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However menstruation uti sarafem 20 mg buy with amex, sexual dysfunction is very complex and multi factorial and of course a surgical procedure to repair vaginal support and reduce the vaginal caliber will not reverse or change psychological or psychosocial sexual dysfunction arising from previous abuse, primary anorgasmia, relationship issues, depression, or other more complex psychological dysfunction. In addition to a medical and psychosocial history, an adequate urogynecological history and physical examination must be completed. Since sexual dysfunction related to a sense of a relaxed or loose vagina may be the first sign of the beginning stages of pelvic floor dysfunction and prolapse, an adequate history must be taken. It is vitally important to 94 Female genital plastic and cosmetic surgery prechildbirth state from the introitus all the way up to the apex. No "dropoffs," "dips," "ridges," or depressions should be felt, and there should be no tension placed on the levators, which causes lateral banding of the vagina. Additionally, the cosmetic appearance of the introitus and perineal body should also be taken into account and requires an intricate dissection and repair to not only restore function of the introitus but also obtain an appearance that the woman wants. That look is of the vaginal opening being closed, not gaping or wide open with a normal length perineal body that does not bulge out following the repair. This look is sometimes difficult to obtain without making the introitus too tight, which will cause pain with intercourse. If significant symptoms of urogynecologic pathology are present, these must be evaluated preoperatively so that they can be addressed properly during surgery. The foundation of the pelvic floor support must be intact prior to any technique that will tighten the caliber of the vagina or introitus. This is what determines what surgery will need to be undertaken as the prolapse must be corrected first, prior to any rejuvenation procedures being completed, and is really the first step in an overall repair or "rejuvenation" of the vagina and pelvic floor. If significant uterine/vault prolapse and/or anterior compartment (cystocele) defects are encountered, these typically should be repaired abdominally/laparoscopically/robotically or vaginally prior to addressing the posterior compartment and the caliber of the vagina. In a woman with a mild cystocele or mild relaxation of the anterior vaginal wall, a small anterior colporrhaphy can be completed to take care of this prior to repair of the posterior wall. However, one needs to be very careful with this, as if the repair of the anterior wall is too aggressive, it will lead to lateral banding and constriction of the vagina, before reconstruction of the posterior wall is even started. The dissection of the vaginal epithelium may be completed using laser, as championed by Dr. Red Alinsod and Michael Goodman) or completed utilizing more standard techniques with sharp scissors or electrocautery.
The homozygous state for mutations associated with complete loss of enzymatic activity is lethal women's health clinic parramatta cheap sarafem 20 mg fast delivery. The inhibitor has been identified as uroporpho methene, an aberrant oxidative product of the normal substrate of the enzyme uroporphyrinogen. It is thought that the iron functions as an oxidant, facilitating the formation of the uroporphomethene inhibitor. Second, many cases will show evidence of liver dysfunction, commonly due to alcohol or hepatitis C viral infection. It has been suggested that common factors may be downregulation of hepcidin, leading to iron overload, and increased oxidative stress, with these two factors potentiating the inhibitory mechanism. In some cases, iron loading has been shown to relate directly to the inheri tance of mutations in genes responsible for iron regulation. Disease therefore results from a combination of an inherited mutation and environmental factors that result in inhibition of the remaining functional enzyme. Erythropoietic Protoporphyria this is the most recent form of porphyria to be identified. These are therefore gainoffunction mutations that result in an increased flux of porphyrins through the erythroid heme biosynthetic pathway. Both ferrochelatase and iron availability become rate limiting, such that large amounts of protoporphyrin cannot be further metabolized to heme but are diverted to the plasma. Transmission is as expected of an Xlinked disorder, one manifestation of which is the absence of father to son transmission. Somatic Mutations Very rarely, nongermline tissuespecific mutations may result in manifest porphyria. Molecular analysis demonstrates the presence of an inherited mutation on one allele resulting in reduced enzymatic activity. A small proportion will be found to be homozygous, resulting in sufficiently reduced ferrochelatase activity for the disease to become clinically manifested. The summative effect of the familyspecific mutation and lowexpression allele is sufficient to reduce ferrochelatase activities to a level below approximately 35%, at which stage the clinical syndrome may develop. Thus, the prevalence is much higher than would typically be expected of an autosomal recessive In those porphyrias associated with skin disease, porphyrins are found in high concentrations in plasma, skin, and blister fluid. Stimulation by light results in an excitation of the porphyrin molecules, the promotion of electrons to a higher energy state, and the production of singlet oxygen. Relaxation to the ground state is accompanied by loss of energy manifesting as a radiation of red light. In the skin, this energy may be trans ferred to biologic molecules, resulting in oxidation of membrane lipids, poly peptides, and nucleic acids, thus accounting for the skin disease. The most potent wavelengths for porphyrin excitation lie within the ultraviolet spec trum, in the Soret band between 400 and 410 nm. Four additional absorption bands are present in the range of 500 to 700 nm; thus even visible light, against which most sunscreens are ineffective, is harmful to the skin in sub jects with a cutaneous porphyria. Pathologic examination will reveal epidermal bullae, duplication of base ment membranes, and deposition of hyaline material, which appears to be associated with fibrin, immunoglobulins, and complement in and around the blood vessels of the dermis, suggesting that these vessels may be the principal target for lightinduced injury.
Syndromes
The common venous edge bleeders in the inferior portion of the labia minora usually are controlled with skin sutures menstrual cycle age 7 sarafem 10 mg buy mastercard, locking where necessary Conservative trimming: the most common complication [of linear sculpting] is unintentionally taking too much if not completely removing a labum minus. This occurs because often the attachment of the labia minora laterally (inter labial fold) is far shorter than may be imagined viewing the labum from only the mucosal aspect. Also, less skilled surgeons may pull on the labia (which in some cases are very elastic), thus further distorting the anatomy. The waveform is different, but the concept is not at all dissimilar to that of the use of lightwave energy in laser applications. Like laser, very little heat is produced at its acutely finetipped edge, with negligible dispersal into tissue. This is a "touch" instrument with cutting produced via touch of the wire tip with the tissue, providing cutting with minimal heat conduction. Take great care to not put the labum on stretch when drawing lines, remember to curve the line, leaving perhaps more tissue in situ at the cephalad portion of the incision line than your eyes may tell you. Labia are marked for linear resection; hood hypertrophy will be separately diminished via the use of bilateral elliptical excisions. Clitoral hoods "flow down" into the labia in ways varying from individual to individual, and from side to side in the same woman. When the labum "flows" directly from one fold only, be it from the lateral aspect of the clitoral hood, frenulum, or prepucial fold, the procedure is straightforward, and the sculpted excisional line proceeds directly, encompassing the labum and hood fold, beveling at both cephalad and caudad portions, taking care to not remove excessive epithelium, especially at the posterior commissure, and to stray no closer than 1 cm from the clitoral glans or immediate central hood. Difficulty, however, will be encountered when, as it frequently does, the labia contain components from various portions of the hood, with different insertions and dissymmetry bilaterally. If removal of noncontinuous hood folds is aesthetically appropriate, this may be accomplished with the use of ellipticalshaped separate excisions, taking care to leave at least 5 mm (the more the better) between incision lines, avoiding any "Ting" or lines, with resultant increased risk of wound separation at the junction. Either a Zplasty (rarely used) or an upwards oriented "hockeystick" curvature is utilized laterally to take up redundancy and prevent a "dogear. Individual women have vastly different anatomy, and in no area is this more evident than in their vulvar structures, where appearance may radically differ from both person to person, and from side to side in the same individual. Thus, it is helpful for the genital plastic/cosmetic surgeon to have alternate surgical techniques at his/her disposal to better manage disparate anatomy. While it is impossible for a textbook to instruct the student on procedural choice for an individual surgical candidate, suffice it to state that wedge procedures fit nicely into the armamentarium of the genital surgeon, managing certain 66 Female genital plastic and cosmetic surgery the early postoperative period than a Vwedge, which is on greater tension and exhibits a greater risk of wound disruption when confronted with inappropriate early recovery activities. Not infrequently, my patient will hold a mirror and observe this portion of her procedure. Through years of trial and error, the author does the following: (a) Injection solution: 0.
The administered protein dose should be adjusted downward as a function of the degree and tempo of azotemia (in the absence of dialysis therapy) and hyperbilirubinemia (see Table 217-3) women's health clinic elmendorf afb cheap 20 mg sarafem overnight delivery. This strategy takes into account the relative inability of catabolic patients to efficiently use exogenous nutrients and the knowledge that most protein and lean tissue repletion occurs in a period of several weeks to months during post-hospital convalescence. Parenteral nutrition solutions for peripheral or central vein administration provide known essential L-amino acids combined with several nonessential amino acids. Limited data from randomized controlled trials on optimal protein/amino acid dosing in hospitalized patients are available. The nonprotein calorie-to-nitrogen ratio used in most centers now typically ranges from 75: 1 to 125: 1 (nitrogen = protein/6. Special supplements designed for patients with chronic renal failure featuring concentrated calories and low amounts of protein and electrolytes are available, as are a variety of formulations designed for other specific disease categories (see later). Several studies show that convalescence is enhanced with addition of one or two cans per day of complete liquid nutrient supplements to meals after stresses such as total hip replacement and gastrointestinal surgery. These provide calories, carbohydrate, high-quality protein, fat, and micronutrients; they are lactose and gluten free and may contain small peptides and mediumchain triglycerides to facilitate amino acid and fat absorption, respectively. For patients who can tolerate oral medications, it is probably prudent to prescribe a potent oral multivitamin-mineral preparation, at least for several months, especially for those who either exhibit or are at risk for micronutrient depletion (see E-Table 217-1 and Table 217-2). A5, Administration of Parenteral Nutrition Administration of Enteral Tube Feeding Patients with conditions outlined in Table 217-4 may have a functional gastrointestinal tract but may be unable to consume an adequate diet orally because of medical or surgical conditions. These solutions are most useful in stable patients who can tolerate the large fluid volumes required to meet amino acid and energy goals (usually 2. This has led to the approval and clinical availability of intravenous fish oil, olive oil/soybean oil, medium-chain triglyceride/soybean oil, and combinations of these formulations in Europe and other non-U. Dose of amino acids is adjusted downward or upward to goal as a function of the degree of azotemia or hyperbilirubinemia in patients with renal and hepatic failure, respectively. It is important to monitor blood triglyceride levels at baseline and then approximately weekly and as indicated to assess clearance of intravenous fat. Triglyceride levels should be maintained below 400 mg/ dL to decrease the risk of pancreatitis or diminished pulmonary diffusion capacity in patients with severe chronic obstructive lung disease. The higher concentrations of dextrose and amino acids possible allow most patients to achieve calorie and amino acid goals with only 1 to 1. These percentages are adjusted as indicated on the basis of blood glucose and triglyceride levels, respectively.
Furthermore sexual function scores were found to be reduced in those women having surgery involving the Gspot area breast cancer jobs cheap sarafem 20 mg on-line. The evidence from these two studies from one Egyptian institution would appear to give some support to the Gspot being an anatomical structure, although these findings have not been reproduced by other studies. Conclusion Gspot amplification If the Gspot does exist, then, theoretically, augmenting the size of the Gspot may lead to more friction during intercourse and this may possibly lead to increased sexual satisfaction. It is described as an officebased procedure where a bioengineered human high molecular weight hyaluraonic acid is injected in the area of the Gspot as localized by the patient in order to augment sensation during intercourse. The published evidence regarding the existence of the Gspot remains highly divisive and controversial. While twin studies have shown no evidence of a genetic influence some anatomical studies have reported the presence of structures within the anterior wall that con sist of contractile tissue and have dense innervation. There is also some clinical evidence, although limited, to support these findings. Conversely, however, imaging studies have suggested that it is perhaps the proximity of the clitoris to the anterior vaginal wall and urethra that is responsible for this localised area of increased sensitivity. While the concept of the Gspot remains an intellec tual enigma it also has significant commercial signifi cance attached to it, and augmentation of sexual response by using Gspot amplification techniques is becoming the Gspot more common despite a lack of evidence regarding safety and efficacy. Consequently there is currently a pressing need to validate anatomical and physiological studies so the controversy regarding the existence of the Gspot may be finally settled without exposing more women to unproven and potentially harmful treatments. Genetic and environmental influences on self reported G spots in women; a twin study. Reality of the G spot and its relation to female circumcision and vaginal surgery. New findings and concepts about the G spot in normal and absent vagina: Precautions possibly needed for preservation of the G spot and sexuality during surgery. Preoperative patient choice and preparation, choice of specific procedure, suture material, choice of anesthesia, and meticulous surgical technique are important, but all is for naught if the surgeon is not aware of/does not instruct his/her patient in appropriate postoperative care or if the patient fails to follow instructions or is not a good candidate for elective vulvovaginal aesthetic surgery. This cannot be stressed enough: careful, clear postop instructions from the physician and/or patient care coordinator and reemphasis to be certain your patient fully understands the instructions and the importance of following them are imperative. Outcome is proportional to cautious postop care on the part of your properly chosen patient. If she has a history of recurrent herpes genitalis, have you prescribed perioperative prophylaxis Both general postoperative protocol and "tailoring" for her individual situation and procedure should be discussed on at least two occasions, the first well prior to the date of surgery, and again inoffice prior to her procedure, and clear written instructions should be given at these times. Preoperative preparation for postoperative care Postoperative care must be discussed with your patient at a visit well prior to her surgical date. Patients with more involved incisions and for Vwedge modifications should be Female Genital Plastic and Cosmetic Surgery, First Edition.
It begins many years after the original measles infection with insidious intellectual deterioration menopause 34 years old sarafem 20 mg buy visa, apathy, myoclonic jerks, rigidity and dementia. Tetanus is caused by the Gram-positive bacillus Clostridium tetani, a commensal of human and animal guts and found in the soil. The bacterium secretes an exotoxin that causes trismus (painless masseter spasm) and contraction of the muscles of the face, neck and trunk. Squamous cell carcinomas differ from keratoacanthomas in that they grow slowly, there is no central core and they gradually ulcerate. Predisposing factors for their development include X-ray exposure, smoking, human papillomavirus and a genetic susceptibility. Management is by surgical excision, with lymph node dissection or radiotherapy if there is evidence of spread. It is most common in white people living near the equator, and is twice as common in women. Risk factors include repeated ultraviolet exposure, previous malignant melanoma, multiple melanocytic naevi and having a large congenital naevus. Superficial spreading malignant melanoma is the most common type of malignant melanoma. Lentigo maligna is associated with malignant transformation to melanoma (lentigo maligna melanoma). Thickening, darkening or ulceration within a lentigo maligna signals the onset of malignancy. Lentigo, from Latin lentigo = lentil; the word was originally used to describe freckles. Other forms of malignant melanoma include nodular, acral lentiginous and amelanotic types. Nodular melanomas present as thick, protruding, smooth, sharply defined lesions that grow in a vertical direction and may bleed and ulcerate.
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Other statins were prescribed menstruation at age 8 sarafem 10 mg order overnight delivery, and all were associated with increased muscle cramping, especially noticed at night. He has now been off statins for a month and currently complains of muscle pain, constipation, and recent weight gain of about 10 pounds that he attributes to physical inactivity due to muscle pain. His examination is notable for a blood pressure of 142/94 mm Hg with two antihypertensives, pulse of 58, periorbital edema, no evidence of heart failure, mild diffuse muscle tenderness without fasciculations, and trace lower extremity edema. Assessment of renal and thyroid function Answer: D this patient has hypothyroidism. He does not have rhabdomyolysis, which is associated with extreme elevations of muscle enzymes, severe muscle pain, dark urine, and renal dysfunction. Ezetimibe might be a useful adjunct, but its use does not address his muscle symptoms. The current level of creatine kinase elevation is modest, but it is prudent to assess renal function because this patient may have had greater degrees of muscle dysfunction while taking statins. In this patient, thyroid-stimulating hormone was elevated and free thyroxine was decreased, consistent with primary hypothyroidism. This condition is common, increases the risk for statin-induced myopathy, and causes myopathy independent of statins. Once thyroid status is corrected with thyroid hormone, statin therapy, reintroduced cautiously, can be well tolerated. A 56-year-old woman with type 2 diabetes presents to your office for routine care. She is postmenopausal and has intermittent vasomotor symptoms but does not wish to take estrogens because of concerns about side effects. She smoked less than a pack of cigarettes a day in her 20s but quit more than 20 years ago. Begin insulin therapy with a goal of lowering the hemoglobin A1c to a nearly normal level. Institute an aggressive program of weight loss through diet and exercise to decrease the risk of cardiovascular disease. Begin nutritional supplements including chromium, antioxidant vitamins, and low-dose fish oils. Answer: A Even if lipid levels are initially fairly low, patients at risk for coronary disease, like this woman with diabetes, benefit from statin treatment. Aggressive attempts to improve glycemia in this population of patients do not clearly provide benefit and may cause harm.
Romanes summarized his studies in a monograph in 1885 menstruation quotes order sarafem 10 mg online, which included these extraordinary conclusions. For these researches have shown that Support Builds for Networks 61 the nerve-fibres which so thickly overspread the muscular sheet of Aurelia do not constitute a true plexus, but that each fibre is comparatively short and nowhere joins with any of the other fibres; that is to say, although the constituent fibres of the network cross and recross one another in all directions-sometimes, indeed, twisting round one another like the strands of a rope-they can never be actually seen to join, but remain anatomically insulated throughout their length [ed. So that the simile by which I have represented this nervous network-the simile, namely, of a sheet of muslin overspreading the whole of the muscular sheet-is, as a simile, even more accurate than has hitherto appeared; for just as in a piece of muslin the constituent threads, although frequently meeting one another, never actually coalesce, so in the nervous network of Aurelia, the constituent fibres, although frequently in contact, never actually unite [ed. There can scarcely be any doubt that some influence is communicated from a stimulated fibre a to the adjacent fibre b at the point where these fibres come into close apposition. But what the nature of the process may be whereby a disturbance in the excitable protoplasm of a sets up a sympathetic disturbance in the anatomically separate protoplasm of b, supposing it to be really such- this is a question concerning which it would as yet be premature to speculate. But I think it may be well for physiologists to keep awake to the fact that a process of this kind probably takes place in the case of these nerve-fibres. For it thus becomes a possibility which ought not to be overlooked, that in the fibres of the spinal cord, and in ganglia generally, where histologists have hitherto been unable to trace any anatomical or structural continuity between cells and fibres, which must nevertheless be supposed to possess physiological or functional continuity-it thus becomes a possibility that in these cases no such anatomical continuity exists, but that the physiological continuity is maintained by some such process of physiological induction as probably takes place among the nerve-fibres of Aurelia. Subsequent observers (Bullock and Horridge, 1965; Satterlie, 2002; Anctil, 2014) have commented on the remarkable prescience of these suggestions, whose basic insights remain true today. But it had practically no impact on mainstream studies leading up to the neuron doctrine. The schism was forming between medical science concerned with human function and disease, and zoology based on comparative structure and function and evolution. Whether humans were descended from apes may have been a question debated in the popular press, but for the classical histologists the importance of studies of invertebrate cells was limited to their relevance to nerve cells and their interconnections. As a result, they ignored the possible significance of nerve cells in primitive organisms for the evolution of nervous systems. Support Builds for Networks 63 7 the Nerve Cell Studies of Freud Although Gerlach gave a new level of credibility to the reticular idea, there were many microscopists in the 1870s who were relatively unswayed by such theoretical considerations and simply pushed forward in the attempt to see more clearly the nerve cell and its relation to nerve fibers. His neuroanatomical work early in his career is of particular interest because of the claim by several of his biographers that it led him to the brink of the neuron doctrine (Brun, 1936; Jelliffe, 1937; Jones, 1953). These studies are also of interest because they were the first step in the scientific career pursued by Freud before he began the work that led to his theories of psychoanalysis. We will briefly review the aspects of his early work that directly concern the structure and organization of nerve cells (see Jelliffe, 1937; Bernfeld, 1944; 1947; 1950; 1951 Jones, 1953; Amacher, 1965), and end with a brief consideration of his desperate attempt at a synthesis. The family moved to Vienna in 1860, where Freud grew up in rather straitened circumstances. Being Jewish, of a nonacademic family, and impecunious were considerable obstacles to an academic career in nineteenth-century Europe.
An oculomotor nerve palsy will therefore result in unopposed action of the lateral rectus and superior oblique (the eye looks down and out) menstruation joint pain cheap sarafem 20 mg buy, ptosis (drooping of the eyelid) and mydriasis (dilated pupil). Because the trochlear nerve supplies the superior oblique, which moves the eye down and out, trochlear nerve palsy will result in vertical diplopia (double vision when looking down). Each optic tract contains fibres from the ipsilateral temporal retina (supplying the ipsilateral nasal visual field) and the contralateral nasal retina (supplying the contralateral temporal visual field). A lesion of the optic tract will therefore cause blindness in the contralateral half of the visual field in each eye. In other words, a lesion of the left optic tract results in blindness in the right side of the visual field in both eyes (and vice versa). Whereas lesions in the optic tract cause a contralateral homonymous hemianopia (see above), a lesion in the temporal lobe will result in a contralateral homonymous upper quadrantopia (loss of the upper quarter of the visual field on the same side in both eyes). Similarly, parietal lobe lesions cause a contralateral homonymous lower quadrantopia. Occipital lobe lesions result in a homonymous hemianopia, often with macular sparing. It usually begins with a small red pustule that gradually increases in size and ulcerates over time. The treatment of pyoderma gangrenosum requires management of the underlying condition and the use of topical or systemic steroids. In more severe disease, immune system modulators such as azathioprine or sulfasalazine may be indicated. It usually presents with a number of raised, painful, reddish-purple lesions on the shins. Other signs of iron-deficiency anaemia include koilonychia (spoon-shaped nails), palmar crease pallor, conjunctival pallor and tachycardia. It is usually found on the extensor surfaces of the elbows and knees, but can also be found on the back, buttocks and forehead.
Surgery must be carried out under - and -blockade to protect against the potential release of large amounts of catecholamines into the circulation that can occur when the tumour is manipulated menstruation judaism generic 10 mg sarafem. The aorta is locally narrowed, causing proximal hypertension, reduced or absent femoral pulses, radiofemoral delay and an interscapular systolic murmur. In most cases, the lesion is distal to the origin of the left subclavian artery, so the blood pressure is equal in both arms. If the coarctation occurs between the origins of the right and left subclavian arteries, radioradial delay will be present on examination. Pharmacological treatment of hypertension is essential, but curative vascular surgery is often required, although hypertension may not resolve if the kidney has been irreversibly damaged. In early adulthood, the patient develops multiple large cysts, predominantly in the kidneys but also in the liver, pancreas and spleen. Adult polycystic disease is also associated with berry aneurysms in the circle of Willis, which may rupture causing a potentially fatal subarachnoid haemorrhage. On examination, the patient is hypertensive and usually has palpable cystic kidneys with or without hepatosplenomegaly. The management of adult polycystic disease includes treating the hypertension and providing renal replacement therapy such as peritoneal dialysis, haemodialysis and eventually renal transplantation. Over the past couple of years, he has suffered from repeated chest infections, and his mother is worried that he is not putting on any weight. On examination, there are coarse crepitations throughout both lung lobes and his fingers are clubbed. A 67-year-old man complains of a long history of shortness of breath on exertion and a productive cough. He has been coughing up sputum for the last 4 months, but has had symptoms on and off for a few years. He has lost a stone in weight over the last month and has been having night sweats. A 67-year-old man presents with a 3-week history of a cough productive of bloodstained sputum. Auscultation of the lungs is unremarkable, and a chest X-ray shows a 2 cm density in the left lower lobe. A 58-year-old man complains of left-sided chest discomfort that has been progressing over the last fortnight. On examination, the left lower lobe is dull to percussion, and a chest X-ray confirms a left-sided pleural effusion. Common peroneal nerve Femoral nerve Lateral femoral cutaneous nerve Lateral plantar nerve Medial plantar nerve Obturator nerve Sciatic nerve Saphenous nerve Sural nerve Tibial nerve For each of the following scenarios, select the most likely nerve lesion. A 25-year-old man is taken to theatre after fracturing his hip in a motorbike accident.
Tizgar, 24 years: To overcome this, he set about in the early 1880s to collect his main studies of nerve cells and have them translated into a widely used language. In addition, imaging studies have been unable to demonstrate a unique entity, other than the clitoris, whose direct stimulation leads to a vaginal orgasm.
Quadir, 48 years: Tennis elbow is inflammation at the insertion of the tendon into the lateral epicondyle of the elbow. Compared to orgasms that you have had in the past, how intense are the orgasms you have had in the past 6 months
Tempeck, 57 years: The patient also has a partial upper airway obstruction, indicated by the snoring respiratory noises. Although this introduces increased amounts of metallic deposit that can obscure the image, it has the double advantage of revealing better the finest processes, and of permitting the use of thicker sections, thereby enabling one "to follow a nervous conductor from its origin to its termination" (Cajal, 1989).
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