Research Article
BibTex RIS Cite

İntravitreal enjeksiyonda müzik müdahalesinin ağrı, anksiyete, vital bulgular ve hasta memnuniyetine etkisi: randomize kontrollü çalışma

Year 2022, Volume: 27 Issue: 2, 150 - 161, 24.05.2022
https://doi.org/10.21673/anadoluklin.1049397

Abstract

Amaç: Bu çalışmanın amacı, intravitreal enjeksiyon (IVTE) girişimi yapılacak hastalara iki farklı dönemde (IVTE öncesi ve IVTE sırası) uygulanan müzik müdahalesinin, hastaların anksiyetesi, ağrı algısı, vital bulgular ve hasta memnuniyetine etkisinin incelenmesidir.

Yöntemler: Bu randomize kontrollü çalışma iki müdahale (IVTE öncesi (Grup 1) ve IVTE sırası (Grup 2) müzik müdahale grup) ve bir kontrol grubu olmak üzere toplam üç grup ile yürütüldü (Grup 1 n= 73, Grup 2 n = 74, kontrol grubu n =72). astaların ağrı ve anksiyetesinin değerlendirilmesinde Görsel Kıyaslama Ölçeği (GKÖ) ağrı ve GKÖ anksiyete (GKÖ-A) kullanıldı. IVTE prosedüründen memnuniyet ise 5’li likert özellikte olan bir soru ile değerlendirildi.

Bulgular: Anksiyete ve ağrı skorları Grup 1 ve 2’de kontrol grubuna göre daha düşüktü (p<0,001). Üç gruptaki hastaların enjeksiyondan hemen ve 15 dakika sonraki GKÖ-ağrı skorları
karşılaştırıldığında, bütün gruplarda hastaların ağrı düzeyleri düşüktü. Grup 2’nin iki ölçümü arasında anlamlı fark vardı (pb=0,009). Grup 1 ve 2’deki hastalar kontrol grubuna göre IVTE prosedüründen önemli ölçüde daha yüksek hasta memnuniyetine sahipti (p<0.001).

Sonuç: Bu çalışmanın sonuçları IVTE uygulanan hastalarda müzik müdahalesinin, hastaların anksiyete, ağrı algısı ve hasta memnuniyeti üzerine olumlu etkilerinin olduğunu ortaya koymaktadır. Bu nedenle, IVTE öncesi ve sırasında hastalara müzik müdahale yapılmasını önermekteyiz.

References

  • Küçümen RB, Yenerel NM. Diabetic macular edema and its treatment modalities. Turk J Ophthalmol. 2012;42(1):53-60.
  • Avery RL, Bakri SJ, Blumenkranz MS, Brucker AJ, Cunningham ET, DʼAmico DJ, et al. Intravitreal injection technique and monitoring: Updated guidelines of an expert panel. Retina. 2014;34:1-18.
  • Coşkun M. Effects of intravitreal injection needle diameter on the intraocular pressure. Anatol Clin. 2018;23(3):143-6.
  • Storey PP, Tauqeer Z, Yonekawa Y, Todorich B, Wolfe JD, Shah SP, et al. The impact of prefilled syringes on endophthalmitis following intravitreal injection of ranibizumab. Am J Ophthalmol. 2019;199:200-8.
  • Rifkin L, Schaal S. Factors affecting patientsʼ pain intensity during in-office intravitreal injection procedure. Retina. 2012;32(4):696-700.
  • Jeong KD, Kim JH, Kim JS, Hwang JH. Relationship between pain and injection site during intravitreal injection. J Korean Ophthalmol Soc. 2016;57(6):930-4.
  • Kipnis G, Tabak N, Koton S. Background music playback in the preoperative setting: Does it reduce the level of preoperative anxiety among candidates for elective surgery? J Perianesth Nurs. 2016;31(3):209-16.
  • Chen X, Seth RK, Rao VS, Huang JJ, Adelman RA. Effects of music therapy on intravitreal injections: A randomized clinical trial. J Ocul Pharmacol Ther. 2012;28(4):414-9.
  • Senra H, Macedo A, Nunes N, Balaskas K, Aslam T, Costa E. Psychological and psychosocial ınterventions for depression and anxiety in patients with age-related macular degeneration: A systematic review. Am J Geriatr Psychiatry. 2019;27(8):755-73.
  • Sivaprasad S, Oyetunde S. Impact of injection therapy on retinal patients with diabetic macular edema or retinal vein occlusion. Clin Ophthalmol. 2016;10:939-46.
  • Beasley R. Pre-procedural education on anxiety levels during intravitreal injections. International Journal of Ophthalmic Practice. 2011;2(1):20-7.
  • Segal O, Segal-Trivitz Y, Nemet AY, Cohen P, Geffen N, Mimouni M. Anxiety levels and perceived pain intensity during intravitreal injections. Acta Ophthalmol. 2016;94(2):203-4.
  • Katz J, Poleshuck EL, Andrus CH, Hogan LA, Jung BF, Kulick DI, et al. Risk factors for acute pain and its persistence following breast cancer surgery. Pain. 2005;119(1-3):16-25.
  • Jiménez-Jiménez M, García-Escalona A, Martín-López A, De Vera-Vera R, De Haro J. Intraoperative stress and anxiety reduction with music therapy: A controlled randomized clinical trial of efficacy and safety. J Vasc Nurs. 2013;31(3):101-6.
  • Bae I, Lim HM, Hur MH, Lee M. Intra-operative music listening for anxiety, the BIS index, and the vital signs of patients undergoing regional anesthesia. Complement Ther Med. 2014;22(2):251-7.
  • Poulsen MJ, Coto J. Nursing music protocol and postoperative pain. Pain Manag Nurs. 2018;19(2):172-6.
  • Ciğerci Y, Kısacık GÖ, Özyürek P, Çevik C. Nursing music intervention: A systematic mapping study. Complementary Ther Clin Pract. 2019;35:109-20.
  • Wu PY, Huang ML, Lee WP, Wang C, Shih WM. Effects of music listening on anxiety and physiological responses in patients undergoing awake craniotomy. Complement Ther Med. 2017;32:56–60.
  • Dileo C, Bradt J. Music therapy: Applications to stress management. In: Lehrer PM, Woolfolk RL, Sime WE, editors. Principles and practice of stress management. New York: Guilford Press; 2007. 519-42 p.
  • Wiwatwongwana D, Vichitvejpaisal P, Thaikruea L, Klaphajone J, Tantong A, Wiwatwongwana A, et al. The effect of music with and without binaural beat audio on operative anxiety in patients undergoing cataract surgery: A randomized controlled trial. Eye. 2016;30(11):1407-14.
  • Choi S, Park SG, Bellan L, Lee HH, Chung SK. Crossover clinical trial of pain relief in cataract surgery. Int Ophthalmol. 2018;38(3):1027-33.
  • Cruise CJ, Chung F, Yogendran S, Little D. Music increases satisfaction in elderly outpatients undergoing cataract surgery. Can J Anaesth. 1997;44(1):43-8.23.
  • Bellan L, Gooi A, Rehsia S. The Misericordia Health Centre cataract comfort study. Can J Ophthalmol. 2002;37(3):155-60.
  • Merakou K, Varouxi G, Barbouni A, Antoniadou E, Karageorgos G, Theodoridis D, et al. Blood pressure and heart rate alterations through music in patients undergoing cataract surgery in Greece. Ophthalmol Eye Dis. 2015;11(7):7-12.
  • Cline ME, Herman J, Shaw ER, Morton RD. Standardization of the visual analog scale. Nurs Res. 1992;41(6):378-80.
  • Yılmaz E, Birer Z, Baydur H. The effect of therapeutic touch performed during cataract surgery on anxiety and patient satisfaction. J Clin Exp Invest. 2016;7(1):52-62.
  • Williams VS, Morlock RJ, Feltner D. Psychometric evaluation of a visual analog scale for the assessment of anxiety. Health Qual Life Outcomes. 2010;8:57.
  • Chlan LL, Weinert CR, Heiderscheit A, Tracy MF, Skaar DJ, Guttormson JL, et al. Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: A randomized clinical trial. JAMA. 2013;309(22):2335-44.
  • Eti Aslan F. The assessment methods of pain. Cumhuriyet Üniversitesi Hemşirelik Yüksekokulu Dergisi. 2002;6(1):9-16.
  • Arslan M, Albaş S, Küçükerdem HS, Pamuk G, Can H. The evaluation of pain treatment the effectiveness in palliative cancer patients with visual analog scale Fam Pract Palliat Care. 2016;1(1):5-8.
  • Wu KL, Chen SR, Ko WC, Kuo SY, Chen PL, Su HF, et al. The effectiveness of an accessibility-enhanced multimedia informational educational programme in reducing anxiety and increasing satisfaction of patients undergoing cardiac catheterisation. J Clin Nurs. 2014;23(13-14):2063-73.
  • Comeaux T, Steele-Moses S. The effect of complementary music therapy on the patient's postoperative state anxiety, pain control, and environmental noise satisfaction. Medsurg Nurs. 2013;22(5):313-8.
  • Sven-Olof Trängeberg Ö, Stomberg MW. Listening to music during regional anesthesia: patients' experiences and the effect on mood. J Perianesth Nurs. 2013;28(5):291-7.
  • Millan-Calenti JC, Lorenzo-Lopez L, Alonso-Bua B, De Labra C, Gonzalez-Abraldes I, Maseda A. Optimal nonpharmacological management of agitation in Alzheimer’s disease: Challenges and solutions. Clin Interv Aging. 2016;11:175-84.
  • Heiderscheit A, Breckenridge SJ, Chlan LL, Savik K. Music preferences of mechanically ventilated patients participating in a randomized controlled trial. Music Med. 2014;6(2):29-38.
  • Livingston, G., Kelly, L., Lewis-Holmes, E., Baio, G., Morris, S., Patel, N., et al. A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological, and behavioral interventions for managing agitation in older adults with dementia. Health Technol Assess. 2014;18(39):1-226.
  • Robb SL, Carpenter JS, Burns DS. Reporting guidelines for music-based interventions. J Health Psychol. 2011;16(2):342-52.
  • Uyar M, Akın Korhan E. The effect of music therapy on pain and anxiety in intensive care patients. Agri. 2011;23(4):139-46.
  • Twiss E, Seaver J, Mccaffrey R. The effect of music listening on older adults undergoing cardiovascular surgery. Nurs Crit Care. 2006;11(5):224-31.
  • Richards T, Johnson J, Sparks A, Emerson H. The effect of music therapy on patients’ perception and manifestation of pain, anxiety, and patient satisfaction. Medsurg Nurs. 2007;16:7-14.
  • Bremner MN, Blake BJ, Wagner VD, Pearcey SM. Effects of reiki with music compared to music only among people living with HIV. J Assoc Nurses AIDS Care. 2016;27(5):635-47.
  • Evans D. The effectiveness of music as an intervention for hospital patients: A systematic review. J Adv Nurs. 2002;37(1):8-18.
  • Rothenhäusler HB, Grieser B, Nollert G, Reichart B, Schelling G, Kapfhammer HP. Psychiatric and psychosocial outcome of cardiac surgery with cardiopulmonary bypass: a prospective 12-month follow-up study. Gen Hosp Psychiatry. 2005;27(1):18-28.
  • Berger V, Munk MR, Lersch F, Wolf S, Ebneter A, Zinkernagel MS. Association of intravitreal injections with blood pressure increase. JAMA Ophthalmol. 2019;137(1):87-90.
  • McCaffrey R, Freeman E. Effect of music on chronic osteoarthritis pain in older people. J Adv Nurs. 2003;44(5):517-24.
  • Roth DB, Scott IU, Gulati N, Prenner J. Patient perceptions of discomfort and changes in vision and functional status associated with intravitreal triamcinolone injection. Am J Ophthalmol. 2006;142(3):492-4.
  • De Oliveria AM, Radanovic M, De Mello PCH, Buchain PC, Vizzotto ADB, Celestino DL, et al. Nonpharmacologic interventions to reduce behavioral and psychological symptoms of dementia: A systematic review. Biomed Res Int. 2015;2015:218980.
  • Stouffer JW, Shirk BJ, Polomano CR. Practice guidelines for music interventions with hospitalized pediatric patients. J Pediatr Nurs. 2007;22(6):448-56.
  • Knox D, Beveridge S, Mitchell LA, MacDonald RA. Acoustic analysis and mood classification of pain-relieving music. J Acoust Soc Am. 2011;130(3):1673-82.

The effects of the music intervention on anxiety, pain, vital signs, and patient satisfaction in intravitreal injection: a randomized controlled study

Year 2022, Volume: 27 Issue: 2, 150 - 161, 24.05.2022
https://doi.org/10.21673/anadoluklin.1049397

Abstract

Aim: This study aimed to investigate the effects of music intervention applied in two different periods Before intravitreal injection (IVTI) on anxiety, pain perception, vital signs, and
satisfaction in patients receiving intravitreal injection..

Methods: This randomized controlled study was conducted with a total of three groups including two music intervention groups (pre-IVTI (group 1) and during IVTI (group 2)) and a
control group (Group 1 n= 73, Group 2 n = 74, Control Group n =72). The patients’ pain was evaluated with the Visual Analog Scale (VAS) pain, anxiety with the Visual Analog Scale
Anxiety (VAS-A), and satisfaction with the IVTI procedure with a 5-point Likert scale.

Results: The anxiety and pain scores were lower in groups 1 and 2 than in the control group (p<0.001). All three groups had low pain levels when their VAS-Pain scores were compared immediately and 15 minutes after IVTI. Group 2 was found to have a significant difference between the two measurements (pb =0.009). Further, Groups 1 and 2 had significantly higher patient satisfaction with the IVTI procedure than the control group (p<0.001).

Conclusion: The study results showed that music intervention has positive effects on anxiety, pain perception, and satisfaction in patients receiving IVTI therapy. As a result, we recommend the use of listening to music on patients before and during the IVTI procedure.

References

  • Küçümen RB, Yenerel NM. Diabetic macular edema and its treatment modalities. Turk J Ophthalmol. 2012;42(1):53-60.
  • Avery RL, Bakri SJ, Blumenkranz MS, Brucker AJ, Cunningham ET, DʼAmico DJ, et al. Intravitreal injection technique and monitoring: Updated guidelines of an expert panel. Retina. 2014;34:1-18.
  • Coşkun M. Effects of intravitreal injection needle diameter on the intraocular pressure. Anatol Clin. 2018;23(3):143-6.
  • Storey PP, Tauqeer Z, Yonekawa Y, Todorich B, Wolfe JD, Shah SP, et al. The impact of prefilled syringes on endophthalmitis following intravitreal injection of ranibizumab. Am J Ophthalmol. 2019;199:200-8.
  • Rifkin L, Schaal S. Factors affecting patientsʼ pain intensity during in-office intravitreal injection procedure. Retina. 2012;32(4):696-700.
  • Jeong KD, Kim JH, Kim JS, Hwang JH. Relationship between pain and injection site during intravitreal injection. J Korean Ophthalmol Soc. 2016;57(6):930-4.
  • Kipnis G, Tabak N, Koton S. Background music playback in the preoperative setting: Does it reduce the level of preoperative anxiety among candidates for elective surgery? J Perianesth Nurs. 2016;31(3):209-16.
  • Chen X, Seth RK, Rao VS, Huang JJ, Adelman RA. Effects of music therapy on intravitreal injections: A randomized clinical trial. J Ocul Pharmacol Ther. 2012;28(4):414-9.
  • Senra H, Macedo A, Nunes N, Balaskas K, Aslam T, Costa E. Psychological and psychosocial ınterventions for depression and anxiety in patients with age-related macular degeneration: A systematic review. Am J Geriatr Psychiatry. 2019;27(8):755-73.
  • Sivaprasad S, Oyetunde S. Impact of injection therapy on retinal patients with diabetic macular edema or retinal vein occlusion. Clin Ophthalmol. 2016;10:939-46.
  • Beasley R. Pre-procedural education on anxiety levels during intravitreal injections. International Journal of Ophthalmic Practice. 2011;2(1):20-7.
  • Segal O, Segal-Trivitz Y, Nemet AY, Cohen P, Geffen N, Mimouni M. Anxiety levels and perceived pain intensity during intravitreal injections. Acta Ophthalmol. 2016;94(2):203-4.
  • Katz J, Poleshuck EL, Andrus CH, Hogan LA, Jung BF, Kulick DI, et al. Risk factors for acute pain and its persistence following breast cancer surgery. Pain. 2005;119(1-3):16-25.
  • Jiménez-Jiménez M, García-Escalona A, Martín-López A, De Vera-Vera R, De Haro J. Intraoperative stress and anxiety reduction with music therapy: A controlled randomized clinical trial of efficacy and safety. J Vasc Nurs. 2013;31(3):101-6.
  • Bae I, Lim HM, Hur MH, Lee M. Intra-operative music listening for anxiety, the BIS index, and the vital signs of patients undergoing regional anesthesia. Complement Ther Med. 2014;22(2):251-7.
  • Poulsen MJ, Coto J. Nursing music protocol and postoperative pain. Pain Manag Nurs. 2018;19(2):172-6.
  • Ciğerci Y, Kısacık GÖ, Özyürek P, Çevik C. Nursing music intervention: A systematic mapping study. Complementary Ther Clin Pract. 2019;35:109-20.
  • Wu PY, Huang ML, Lee WP, Wang C, Shih WM. Effects of music listening on anxiety and physiological responses in patients undergoing awake craniotomy. Complement Ther Med. 2017;32:56–60.
  • Dileo C, Bradt J. Music therapy: Applications to stress management. In: Lehrer PM, Woolfolk RL, Sime WE, editors. Principles and practice of stress management. New York: Guilford Press; 2007. 519-42 p.
  • Wiwatwongwana D, Vichitvejpaisal P, Thaikruea L, Klaphajone J, Tantong A, Wiwatwongwana A, et al. The effect of music with and without binaural beat audio on operative anxiety in patients undergoing cataract surgery: A randomized controlled trial. Eye. 2016;30(11):1407-14.
  • Choi S, Park SG, Bellan L, Lee HH, Chung SK. Crossover clinical trial of pain relief in cataract surgery. Int Ophthalmol. 2018;38(3):1027-33.
  • Cruise CJ, Chung F, Yogendran S, Little D. Music increases satisfaction in elderly outpatients undergoing cataract surgery. Can J Anaesth. 1997;44(1):43-8.23.
  • Bellan L, Gooi A, Rehsia S. The Misericordia Health Centre cataract comfort study. Can J Ophthalmol. 2002;37(3):155-60.
  • Merakou K, Varouxi G, Barbouni A, Antoniadou E, Karageorgos G, Theodoridis D, et al. Blood pressure and heart rate alterations through music in patients undergoing cataract surgery in Greece. Ophthalmol Eye Dis. 2015;11(7):7-12.
  • Cline ME, Herman J, Shaw ER, Morton RD. Standardization of the visual analog scale. Nurs Res. 1992;41(6):378-80.
  • Yılmaz E, Birer Z, Baydur H. The effect of therapeutic touch performed during cataract surgery on anxiety and patient satisfaction. J Clin Exp Invest. 2016;7(1):52-62.
  • Williams VS, Morlock RJ, Feltner D. Psychometric evaluation of a visual analog scale for the assessment of anxiety. Health Qual Life Outcomes. 2010;8:57.
  • Chlan LL, Weinert CR, Heiderscheit A, Tracy MF, Skaar DJ, Guttormson JL, et al. Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: A randomized clinical trial. JAMA. 2013;309(22):2335-44.
  • Eti Aslan F. The assessment methods of pain. Cumhuriyet Üniversitesi Hemşirelik Yüksekokulu Dergisi. 2002;6(1):9-16.
  • Arslan M, Albaş S, Küçükerdem HS, Pamuk G, Can H. The evaluation of pain treatment the effectiveness in palliative cancer patients with visual analog scale Fam Pract Palliat Care. 2016;1(1):5-8.
  • Wu KL, Chen SR, Ko WC, Kuo SY, Chen PL, Su HF, et al. The effectiveness of an accessibility-enhanced multimedia informational educational programme in reducing anxiety and increasing satisfaction of patients undergoing cardiac catheterisation. J Clin Nurs. 2014;23(13-14):2063-73.
  • Comeaux T, Steele-Moses S. The effect of complementary music therapy on the patient's postoperative state anxiety, pain control, and environmental noise satisfaction. Medsurg Nurs. 2013;22(5):313-8.
  • Sven-Olof Trängeberg Ö, Stomberg MW. Listening to music during regional anesthesia: patients' experiences and the effect on mood. J Perianesth Nurs. 2013;28(5):291-7.
  • Millan-Calenti JC, Lorenzo-Lopez L, Alonso-Bua B, De Labra C, Gonzalez-Abraldes I, Maseda A. Optimal nonpharmacological management of agitation in Alzheimer’s disease: Challenges and solutions. Clin Interv Aging. 2016;11:175-84.
  • Heiderscheit A, Breckenridge SJ, Chlan LL, Savik K. Music preferences of mechanically ventilated patients participating in a randomized controlled trial. Music Med. 2014;6(2):29-38.
  • Livingston, G., Kelly, L., Lewis-Holmes, E., Baio, G., Morris, S., Patel, N., et al. A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological, and behavioral interventions for managing agitation in older adults with dementia. Health Technol Assess. 2014;18(39):1-226.
  • Robb SL, Carpenter JS, Burns DS. Reporting guidelines for music-based interventions. J Health Psychol. 2011;16(2):342-52.
  • Uyar M, Akın Korhan E. The effect of music therapy on pain and anxiety in intensive care patients. Agri. 2011;23(4):139-46.
  • Twiss E, Seaver J, Mccaffrey R. The effect of music listening on older adults undergoing cardiovascular surgery. Nurs Crit Care. 2006;11(5):224-31.
  • Richards T, Johnson J, Sparks A, Emerson H. The effect of music therapy on patients’ perception and manifestation of pain, anxiety, and patient satisfaction. Medsurg Nurs. 2007;16:7-14.
  • Bremner MN, Blake BJ, Wagner VD, Pearcey SM. Effects of reiki with music compared to music only among people living with HIV. J Assoc Nurses AIDS Care. 2016;27(5):635-47.
  • Evans D. The effectiveness of music as an intervention for hospital patients: A systematic review. J Adv Nurs. 2002;37(1):8-18.
  • Rothenhäusler HB, Grieser B, Nollert G, Reichart B, Schelling G, Kapfhammer HP. Psychiatric and psychosocial outcome of cardiac surgery with cardiopulmonary bypass: a prospective 12-month follow-up study. Gen Hosp Psychiatry. 2005;27(1):18-28.
  • Berger V, Munk MR, Lersch F, Wolf S, Ebneter A, Zinkernagel MS. Association of intravitreal injections with blood pressure increase. JAMA Ophthalmol. 2019;137(1):87-90.
  • McCaffrey R, Freeman E. Effect of music on chronic osteoarthritis pain in older people. J Adv Nurs. 2003;44(5):517-24.
  • Roth DB, Scott IU, Gulati N, Prenner J. Patient perceptions of discomfort and changes in vision and functional status associated with intravitreal triamcinolone injection. Am J Ophthalmol. 2006;142(3):492-4.
  • De Oliveria AM, Radanovic M, De Mello PCH, Buchain PC, Vizzotto ADB, Celestino DL, et al. Nonpharmacologic interventions to reduce behavioral and psychological symptoms of dementia: A systematic review. Biomed Res Int. 2015;2015:218980.
  • Stouffer JW, Shirk BJ, Polomano CR. Practice guidelines for music interventions with hospitalized pediatric patients. J Pediatr Nurs. 2007;22(6):448-56.
  • Knox D, Beveridge S, Mitchell LA, MacDonald RA. Acoustic analysis and mood classification of pain-relieving music. J Acoust Soc Am. 2011;130(3):1673-82.
There are 49 citations in total.

Details

Primary Language English
Subjects Health Care Administration
Journal Section ORIGINAL ARTICLE
Authors

Mustafa Hız 0000-0002-3428-6655

Yeliz Ciğerci 0000-0002-9858-0837

Mustafa Doğan 0000-0001-7237-9847

Publication Date May 24, 2022
Acceptance Date February 14, 2022
Published in Issue Year 2022 Volume: 27 Issue: 2

Cite

Vancouver Hız M, Ciğerci Y, Doğan M. The effects of the music intervention on anxiety, pain, vital signs, and patient satisfaction in intravitreal injection: a randomized controlled study. Anatolian Clin. 2022;27(2):150-61.

13151 This Journal licensed under a CC BY-NC (Creative Commons Attribution-NonCommercial 4.0) International License.