A Call to Action from the Nationís Nurses in the Wake of Newtown - page 15

by NRSKarenRN 16,140 Views | 219 Comments Admin

Reposting from PSNA Communications email. Karen A Call to Action from the Nationís Nurses in the Wake of Newtown More Than 30 Nursing Organizations Call for Action in Wake of Newtown Tragedy (12/20/12) Like the rest... Read More


  1. 0
    I think this entire claim of the last few decades to "lose the stigma" is faux as the entire stigma starts with the label of so-called "illness" or supposed "disease" or "abnormality" (esp. a "permanent genetic default") as the person with the label KNOWS it makes them "different" (with a negative, not a positive correlation of originality) and it is based off someone's decision that their actions, personality, or feelings are supposedly "abnormal." This is unlike diabetes or cardiovascular disease as those affect the human body's cells (e.g., myocardia caused by ischemia) and do not affect people's actions, personality, or character/social place significantly. Any person could get cardiovascular disease no matter what they are like socially or their actions. Yes, there is diet involved and exercise, but that has nothing to do with social norms or communication, ect. Mostly people who do these things WANT CONTROL, I repeat these people WANT CONTROL over their lives. They're acting out because there is an outside problem causing it and they want people to just listen to them for once instead of calling them the so-called "problem." This is like calling a victim of a crime who is feeling trauma from an event a supposed "problem" and saying it was their fault of getting victimized in the first place and they should have "acted better." This is crushing and makes them feel even more vulnerable/out of control. Instead of attacking the victim why don't you attack the criminal and tell them those are normal (repeat, normal) feelings of victimization and lets try to reduce crime. This diverts the problem from them to the actual cause in the first place. It is never the fault of the victim, but of the attacker.

    Chemical reactions do not necessarily mean there is a so-called "illness," but an emotional reaction to stress, fear, anger, not the person's fault or a "disease" (based on social opinion). There are chemical reactions for positive aspects and characteristics as well. Chemical reactions do not have to be labeled "illnesses," but natural human variations. Maybe someone with a supposedly "differing" chemical reaction is the only person who can recognize there is a problem and is trying to tell others. Each person differs in personality thankfully, yet, we are 99.9% the same. This is normal variation, not a "disease" or "ailment" (meaning, needing eradication by taking away their sense of self-control by labeling, i.e., stereotyping them and placing them in a box, and telling them it is their problem). To their bodily cells, their is no ailment killing their cells like a disease would. It's nothing like lysis (from overhydration) or myocardia. Their bodies are not trying to remove any so-called "disease" nor are their human cells significantly altered.

    One can claim it is like having a physical disease like diabetes, yet is is not as this so-called "disease" is directly connected to their daily actions, personality type, self-control, feelings and place in society. It depends, greatly, on social norms and subjected to change (as each year, the supposed "illnesses" increase in number by votes from a board). The supposedly "genetic disease" (not called a normal variation in personality or reaction to distress) aspect did not come until after hundreds of "diseases" were added to the manual. Science is currently being forced to prove the so-called "diseases" which were previously already listed. They were not primarily scientifically discovered as were viruses, cardiovascular disease, diabetes, or paralysis, which are concrete and cannot be disputed as they have a mathematical and human cell response basis, they were primarily socially discovered. Then once they were "discovered" they are trying to use science to prove it. Does this not sound like it does not make sense? You could say it was a hypothesis, but they already had claimed it was an "illness" without this "proof" beforehand due to social standards.

    This is almost like saying the sun revolves around the earth (geocentric model) and accepting it as scientific proof firstly by observations, then trying to use some testing to prove it... not mainly because it is fact, but because it "good" socially for this to happen. It was widely accepted, then continually falsely "added to" for this social convenience. They were at the beginning of a new territory also.

    And those statistics per year are consistently near 10,000 from 1933 to 2000. This was the purpose of me listing them as there has been no change. Th total overall yearly related deaths due to firearms has stayed consistently near 30,000 since they were first published.

    If nurses were more unionized, they would have greater national influence (i.e., lobbying, advertizing and providing information to the public). There are nursing organizations supporting gun reform as well as the AMA already.

    Quote from aknottedyarn
    I am having difficulty following. Am I reading that you don't believe mental illness is an illness? Think genetic diseases are not "real" diseases?

    I agree that culturally some things are more acceptable than in others. In some cultures cock fighting is accepted. In the US we see it as abuse of an animal. Same for dog fights and the same for bull fighting. I don't think these things, by themselves would get someone labeled as psychotic.

    In general when someone is labeled as having mental illness there are many signposts. We are just learning about genetics so this is an area that will be explored more in the future. You have to remember that we did not even know about DNA within my lifetime. That is how quickly things develop. We are in our infancy about the brain. We are just learning about the chemicals and what they mean. In comparison: We are close to where our knowledge of the heart was 40-60 years ago with the working knowledge of chemical interactions causing response. We need much more knowledge to see how specific chemicals react in the brain. Genetics are certainly part of this.

    We used to try to bleed out problems or chase demons because we did not understand physical illnesses. As we are learning more about mental illness we find that it is more of brain dysfunction than a check off list in the current DSM -?

    Taking on year of stats is not valid and you can't determine much from those stats. There are good studies out there. I choose not to get into the gun control fight as much as some. I prefer to focus on what nurses can control. I figure there are other forums that can focus on guns. Our expertise is with human responses. To me that means all of us need to be involved with what we can do to help get more mental health assessment and treatment, not less. It is not a case of being labeled any more than being found to have diabetes labels you. We need to get our heads around that so we can provide adequate care to all our patients and not exclusde their mental status. As I review charts this is the biggest lack I find.
    I care for people with cardiovascular disease. Most often these are not caused by a pathogen.
    Last edit by InfirmiereJolie on Dec 27, '12
  2. 3
    Doctors Say Gun Control is a Public Health Issue | American News Report
    According to the Centers for Disease Control and Prevention (CDC), more than 31,000 Americans die from firearms annually. While there’s decades of research on what leads people to commit violence against themselves or others, there’s significantly less information on how access to firearms contributes to the likelihood and consequences of these acts.
    That dearth of research, say Arthur Kellermann, MD, vice president of the RAND Corporation and Frederick Rivara, MD, Seattle Children’s Hospital, is the direct result of pro-gun members of Congress mounting an effort in 1996 to eliminate funding for the National Center for Injury Prevention and Control at the CDC. Although the effort failed, language was added preventing the CDC from using federal funds “to advocate or promote gun control.”

    So, in 1996 the NRA (through lobbying Congress) was able to get research stopped about what leads people to commit violence, etc.
    How many people have died since then that might have been alive today if research had not been stopped?


    Sad that the ability to sell more guns with less restrictions trumps the value of human life. As we now know the NRA really is only the mouthpiece for gun sales. Those honest shooters who thought the NRA was there to protect their interests need to wake up and smell the gun powder being sold. It has nothing to do with anything except greed.
    tewdles, jadelpn, and herring_RN like this.
  3. 2
    My concern is that, as in so many cases, we (as nurses) are getting dragged into a lot of incorrect perceptions that have "grown legs" (thanks to the media and politicians, both of which I trust lately at a level one step below a stool sample). Nurses will be out there protesting, writing, and campaigning (as in the past with other issues) their way into being looked upon with disfavor when all the chips fall (and they will).

    We are nurses; most of us entered and remain in this profession to help people. We have the ability to make or break a person's life in mere seconds or less. We make a positive difference in people's lives every day. We also exercise great caution, logic, and reason in doing what we do as nurses. We need to exercise that same degree of caution, logic, and reason when pursuing and attaching ourselves the myriad causes out there.
    workingharder and HM-8404 like this.
  4. 1
    Quote from Overland1
    My concern is that, as in so many cases, we (as nurses) are getting dragged into a lot of incorrect perceptions that have "grown legs" (thanks to the media and politicians, both of which I trust lately at a level one step below a stool sample). Nurses will be out there protesting, writing, and campaigning (as in the past with other issues) their way into being looked upon with disfavor when all the chips fall (and they will).

    We are nurses; most of us entered and remain in this profession to help people. We have the ability to make or break a person's life in mere seconds or less. We make a positive difference in people's lives every day. We also exercise great caution, logic, and reason in doing what we do as nurses. We need to exercise that same degree of caution, logic, and reason when pursuing and attaching ourselves the myriad causes out there.
    Excellent post. People need to stop trying to convince themselves they are more politically enlightened than others by virtue of their job. Everyone is entitled to their opinion about everything, but don't make the mistake of thinking your opinion is more informed due to your job. A nurse is no more enlightened about gun control than an actor is about the environment. When people start using their jobs to try to push a personal agenda in politically charged subjects they are doing themselves and others in the same career a disservice. If someone wants to speak as a nurse I would suggest sticking to what nurses do best, advocate for patients.
    Spidey's mom likes this.
  5. 1
    Congratulations! America is ranked #65 out of SEVENTY FIVE (75) listed countries... making it have the 10th highest amounts of gun-related deaths, just behind El Salvador, Jamaica, Honduras, Guatemala, Swaziland, Columbia, Brazil, Panama and Mexico!!!! And BEHIND EVERY 1st WORLD COUNRY, ALL of Europe, and almost all of our trading partners what success!
    El Salvador 50.36 50.36 NA NA NA 2009 OAS 2011[1]
    Jamaica 47.44 47.44 NA NA NA 2009 OAS 2011[1]
    Honduras 46.70 46.70 NA NA NA 2007 OAS 2011[1]
    Guatemala 38.52 38.52 NA NA NA 2009 OAS 2011[1]
    Swaziland 37.16 37.16 NA NA NA 2004 UNODC 2006[1]
    Colombia 28.11 27.10 0.87 0.14 NA 2009 UNODC 2011 [2]
    Brazil 19.01 18.10 0.73 0.18 NA 2008 UNODC 2011[3]
    Panama 12.92 12.92 NA NA NA 2010 OAS 2011[1]
    Mexico 11.14 10.00 0.67 0.47 NA 2010 UNODC 2011[4]
    United States
    10.2 3.7 6.1 0.2 0.1 2009 OAS 2012[5][6] (10th place in HIGHEST number of gun-related deaths.What a horrifying embarressment on the world stage and sad for our poor people!)
    Philippines 9.46 9.46 NA NA NA 2002 UNODC 2002[7]
    South Africa 9.41 NA NA NA NA 2012 UNODC 2012[8] & Stats SA[9]
    Montenegro 8.55 2.06 6.49 NA NA 2009 WHO 2012[10]
    Paraguay 7.35 7.35 NA NA NA 2000 UNODC 2000[11]
    Nicaragua 7.14 7.14 NA NA NA 2007 OAS 2011[1]
    Argentina 5.65 3.00 2.01 0.64 NA 2001 2008 UNODC 2011[12]
    Canada 4.78 0.76 3.72 0.22 NA 1992 Krug 1998[13]
    Zimbabwe 4.75 4.75 NA NA NA 2000 UNODC 2000[11]
    Serbia 3.90 0.62 2.81 0.18 0.29 2010 WHO 2012[10]
    Finland 3.64 0.26 3.34 0.02 0.02 2010 WHO 2012[10]
    Switzerland 3.5 0.52 3.15 0.10 0.07 2010 OAS 2011[1]
    Costa Rica 3.32 3.32 NA NA NA 2002 UNODC 2002[7]
    Uruguay 3.24 3.24 NA NA NA 2002 UNODC 2002[7]
    Croatia 3.01 0.57 2.35 0.07 0.02 2010 WHO 2012[10]
    Barbados 3 3 NA NA NA 2000 UNODC 2000[11]
    France 3.00 0.22 2.33 0.05 0.41 2009 WHO 2012[10]
    Austria 2.94 0.18 2.68 NA 0.08 2010 WHO 2012[10]
    New Zealand 2.66 0.17 2.14 0.09 NA 1993 Krug 1998[13]
    Estonia 2.54 0.30 1.57 0.07 0.60 2010 WHO 2012[10]
    Slovenia 2.44 0.05 2.34 NA 0.05 2010 WHO 2012[10]
    Belgium 2.43 0.29 1.96 0.01 0.16 2006 WHO 2012[10]
    Malta 2.16 0.48 1.68 NA NA 2010 WHO 2012[10]
    Peru 1.87 1.87 NA NA NA 2009 OAS 2011[1]
    Israel 1.86 0.94 0.71 0.03 0.19 2009 WHO 2012[10]
    Republic of Macedonia 1.04 0.45 0.42 0.08 0.08 2011 WHO 2012[10]
    Luxembourg 1.81 0.60 1.00 NA 0.20 2009 WHO 2012[10]
    Norway 1.78 0.04 1.72 0.02 NA 2010 WHO 2012[10]
    Portugal 1.77 0.48 1.09 0.02 0.18 2010 WHO 2012[10]
    Czech Republic 1.76 0.12 1.39 0.10 0.15 2010 WHO 2012[10]
    Slovakia 1.75 0.18 0.94 0.39 0.24 2010 WHO 2012[10]
    Lithuania 1.61 0.24 1.00 0.03 0.33 2010 WHO 2012[10]
    Georgia 1.54 0.23 0.09 1.00 0.23 2009 WHO 2012[10]
    Greece 1.5 0.59 0.84 0.04 NA 1994 Krug 1998[13]
    Sweden 1.47 0.19 1.20 0.06 0.01 2010 WHO 2012[10]
    Denmark 1.45 0.22 1.16 0.04 0.04 2006 WHO 2012[10]
    Latvia 1.43 0.18 0.94 0.04 0.27 2010 WHO 2012[10]
    Bulgaria 1.35 0.23 0.87 0.14 0.11 2011 WHO 2012[10]
    Italy 1.28 0.36 0.81 0.08 0.03 2009 WHO 2012[10]
    Kuwait 1.25 0.36 0.06 0 NA 1995 Krug 1998[13]
    Iceland 1.25 NA 1.25 NA NA 2009 WHO 2012[10]
    Germany 1.10 0.06 0.94 0.02 0.08 2010 WHO 2012[10]
    Moldova 1.04 1.04 NA NA NA 2011 WHO 2012[10]
    Australia 1.05 0.09 0.79 0.02 0.15 2008 UNODC 2011[14]
    Ireland 1.03 0.36 0.56 0.04 0.07 2010 WHO 2012[10]
    Kyrgyzstan 1.01 0.53 0.07 0.28 0.13 2010 WHO 2012[10]
    India 0.93 0.93 NA NA NA 2000 UNODC 2000[11]
    Hungary 0.85 0.13 0.72 NA NA 2009 WHO 2012[10]
    Cyprus 0.83 0.24 0.48 NA 0.11 2010 WHO 2012[10]
    Uzbekistan 0.68 0.58 0.03 NA 0.08 2005 WHO 2012[10]
    Spain 0.63 0.15 0.42 0.05 0.01 2010 WHO 2012[10]
    Netherlands 0.46 0.20 0.24 0.01 0.01 2010 WHO 2012[10]
    Taiwan 0.42 0.13 0.12 0.11 NA 1994 Krug 1998[13]
    Belarus 0.38 0.38 NA NA NA 2002 UNODC 2002[7]
    Ukraine 0.35 0.35 NA NA NA 2000 UNODC 2000[11]
    United Kingdom 0.25 0.04 0.17 0.01 0.02 2011 WHO2012 [10]
    Poland 0.26 0.02 0.12 0.02 0.09 2010 WHO 2012[10]
    Singapore 0.24 0.07 0.17 0 NA 1994 Krug 1998[13]
    Romania 0.20 0.04 0.06 0.09 0.01 2010 WHO 2012[10]
    Hong Kong 0.19 0.12 0.07 0 NA 1993 Krug 1998[13]
    Mauritius 0.19 0 0.09 0.09 NA 1993 Krug 1998[13]
    Qatar 0.18 0.18 NA NA NA 2000 UNODC 2000[11]
    South Korea 0.13 0.04 0.02 0.05 NA 1994 Krug 1998[13]
    Japan 0.07 0.02 0.04 0 NA 1994 Krug 1998[13]
    Azerbaijan 0.07 0.04 0.01 0.02 NA 2007 WHO 2012[10]
    Chile 0.06 0.06 NA NA NA 2002 UNODC 2002[7]
    10.2 (ours) vs the lowest .06 (Chile)... which makes ours ONE HUNDRED SEVENTY (170) TIMES HIGHER! And while the entire European Union (500 million people and 27 countries) had only 1,260 murders by guns... the United States (only 300 million compared to 500 million) had 10,801!!!!!! http://www.fox.temple.edu/cms/wp-con...eanLemaire.pdf That is nearly 10 times higher.

    Atleast someone is doing something about this atrocity against humanity.

    "There is a definite need to control handgun use and the accompanying violence that leads individuals to use handguns. ANA supports both the waiting period for the purchase of handguns and a ban on the sale of all assault weapons.

    Firearms, especially handguns, remain a leading instrument of violent injury. As the largest single group of clinical health care professionals within the health system, licensed registered nurses are on the front lines of the health care system and witness first hand the devastation from the injuries sustained as a result of gun violence."
    The American Nursing Association, letter to the 112th Congress http://www.nursingworld.org/GunContr...hCongress.aspx

    Accross the border in Canada, nurses are doing the something about this cruel atrocity, too.

    "A core purpose of the Canadian Federation of Nurses Unions (CFNU) is to be a proactive,
    unifying national voice for the socio-economic welfare of nurses and others.
    Health promotion is a key role of nurses. Gun control legislation works to prevent injury and death
    and can therefore be likened to other injury and death prevention policies such as seatbelts or
    hockey helmets. As well, gun control is a women’s issue as it reduces the risk of spousal
    homicide, intimidation and injury. 93% of our members are women.

    For nurses, firearms control, including the long-gun registry, is not a north/south or rural/urban
    issue. Gun control is a health and safety issue and it is a gender issue.

    As health professionals, we know the importance of investing in prevention, whether in road
    safety or prevention of infectious diseases. It is true that one cannot easily measure prevention, but
    we can certainly measure the effects of ignoring it. To our knowledge, six different coroners’
    inquests recommended the licensing of gun owners and registration of all firearms. Indeed, our
    daily practice informs us of the very real risks associated with firearms and of the value of a strong
    gun control law.

    Health Promotion and Prevention
    Over 70% of deaths from firearms are suicides.
     Most deaths by firearms and suicides are committed with shotguns or rifles.
     The progress made over the past 15 years in the field of suicide prevention is enormous.
     Many suicide deaths are preventable.
     Reduced access to certain methods of suicide and preventive actions with vulnerable people
    are important measures as part of a strategy for suicide prevention.
     The registration of firearms, requiring licenses renewable every five years for gun owners and
    background checks, as well as efforts to raise awareness of safe storage of firearms have been
    recognized for their impact in significantly decreased suicide rates.

    Reducing Violence Against Women
     72% of women who die from gun shot wounds in Canada are shot with long guns and rifles.
    Guns in the home is a risk factor for spousal homicide, whether long guns or handguns.
    Spousal homicides with guns have fallen since gun control legislation in the 1990s by two
    thirds, whereas spousal homicides without guns have remained the same.
     When a gun is involved in domestic violence, the chance of a woman’s death increases by 12
    times compared to other forms of violence.
     Women who live with a gun in their home are more likely to be shot and killed than those who
    live in gun-free homes. Even if the guns are not directly fired on women, they are often used as
    a tool of intimidation in rape, or physical or psychological violence."
    The Canadian Federation of Nurses Unions, letter to the Canadian Senate Standing Committee
    on Legal and Constitutional Affairs http://www.nursesunions.ca/sites/def...ch_28_2012.pdf

    (old, but interesting) Mrs. McCarthy Goes to Washington: Nurse Takes Gun-Control Crusade to Congress as a U.S. Representative

    "...Congresswoman McCarthy is fully aware that the legislation she either proposes or supports directly impacts those who work on the front lines of health care. She has proposed legislation that seeks to protect healthcare workers, such as the Health Care Worker Protection Act, which requires hospitals to use safer needles and find money for safe training. The Health Care Worker Protection Act recently passed the House.

    ...Her accomplishments notwithstanding, she will not consider her mission complete until every citizen is safe from gun violence. For her efforts, she has received many honors, which are listed on her official Congressional Web site (Congresswoman Carolyn McCarthy : Home). She was named one of New York Newsday’s 100 Long Island Influentials, Congressional Quarterly’s 50 Most Effective Legislators in Congress, one of Redbook Magazine’s nine Mothers and Shakers, Ladies’ Home Journal list of America’s 100 Most Important Women and Advertising Age’s list of Most Impact by Women in 1999." Mrs. McCarthy Goes to Washington: Nurse Takes Gun-Control Crusade to Congress as a U.S. Representative - NurseZone

    aknottedyarn likes this.
  6. 0
    We can have all the rules and what not in our society on how kids do this and that; what makes them violent, which generation is better, how guns are bad, etc... but ultimately it starts with the parents at home. With over 50% of kids growing up in single parent families what leads to the center of the problem is clear to me.

    Is it the video games or is it a coincidence that the divorce rate and teenage pregnancy was on the rise at the same time more or less? Also, the fact that more parents are reluctant to let their kids play outside unsupervised for fear of never seeing them again with all the disappearing children on the increase. Young kids coming home to empty houses due to parent/parents working.

    Is crime on the rise or is it now with advanced technology in place how we are able to hear about every gruesome crime at the exact time it happens just by turning on the TV, radio, or computer? 50 years ago unless we were related to the family members or in the state we wouldn't have heard of nearly any of the stuff we do today.

    It isn't just this generation or the other but all generations had parents trying to act like friends to their kids instead of actual parents. I believe it started witht the increasing divorce rate. Everyone has their opinions and everyone has their own particular soapbox but that doesn't make the next persons any less important. It starts in the home with the aid and access to education of mental health for everyone, including kids (right along with drug and alcohol education), and taking responsibility for each one's children.

    With over 70% of all gun deaths attributed to suicide (InfirmiereJolie) that is very telling. It tells me that gun control isn't the issue; the issue is mental health and home life. You know if they didn't have a gun they would have more then likely killed themselves in another way. Mental health has always taken a back seat to most things, it's time to bring it to the front of the room. When listening to the POTUS promoting his health care bill, I never heard him speak about mental health.

    It's time.
  7. 1
    Well as a nurse all I have to say on this is the day they come for my guns is the day I end up dying more than likely. I will fight anyone that tries totake them away from me. Thankfully though that will not happen as NONE of my guns are registered and I do own quite a few guns including the oh so scary M 4 Bushmaster in bothlong version and theshortversionthat is considereda pistol. Even scarier I own a preban Uzi That is full auto. I even have silencers for a couple of my pistols as well as for the Bushmaster.

    p.s they all are (gasp!) kept loaded
    VivaLasViejas likes this.
  8. 0
    ActuallyI need to amend on part of my post, my Uzi is registered, but that is the only one registered.
  9. 0
    ... The dreaded double post....
  10. 0
    Quote from tyvin
    We can have all the rules and what not in our society on how kids do this and that; what makes them violent, which generation is better, how guns are bad, etc... but ultimately it starts with the parents at home. With over 50% of kids growing up in single parent families what leads to the center of the problem is clear to me.

    Is it the video games or is it a coincidence that the divorce rate and teenage pregnancy was on the rise at the same time more or less? Also, the fact that more parents are reluctant to let their kids play outside unsupervised for fear of never seeing them again with all the disappearing children on the increase. Young kids coming home to empty houses due to parent/parents working.

    Is crime on the rise or is it now with advanced technology in place how we are able to hear about every gruesome crime at the exact time it happens just by turning on the TV, radio, or computer? 50 years ago unless we were related to the family members or in the state we wouldn't have heard of nearly any of the stuff we do today.

    It isn't just this generation or the other but all generations had parents trying to act like friends to their kids instead of actual parents. I believe it started witht the increasing divorce rate. Everyone has their opinions and everyone has their own particular soapbox but that doesn't make the next persons any less important. It starts in the home with the aid and access to education of mental health for everyone, including kids (right along with drug and alcohol education), and taking responsibility for each one's children.

    With over 70% of all gun deaths attributed to suicide (InfirmiereJolie) that is very telling. It tells me that gun control isn't the issue; the issue is mental health and home life. You know if they didn't have a gun they would have more then likely killed themselves in another way. Mental health has always taken a back seat to most things, it's time to bring it to the front of the room. When listening to the POTUS promoting his health care bill, I never heard him speak about mental health.

    It's time.
    I agree with a lot of points in your post. However, in this day and age most parents DO have to work to even make ends meet in today's society. And parents divorce. It is not ideal, but certainly the time of "staying married for the kids" is not always the best choice. There are many, many single parents who raise successful and well adjusted kids. There are many parents who divorce due to the pressure of raising a child with profound difficulties. Hence why the more support we can give the better. Single parents with readily available resources or divorced parents with resources will net better results. Back in the day when Moms stayed home and Dads worked sometimes 2 jobs, and it is akin to being a single parent. And as noted in a previous post, parents need to know that they can take control of their children, and that is what is sorely lacking.


Top