate and biopsy are taken from the back of the pelvic bone. The skin is first cleansed with an antiseptic solution. A local anesthetic is then injected with a very fine needle to freeze the area. Once the freezing is in effect, a larger needle is put into the bone to take out a sample of bone marrow (the aspirate) and a small piece of bone (the biopsy). You may feel some discomfort or pressure during the procedure, as the bone itself cannot be frozen. Tell the doctor if you are feeling too uncomfortable. Once the biopsy is done, a small bandage is put on the site. You will be asked to lie on a pressure bag for 15-20 minutes after the procedure- this helps to prevent bleeding and bruising. The bandage can be removed the next day after which you may bathe or shower normally.
Bronchoscopy is a procedure that allows the physician to see the larynx (voice box), trachea (windpipe), and the large and small air passages in the lungs (bronchi and bronchioles). This procedure is performed by a respirologist (lung doctor).
The bronchoscope is a flexible, small tube. It contains fibres that carry light down the tube and project a picture back up. The bronchoscope also provides a channel used to send down forceps to pinch off a tiny bit of tissue (biopsy) or a small brush to brush the tissue walls to collect cells or secretions.
You must not eat or drink anything for at least eight hours before the exam. Before the procedure, you may be given something to help you relax and to decrease secretions in the lungs. This will make your mouth feel dry.
The exam can be done with you lying on your back or sitting upright. A local anaesthetic and an intravenous sedative are usually used. Your mouth, throat, and tongue will be sprayed with the local anaesthetic. This will stop you from gagging. The spray works in 2-3 minutes. It may taste bitter and make the tongue and throat feel swollen. An anaesthetic jelly is used to help the bronchoscope insert more easily, and to prevent coughing or gagging.
The procedure often takes 1-1 ½ hours. After the procedure, you may feel groggy from the sedative. Your throat may be sore and your voice may be hoarse. These symptoms will go away. You will not be allowed to eat or drink anything until the gag reflex returns. This may take several hours.
A CT or CAT (Computerised Axial Tomography) scan is a special type of x-ray that takes pictures of different cross-sections of a body part by moving the x-ray machine around the patient. Ordinary x-rays, like chest x-rays, give two-dimensional pictures while the CT scan obtains very detailed three-dimensional pictures.
Contrast media (dye) may be used, depending on the test needed. A dye is a chemical substance through which x-rays cannot pass and it can outline certain body structures. Although it is called a dye, it will not change the colour of the body. If a dye is used, you will be asked if you have any allergies, as some dyes may cause a reaction. However, reactions are not common.
The CT scan procedure is not painful, but you must lie very still for up to 15-20 minutes at a time. The procedure may seem frightening because of the size of the machine and because you are alone in the room for several minutes at a time. There is a technician in the next room the whole time that can communicate with you via an intercom. A CT scan takes about 1 ½ to 2 hours to complete.
An electrocardiogram (ECG or EKG) records the electrical activity of the heart. It is used to diagnose possible heart problems. During the procedure you will be asked to lie flat and quietly on the bed. Several small, stickers will be attached to your chest, arms and legs. Then wires running from the ECG machine, called leads, are attached to the stickers on your body. The electrical activity of your heart is recorded on graph paper. The whole process takes no longer than 5-10 minutes and is painless.
The endoscope is a long, flexible tube passed through the gastrointestinal tract via the mouth or the anus. It contains fibres that carry light down the tube and project a picture back up. A camera is attached to the endoscope to take pictures during the procedure. This procedure is performed by a gastroenterologist (stomach doctor). The endoscope also provides a channel used to send down forceps to pinch off a tiny bit of tissue, called a biopsy. Since there are a very few nerve endings in the stomach, this procedure may feel uncomfortable, but should not hurt.
An endoscopic exam may be done to the upper or the lower gastrointestinal (GI) tract.
An endoscopy of the upper gastrointestinal (GI) tract allows the physician to see the esophagus (the tube which attaches the mouth to the stomach), the stomach, and the duodenum (first part of the small bowel or intestine).
You should not eat or drink anything from midnight the day before the exam. The physician may order some medication to be given before the exam to help you relax. Your throat will be sprayed with a local anaesthetic; this will help prevent gagging during the procedure. The anaesthetic takes about 2-3 minutes to work. It may taste bitter and make your tongue and throat feel swollen.
You will be asked to lie on your left side. This provides the best view of the stomach. A mouthpiece may be put between the teeth to stop the accidental biting of the endoscope. This will not affect breathing.
When the endoscope is passed down into the stomach, you may feel uncomfortable or may retch. You should breathe slowly and deeply to relax the stomach muscles. Some people feel full in the stomach, or feel the urge to move their bowels. This is from air passing into the stomach and intestine.
After an upper GI endoscopy, you may feel groggy from the sedative and may have a sore throat. To relieve the sore throat, drinking fluids or using throat lozenges after the gag reflex returns may help. The nurse will advise when it is safe to drink and eat again.
The procedure takes about half an hour but you may be away from your room for about 1 ½ hours.
An endoscopy of the lower gastrointestinal (GI) tract allows the physician to see the rectum and colon, the large bowel or intestine. You may also here this procedure referred to as an colonoscopy.
You should not eat or drink anything after midnight the day before and an oral laxative is usually given to empty the intestine, so that the bowel lining can be better seen.
You will be asked to lie on your side and intravenous sedation is given. The endoscope is then inserted into the rectum and gradually advanced. You should not experience any pain during this procedure. The procedure takes about half an hour but you may be away from your room for about 1 ½ hours. After a lower GI endoscopy, you may feel groggy from the sedative and if you are receiving the procedure as an outpatient, you should plan for someone to drive you home.
Hickman® Line Insertion
A Hickman® line is a long-term intravenous catheter. The Hickman® line catheter is a hollow flexible tube made of soft rubber-like material. Prior to beginning your treatment, a Hickman® line will be inserted. It is a special intravenous device that can be used for drawing blood, infusing chemotherapy, antibiotics, blood products, stem cell transplant, and other medications. You will have your Hickman® line in place for several weeks during your treatment and recovery periods. If needed, it can be kept for many months.
The Hickman® line is inserted in the “Cath Lab” or sometimes in the operating room, usually under local anesthetic. You may be given some medications to help you relax before the procedure begins. A vascular surgeon will insert your catheter into a large vein in your chest. The insertion procedure takes about an hour. If you are an outpatient, you will be required to stay an additional 2 hours in the BMT Outpatient Day Care Unit for monitoring. It is important that you have someone available to take you home afterwards because you will be tired and may feel some of the side effects of the sedation.
Because of the importance of the Hickman® line and to prevent infection, you will be taught to care for it while you are in hospital.
When the Hickman® line is no longer needed, it is removed. Removal of the line is a simple procedure that may be done prior to discharge from hospital or during a routine visit to the BMT Outpatient Day Care Unit. It does not require local anaesthetic or sedation.
For more information on Hickman Lines and to access a printable Hickman Line Educational Booklet, click below.
A liver biopsy is a procedure in which a small tissue sample from the liver is collected.
Patients with pre-existing liver problems or those with graft-vs-host disease affecting the liver may have liver damage that could influence what chemotherapy drugs are safe to give. In many cases, the only reliable way to assess liver damage is to take a tissue sample, or biopsy, from the liver itself.
You should not eat or drink after midnight the day before the liver biopsy. Testing will be done to ensure that you will have adequate platelet counts and clotting factor levels to prevent bleeding after the biopsy.
A liver biopsy is done using the ultrasound machine to guide a needle between the lower ribs on the right side of the chest and into the liver itself. A local anaesthetic or freezing agent is used to make this insertion as painless as possible. While the liver is not pain-sensitive, the lining around it is. You may feel discomfort in the right side of the abdomen or the right shoulder for a short time afterwards. The procedure takes about 20 minutes to complete.
After the procedure, you are closely monitored for the first few hours for any sign of bleeding from the biopsy site. This complication is serious but rare.
If you are an outpatient, you will need to arrange for someone to take you home from the hospital because you should not drive after having the sedative. Avoid exertion for the next week to allow the liver to fully heal. Follow the doctor’s instructions for rest and recovery.
A lumbar puncture is also called a “spinal tap”. A small amount of spinal fluid, called CSF, is removed through a very thin needle that is inserted into the lower spine and the fluid is tested for cancer cells or infection.
The brain and spinal cord make up the Central Nervous System which is bathed by CSF. The whole system is covered by a membrane. Many medications cannot cross the membrane from the blood to the CSF; however, sometimes cancer cells can and do cross this membrane. This is why the CSF fluid is tested. Chemotherapy can be given into the spinal fluid, to treat the cancer that has entered the spinal fluid, or to prevent it from developing there.
The procedure is usually done by a physician in your hospital room but sometimes it is done in the radiology department when the use of x-ray is required to help guide the insertion of the needle into the CSF. You will be asked to lie on your side with knees pulled up and the chin tucked down. Alternatively, you may be placed in a sitting position, leaning over a bedside table.
The lower back is cleansed with an antiseptic liquid. An injection of local anaesthetic will freeze the area and may sting or burn for a minute or two. A spinal needle is then inserted and the physician will collect it into a test-tube. At this point, chemotherapy may be put in if necessary. A small Band-Aid is placed over the site when finished. The procedure takes about 15-20 minutes.
Following the procedure, you will be asked to lie flat with the head of the bed slightly elevated for 1 hour in order to prevent a headache. If you do get a headache, you should tell the nurse. If your treatment allows, you will be requested to drink plenty of fluids.
MRI (Magnetic Resonance Imaging) allows for detailed pictures of the body to be taken. While similar to an X-ray, MRI does not require radiation. Instead, magnetic forces and radio waves are used to generate the image of the body part being observed.
Patients cannot have metal on or in their body. For example, jewellery and any other metallic objects should be removed before an MRI scan. Patients with pacemakers, artificial joints, ear implants, heart valves, surgical clips or metal foreign bodies cannot have an MRI scan.
MRI scans are not uncomfortable for the patient, but they do require that you remain still in a confined tube surrounded by a large magnet for about one hour. This can create a claustrophobic sensation. Music can be played if you find this relaxes you. Sometimes a mild sedative is given prior to the MRI scan, if necessary.
Pulmonary Function Test
Pulmonary function tests (PFTs) measure:
- How much air the lungs can hold
- How well the air moves through the airways
- How well the oxygen penetrates the lung tissue in order to enter the blood stream
Results of these tests provide the physician with information about how well the lungs work and how well they can provide oxygen to the vital organs. This is a relatively simple procedure and is not uncomfortable, but for some it can be exerting.
No special preparation is needed. However, if you are using bronchodilator medications such as Ventolin, do not use them before the test.
At the PFT lab, you will be required to sit in a Plexiglas booth where you will be instructed to frequently blow into a special tube-like piece of equipment while a technician takes various measurements of your lung capacity. To prevent breathing through your nose, you will be given a pair of nose clips to use. There are four tests in total and the whole procedure takes about 45-60 minutes.
For one of the tests, you will be asked to use an inhaler the technician will give you, called albuterol (Ventolin®). Ventolin is a bronchodilator often used by patients with asthma or bronchitis. It helps to “open up” the air passages in the lungs making it easier for air to flow through.
There are very few side effects to Ventolin. However, let the technician know if you have a pre-existing heart condition, are taking heart medications or you are already on bronchodilators/inhalers.
Radionuclide Ventriculogram (RVG)
A radionuclide ventriculogram (RVG) is a special type of x-ray used to look at how well the heart works. Certain chemotherapy drugs can be harmful to the heart and if the results of this test are outside normal limits, the doctor may change the dose or the type of chemotherapy.
A blood sample will be taken prior to the test, either through your Hickman® line or from your arm. Then a small amount of radioactive material is mixed with the blood sample and injected back into a vein with a small needle.
You will be asked to lie still as the machine traces the path of the injected blood on a monitor screen. From the pictures taken, the doctor can see how well the heart pumps blood and how well the heart valves work.
Since the amount of radiation used to tag the blood is tiny and doesn’t last long, your exposure to radiation is very small. This procedure takes between 1-2 hours.
St. Paul’s Catheter
When patients and donors have poor arm veins, a St. Paul’s central venous catheter must be inserted in order to collect blood stem cells successfully.
The catheter is a hollow, flexible tube made of soft, rubber-like material. It is inserted into one of the large veins in the side of the neck or the groin area. It is usually used to perform cell separation procedures, plasma exchange and blood stem cell collection. It can also be used to perform dialysis or blood specimen collection.
First, you will be given a tour of the Hematology Apheresis Unit (HAU) before the catheter is inserted. You will meet with one of the nurses who is a specialist in HAU procedures and the care of the St. Paul’s Catheter. During this meeting, you will learn how the catheter is inserted, how to care for it yourself and how to get help if there are any problems. You may bring a friend or family member with you to this session.
On the day of the procedure, you will check in at the HAU, but the catheter insertion is performed in a procedure room at the radiology department. A physician will insert the St. Paul’s catheter. Local anaesthetic will be injected into the skin with a very small needle to freeze the area. You will be awake during the procedure. You should not feel much discomfort, but may feel some pressure.
The catheter is inserted through a needle and secured to the skin by two stitches. Then a bandage is applied. The procedure takes about one hour. An x-ray will be taken after the procedure to check the location of the catheter. Soon after the procedure, you will return to the HAU for assessment and a short recovery period. Some discomfort following insertion is possible. Patients often describe a stiff neck or bruised feeling. This discomfort usually lasts a day or two. Pain medication is available on request or you may receive a prescription for pain medications from the physician.
A physician will examine you after the procedure to decide when you are able to go home. You should arrange to have a family member or friend pick you up after the procedure and stay overnight with you. The evening after line insertion, a nurse will telephone you at home to see how you are doing.
Follow these instructions and precautions after the procedure:
- Diet: Resume normal diet.
- Activity: Rest quietly at home for the rest of the day. Avoid strenuous activity. When the line is in place, do not have a bath or shower. Avoid getting the dressing wet.
- Pain: Take pain medication if necessary. Most patients find that plain Tylenol taken a couple of times over the first 24 hours is effective in controlling the minor discomfort that may be experienced. It is not unusual to feel a bit of tenderness, and sometimes some pressure or tightness from the dressing. If you notice any increased pain, you should contact the physician right away.
- Bleeding: It is not unusual to see a bit of blood seep through the dressing. If there is bright red blood when the patient returns home, apply pressure directly over the area and contact the physician. Do not remove any part of the dressing.
- Infection: Always keep the area around the catheter insertion site clean and dry. Do not shower or bathe while the catheter is in place. Do not remove the dressing or touch the catheter insertion site. You should take your temperature before dinnertime, at bedtime, and when you wake up in the morning. If there is a fever (38°C or higher), chills, a flu-like feeling, lack of energy, or redness, swelling or pus around the catheter insertion site, you should contact the physician immediately.
- Line Care: Additional clean gauze may be placed over the dressing if there is a small amount of bleeding. Do not remove any part of the dressing.
Ultrasound uses sound waves to look for abnormalities in the body. Unlike x-rays, it does not use radiation to generate pictures or images. Ultrasound waves are sent into the body by a transducer, which is a small hand-held object about the size of a microphone. The sound waves bounce off body structures and are recorded to generate images.
Preparation depends on the test involved. The nurse will let you know about any preparation needed. A jelly-like substance is used to make sure there is good contact between the transducer and the skin. The movement of the transducer on the skin is not painful but pressure will be applied. The procedure takes about 1 to 1 ½ hours.
There are several urine tests of which two are commonly performed:
The creatinine clearance test is used to see how well the kidneys work. Creatinine is a waste product put out in urine by the kidneys. The test evaluates the amount of creatinine put out by the kidneys in a 24-hour period. A decreased rate of clearance means the kidneys are not working as well as they should.
This is a routine test started soon after you come in to hospital. You will be given instructions on when the 24-hour period will begin. After this, all urine must be saved for the next 24 hours in large plastic bottles provided to you by your nurse. It’s easiest to keep these bottles in your bathroom. However, if you have to go for an appointment, take a bottle with you. It is essential that all urine be collected during this 24-hour period. If any urine is accidentally thrown away or mixed with stool, the test will have to be started again. At the end of the 24 hours, the bottles will be sent to the lab for testing.
In this test, urine is tested for organisms that may cause an infection. This test can also tell the physician which are the best antibiotics to use if there is an infection. Ideally, the sample is collected in the morning because urine is more concentrated then. A midstream sample is needed- this means patients must begin to urinate into the toilet, stop, and then continue to urinate into a sterile plastic jar. When finished, patients should tell the nurse so the sample can be sent to the lab right away.
An x-ray is used to take a picture of the body or a part of the body using a small, controlled amount of radiation. You may have several x-rays before and throughout your transplant treatment. Prior to your transplant, you will have a skeletal survey and a chest x-ray done. This gives the doctors a baseline (a normal picture) to which later x-rays can be compared. This allows the doctors to monitor how well you are doing with treatment.
No special preparation is needed for a chest X-ray. Any jewellery or metal worn around the neck must be removed. A chest x-ray takes about 15 minutes to complete but some waiting may be involved and therefore the whole process may take up to 45 minutes.