By L. Koraz. Molloy College.
Limiting sarcolemmal Na+ entry attenuated increases in cytosolic Na+ and mitochondrial Ca2+ overload during chest compression and the postresuscitation phase discount ashwagandha 60caps free shipping. After this interval buy 60 caps ashwagandha with amex, extracorporeal circulation was started and systemic (extracorporeal) blood Àow adjusted to maintain a coronary perfusion pressure at 10 mmHg for 10min before attempting de¿bril- lation and restoration of spontaneous circulation. The target coronary perfusion pressure was chosen to mimic the low coronary perfusion pressure generated by closed-chest resus- citation. Instead, myocardial tissue measurements indicated that zoniporide administration prevented progressive loss of oxidative phosphorylation during the interval of simulated resuscitation. All these ¿ndings are indicative of preserved mitochondrial bioenergetic function. However, several studies have recently shown that erythropoietin also activates potent cell survival mechanisms during ischaemia and reperfusion through genomic and nongenomic signalling pathways in a broad array of organs and tissues, including the heart [58–63], brain [64, 65], spinal cord , retina , kidney , liver  and skin . Although important in other settings, these effects are not likely to play a role for initial cardiac resuscitation. The depth of compression was adjusted to maintain an aortic diastolic pressure between 26 and 28 mmHg. This level of 14 Physiopathology and Severity of Postresuscitation Myocardial Dysfunction 171 diastolic aortic pressure secured a coronary perfusion pressure above the resuscitability threshold of 20 mmHg in rats. This difference represented a 25% improvement in the haemodynamic ef¿cacy of chest compression with erythropoietin given at the beginning of chest compression. However, the protocol was modi¿ed such that the chest was compressed to the maximum depth of 17 mm in rats. Beta-epoetin was kept refrigerated (2–8°C) in the ambulance until immediately before use. However, disrup- tion in the supply of erythropoietin prompted investigators to administer erythropoietin or 0. Post hoc, a second control group was included in which 48 of 126 patients were selected who had out-of-hospital cardiac arrest treated with the same resuscitation protocol the year before. These 48 patients were selected using propensity scores assigning two controls for each erythropoietin-treated patient. Future effort should focus on the translation of these concepts through additional clinical trials that could not only support these ¿ndings but also quantitate their treatment effects paving the way for ultimately clinical implementation. Binak K, Harmanci N, Sirmaci N (1967) Oxygen extraction rate of the myocardium at rest and on exercise in various conditions. Br Heart J 29:422–427 14 Physiopathology and Severity of Postresuscitation Myocardial Dysfunction 173 2. Yusa T, Obara S (1981) Myocardial oxygen extraction rate under general anesthe- sia. Continuous cardiac magnetic resonance imaging during untreated ventricular ¿bril- lation. Ruiz-Bailen M, Aguayo dH, Ruiz-Navarro S et al (2005) Reversible myocardial dysfunction after cardiopulmonary resuscitation. Xu T, Tang W, Ristagno G et al (2008) Postresuscitation myocardial diastolic dys- function following prolonged ventricular ¿brillation and cardiopulmonary resusci- tation. Grmec S, Strnad M, Kupnik D et al (2009) Erythropoietin facilitates the return of spontaneous circulation and survival in victims of out-of-hospital cardiac arrest. Karmazyn M, Sawyer M, Fliegel L (2005) The na(+)/h(+) exchanger: a target for cardiac therapeutic intervention. Imahashi K, Kusuoka H, Hashimoto K et al (1999) Intracellular sodium accumu- lation during ischemia as the substrate for reperfusion injury. Hinokiyama K, Hatori N, Ochi M et al (2003) Myocardial protective effect of lido- caine during experimental off-pump coronary artery bypass grafting. Namiuchi S, Kagaya Y, Ohta J et al (2005) High serum erythropoietin level is as- sociated with smaller infarct size in patients with acute myocardial infarction who undergo successful primary percutaneous coronary intervention. Ghezzi P, Brines M (2004) Erythropoietin as an antiapoptotic, tissue-protective cy- tokine. Celik M, Gokmen N, Erbayraktar S et al (2002) Erythropoietin prevents motor neu- ron apoptosis and neurologic disability in experimental spinal cord ischemic injury. Buemi M, Vaccaro M, Sturiale A et al (2002) Recombinant human erythropoietin inÀuences revascularization and healing in a rat model of random ischaemic Àaps. Li Y, Takemura G, Okada H et al (2006) Reduction of inÀammatory cytokine ex- pression and oxidative damage by erythropoietin in chronic heart failure. Cardio- 14 Physiopathology and Severity of Postresuscitation Myocardial Dysfunction 177 vasc Res 71:684–694 73. Hirata A, Minamino T, Asanuma H et al (2006) Erythropoietin enhances neovascu- larization of ischemic myocardium and improves left ventricular dysfunction after myocardial infarction in dogs. In the United States, every year approximately 300,000 individuals suffer an episode of out-of-hospital sudden cardiac arrest . Efforts to reestablish life are formidably challenging, requiring not only that cardiac activity be reestablished but that injury to vital organs be prevented, minimised, or reversed. Resus- citation methods yield an average survival and hospital discharge rate with intact neuro- logical function that approaches 7.
When wholly exposed order ashwagandha 60 caps without a prescription, the fossil corresponded with his dream and his drawing order 60 caps ashwagandha with amex, and he suc- ceeded in classifying it with ease. There must be some grounds, some justification, some reason for deciding that the old picture of self is in error, and that a new picture is appropriate. You cannot merely imagine a new self-image; unless you feel that it is based upon truth. Experience has shown that when a per- son does change his self-image, he has the feeling that for one reason or another, he "sees," or realizes the truth about himself. The truth in this chapter can set you free of an old in- adequate self-image, if you read it often, think intently about the implications, and "hammer home" its truths to yourself. Science has now confirmed what philosophers, mystics, and other intuitive people have long declared: every human being has been literally "engineered for success" by his Creator. Study it and digest it Look for ex- amples in your experiences, and the experiences of your friends, which illustrate the creative mechanism in action. You do not need to be an electronic engineer, or a physicist, to operate your own servo-mechanism, any more than you have to be able to engineer an automobile in order to drive one, or become an electrical engineer in order to turn on the light in your room. You do need to be familiar with the following, however, because having memorized them, they will throw "new light" on what is to follow: 1. It operates by either (1) steering you to a goal already in existence or by (2) "discovering" some- thing already in existence. The automatic mechanism is teleological, that is, oper- ates, or must be oriented to "end results," goals. It is the function of the automatic mechanism to supply the "means whereby" when you supply the goal. Think in terms of the end result, and the means whereby will often take care of themselves. All servo-mechanisms achieve a goal by nega- tive feedback, or by going forward, making mistakes, and immediately correcting course. Skill learning of any kind is accomplished by trial and error, mentally correcting aim after an error, until a "successful" motion, movement or performance has been achieved. You must learn to trust your creative mechanism to do its work and not "jam it" by becoming too concerned or too anxious as to whether it will work or not, or by attempting to force it by too much conscious effort. This trust is necessary because your creative mecha- nism operates below the level of consciousness, and you cannot "know" what is going on beneath the surface. It comes into operation as you act and as you place a demand upon it by your actions. You must not wait to act until you have proof—you must act as if it is there, and it will come through. A particularly memorable instance of this fact con- cerned a patient who was literally forced to visit my office by his family. He was a man of about 40, unmarried, who held down a routine job during the day and kept himself in his room when the work day was over, never going any- where, never doing anything. He had had many jobs and never seemed able to stay with any of them for any great length of time. His problem was that he had a rather large nose and ears that protruded a little more than is normal. The poor man even imag- ined that Ms family was "ashamed" of him because he was "peculiar looking," not like "other people. His nose was of the "classical Roman" type, and his ears, though somewhat large, attracted no more attention than those of thousands of people with similar ears. His imagination had set up an automatic, negative, failure mechanism within him and it was operating full blast, to his extreme misfortune. Fortunately, after several sessions with him, and with the help of his family, he was able gradually to realize that the power of his own imagination was responsible for his plight, and he succeeded in build- ing up a true self-image and achieving the confidence he needed by applying creative imagination rather than de- structive imagination. We act, or fail to act, not because of "will," as is so commonly be- lieved, but because of imagination. A human being always acts and feels and performs in accordance with what he imagines to be true about him- self and his environment. When we see this law of mind graphically and dramati- cally demonstrated in a hypnotized subject, we are prone to think that there is something occult or supra-normal at work. Actually, what we are witnessing is the normal operating processes of the human brain and nervous system. For example, if a good hypnotic subject is told that he is at the North Pole he will not only shiver and appear to be cold, his body will react just as if he were cold and goose pimples will develop. Tell a hypnotized sub- ject that your finger is a red hot poker and he will not only grimace with pain at your touch, but his cardiovas- cular and lymphatic systems will react just as if your finger were a red hot poker and produce inflammation and perhaps a blister on the skin. When college students, wide awake, have been told to imagine that a spot on their fore- heads was hot, temperature readings have shown an actual increase in skin temperature. Your nervous system cannot tell the difference between an imagined experience and a "real" experience. In either case, it reacts automatically to information which you give to it from your forebrain.
One of the key ways the body works to neutralize excessive acid in the blood is by taking calcium from bone cheap ashwagandha 60 caps free shipping. Alkalinizing the diet decreases the excretion of calcium in the urine discount ashwagandha 60 caps on-line, suggesting that less calcium is being taken from the bones. People with uric acid stones should entirely avoid foods high in purine, including organ meats, other red meats, shellﬁsh, yeast (brewer’s and baker’s), herring, sardines, mackerel, and anchovies. They should also watch their consumption of foods with moderate levels of purine, including dried legumes, spinach, asparagus, other types of fish, poultry, and mushrooms. Low-Oxalate Diet Dietary oxalate may be responsible for as much as 80% of the urine oxalate in some people with recurrent kidney stones, indicating that restricting dietary oxalate intake may have a protective action. A low-oxalate diet is usually deﬁned as one containing less than 50 mg oxalate per day, so foods that have high or moderate levels of oxalate should be avoided. Oxalate Content of Selected Foods Very high oxalate, >50 mg per serving • Vegetables Beets (greens or root) Okra Spinach Swiss chard • Fruits Figs, dried Rhubarb • Grains Buckwheat • Nuts and seeds Almonds Peanuts Peanut butter Sesame seeds High oxalate, >10 mg per serving • Vegetables Celery Collards Dandelion greens Eggplant Escarole Green beans Kale Leeks Parsley Parsnips Peppers, green Potatoes Pumpkin Squash, yellow summer Sweet potatoes Tomato sauce, canned Turnip greens Watercress • Fruits Concord grapes Kiwi Lemon peel Lime peel Orange peel • Grains Bread, whole wheat Oatmeal Popcorn Spelt Wheat bran Wheat germ Whole wheat flour • Legumes Garbanzo beans Lentils Soybeans and all soy products • Nuts and seeds Brazil nuts Hazelnuts Pecans Sunflower seeds • Miscellaneous Beer Chocolate Cocoa Soy sauce (1 tbsp) Tea, black or green Moderate oxalate, 6 to 10 mg per serving • Vegetables Asparagus Artichokes Broccoli Brussels sprouts Carrots Cucumber Garlic Lettuce Mushrooms Mustard greens Onions Pumpkin Radishes Snow peas Tomato, fresh Tomato sauce, canned (1/4 cup) • Fruits Apples Apricots Blackberries Blueberries Cherries, sour Cranberries, dried Currants, black Oranges Peaches Pears Pineapple Plums Prunes Red raspberries Tangerines • Grains Bagel (1 medium) Barley, cooked Bread, white (2 slices) Corn Corn tortilla (1 medium) Cornbread Cornmeal, yellow (1 cup dry) Cornstarch (1/4 cup) Pasta Rice, brown Spaghetti White flour • Legumes Lima beans Split peas • Nuts and seeds Cashews Flaxseed Walnuts • Herbs Basil, fresh (1 tbsp) Dill (1 tbsp) Ginger, raw, sliced (1 tsp) Malt powder (1 tbsp) Nutmeg (1 tbsp) Pepper (1 tsp) • Miscellaneous Coffee Red wine Sardines Tea, rose hip Low oxalate, 2 to 5 mg per serving • Vegetables Acorn squash Arugula Ketchup (1 tbsp) Onions Peppers, red Zucchini • Fruits Avocado Cantaloupe Cherries, sweet Cranberries Grapes Lemons Limes Raisins • Grains Rice, white Rice, wild Rye bread • Legumes Peas, green • Nuts and seeds Coconut • Herbs Cinnamon, ground (11/2 tsp) Ginger, powdered (1 tbsp) Mustard, Dijon (1/4 cup) Thyme, dried (1 tsp) • Miscellaneous Beef Chicken Corned beef Eggs Fish (haddock, plaice, and flounder) Ham Lamb Pork Turkey Venison Nutritional Supplements Vitamin C Vitamin C is often cited in the medical literature as a potential factor in the development of calcium oxalate kidney stones. However, numerous studies have now clearly demonstrated that high doses of vitamin C do not cause kidney stones. Studies have shown that vitamin C ingestion of up to 10 g per day does not have any effect on urinary oxalate levels. One trial showed that 120 mg inositol hexaphosphate signiﬁcantly reduced the formation of calcium oxalate crystals in the urine of people with a history of kidney stone formation, in only 15 days. Since dietary management is effective, relatively inexpensive, and free of side effects, it is the treatment of choice. The speciﬁc treatment is determined by the type of stone and may include reducing urinary calcium, reducing purine intake, avoiding high-oxalate foods, increasing foods high in magnesium-, and increasing foods rich in vitamin K. Note: In acute cases, surgical removal or breaking up the stone with sound waves (lithotripsy) may be necessary. For Calcium Stones Diet Follow the general recommendations given in the chapter “A Health-Promoting Diet. Increase consumption of magnesium-rich foods (barley, bran, corn, buckwheat, rye, soy, oats, brown rice, avocados, bananas, cashews, coconut, peanuts, sesame seeds, lima beans, potatoes). For Cystine Stones • Avoid methionine-rich foods (soy, wheat, dairy products, ﬁsh, meat, lima beans, garbanzo beans, mushrooms, and all nuts and seeds except coconut, hazelnuts, and sunflower seeds) • Alkalinize the urine by eating an alkaline-rich diet and taking magnesium citrate (250 mg elemental magnesium three times daily): optimal pH is 7. Degeneration of the macula is the leading cause of severe visual loss in the United States and Europe in people 55 or older, and is second to cataracts as the leading cause of decreased vision in people over 65. It is estimated that more than 150,000 Americans are legally blind from age-related macular degeneration, with 20,000 new cases occurring each year. However, decreased blood and oxygen supply to the retina is the key factor leading to macular degeneration. The patient may note that straight objects appear distorted or bent, that there is a dark spot near or around the center of the visual ﬁeld, and that, while he or she is reading, parts of words are missing. This extrusion, which can be seen with the aid of an ophthalmoscope, is referred to as drusen. The disease progresses slowly, and only central vision is lost; peripheral vision remains intact. Because the disease can rapidly progress to a point at which laser surgery cannot be used, treatment should be performed as soon as possible. These drugs can shrink the abnormal blood vessels and improve vision when injected directly into the vitreous humor of the eye. Examples of these agents include ranibizumab (Lucentis), bevacizumab (Avastin), and pegaptanib (Macugen). While a number of genetic markers have been identiﬁed, a family history may be the easiest screening method. The lifetime risk of developing late-stage macular degeneration is 50% for people who have a relative with macular degeneration, vs. Presumably this protection is the result of greater intake of antioxidant vitamins and minerals. The macula, especially its central portion, the fovea, owes its yellow color to its high concentration of lutein and zeaxanthin. These yellow carotenoids function in preventing oxidative damage to the area of the retina responsible for ﬁne vision and have a central role in protecting against the development of macular degeneration. It is important to note that beer consumption increases drusen accumulation and the risk of exudative macular disease and therefore should be avoided. Fifteen of the treated patients showed improvement in their vision by one line or more on a vision acuity chart, compared with only 6 of the control group. In addition, only 3 of the 38 in the treatment group lost one line or more of vision, compared with 13 in the control group.
The effect of direct exchange of room air into the air Housing sac and the potential for introduction of contami- nants and infectious organisms into the cannulated Many sick birds are too weak to perch purchase 60caps ashwagandha overnight delivery. Thick paper or non-woven An air sac tube allows many treatment techniques to towels can be used on the bottom of the enclosure order ashwagandha 60caps overnight delivery. Seeds, fruits and vegetables can directly into the trachea for the treatment of bact- be spread around the bird to encourage eating. The bird can be anesthe- bird is still perching, food and water containers tized through the tube for surgery or endoscopy of the should be placed next to the perches to encourage trachea or head, and the tube can be used for positive food consumption. If apnea occurs, a needle can be used in place tempted while the bird is sick, offering the bird a of a tube for providing a rapid source of oxygen. Food and water should be removed from the enclosure of A warm ambient environment is necessary for birds birds that are seizuring, obtunded or post-anesthetic that are debilitated or in shock. Floor heating elements may tained in a wire enclosure on thick cage paper or occasionally cause hyperthermia when debilitated toweling. These birds will grasp the wire siding with birds are forced to stand or lie on the enclosure floor their beak to steady themselves. Alterna- vided, they should be close to the enclosure floor to tively, heat can be provided by a hot water bottle or prevent injuries. Birds receiving supplemental heat from any source other than a commercial incubator should be carefully monitored to prevent burns. Small, heated rooms Emergency Problems that hold two to three enclosures allow birds to be treated in a temperature-stable environment, reduc- ing the stress associated with being removed from a warm incubator to a cooler treatment area. It should Cardiovascular System be noted that none of the commercially available incubators with forced air heating systems can be Bleeding and Anemia properly sterilized with any procedure that does not The emergency clinician is often presented with involve the generation of formalin gas. Ane- mia in birds may be caused by blood loss, decreased Enclosures should be equipped with thermometers to red blood cell production and increased red blood cell monitor ambient temperature. Unfeathered baby The most common cause of blood loss in birds is birds less than ten days old need an ambient tem- trauma (Figure 15. Birds in heated enclosures should be monitored hemolysis and idiopathic hemorrhage. Cloacal bleeding may be caused by cloacal papillomas, cloacitis, egg laying, or cloacal or uterine prolapse. Heavy metal toxicity can cause hemolysis, which may result in dramatic hemoglo- binuria in some birds, especially Amazon parrots. Conures may present for a sudden onset of weakness, ataxia, epistaxis, bloody regurgitation, bleeding from the oral cavity, hematochezia, hemorrhagic conjunc- tivitis or muscle petechiation. Anemias resulting from decreased red blood cell pro- duction are common in birds, possibly because of the relatively short life-span (28 to 45 days) of the avian erythrocyte. A rapidly fatal non-regenerative anemia seen in two- to four-month-old African Grey Parrots is sus- pected to be of viral etiology. If an intraosseous cannula will be nec- feather is removed from its follicle by gently placing essary for stabilizing the patient, a bone marrow opposing pressure on the structure around the sample can be obtained through the cannula at the feather base (Figure 15. It should be noted that the should not be used inside the feather follicle because volume of serum or plasma relative to the volume of the subsequent inflammation and tissue damage can whole blood will be increased due to the anemia; the cause abnormal feather regrowth, resulting in the minimum amount of blood necessary to perform the formation of feather cysts. For home first aid, the client can be advised to wash If the bird is actively bleeding on presentation, local- any blood away with hydrogen peroxide, apply corn- ization of hemorrhage and hemostasis are the first starch or flour to the bleeding area and place the bird priorities. Developing feathers are called “blood in a dark area until it can be presented to the clini- feathers” because of the rich vascular supply within cian for evaluation. When one of these feathers is broken, it rested using ferric subsulfate, silver nitrate or bipo- may continue to bleed until it is removed from its lar radiosurgery. For removal, the base of the damaged feather a red-hot item can also serve as first aid measures. Glue applied to the beak must not be allowed to run into the mouth or onto the eyelids. Damaged pin feathers can result in replacement by subcutaneous or intravenous fluids, substantial blood loss. Correctly removing the feather will allow and the administration of iron dextran and B vita- the nutrient artery to collapse and will stop the bleeding. To remove a pin feather, the base of the feather is grasped with a pair mins (see Chapter 18). The skin is and further supportive care depends on physical ex- supported by applying gentle, opposing force around the feather amination findings. Birds on an Persistent bleeding from soft tissue wounds is less all-seed diet can be assumed to be nutritionally defi- common. If such bleeding occurs, it can be controlled cient and will benefit from an injection of vitamin K1.
J Clin ventilated ashwagandha 60caps fast delivery, critically ill children during the early postinjury Invest 96:2528–2533 period order 60 caps ashwagandha with amex. Clin Nutr agreement between indirect calorimetry and prediction equa- 26:677–690 tions using the Bland-Altman method. J Ren Nutr expenditure by continuous, online indirect calorimetry in 6:203–206 Tools for the Diagnosis 10 of Renal Disease K. This will provide strong clues to scores the importance of careful attention to ongoing the etiology of presenting renal and electrolyte abnormali- fluid, electrolyte, and biochemical balance. Predisposing existing medical with objective scientific measures or tools, which can be conditions, chronic medications, and knowledge reliably used to make a diagnosis and guide therapy. Clinical history and physical examination with While some provide anatomic information, e. As such, awareness of the limitations may otherwise remain unappreciated [27, 38, 39]. Effective cir- culating volume, that portion of the body water actually perfusing the tissues and accomplishing homeostasis, 10. At the same time, urine samples urinary osmolality (>500mOsm kg−1) suggest volume can be obtained for biochemical, microscopic, and depletion and are the most common urinary assess- microbiological analysis. Serum organic acids (lactic acid, pyruvic acid), Changes in serum calcium during intensive care serum ammonia levels, and urinary amino and organic treatments demonstrate distinct response patterns for acid screening is helpful in differentiation of potential survivors vs. The magnitude of increase metabolic abnormalities, particularly in the neonatal in the serum calcium after fluid resuscitation is a period. Examples include aminoacidopathies such as marker correlating with the patient’s ability to with- maple syrup urine disease, tyrosinemia, urea cycle stand physiologic stress, especially after major trauma. Certain serum patterns of chemistries can also pro- vide clues as to underlying etiology, for example, (1) 10. In rare hyperparathyroidism, while (3) hypocalcemia, hyper- circumstances, a 24-h urine collection for creatinine 142 K. It is extremely This measures sodium excreted in the urine as a important to be sure to discard the first bladder urine at percentage of sodium filtered at the glomerulus. It time zero, measure the time accurately, and obtain the may be used in assessment of either volume status or total urine volume for optimal results. In the setting of acute kidney injury, necessary to allow for medication dosage adjustments. U /P is also helpful in dis- Osm Osm tinguishing between the various causes of acute renal These values, calculated from direct chemical meas- failure (Table 10. There are no absolute normal values and there is a By providing a ratio of tubular fluid potassium to wide range in normal expected responses depending plasma potassium corrected for water reabsorp- on dietary intake, fluid balance, and intercurrent med- tion, this tool provides an indication of adequacy of ications. It is best to compare values obtained in any tubular handling of potassium and the driving force patient with expected values under similar clinical for its excretion in the distal tubule. However, this and plasma, thus adjusting for reabsorption of water along the whole nephron. There is good evidence that this correlates well with 24- h protein excretion [29, 31]. This may be used as a surrogate for urinary ammonium and therefore, hydrogen ion excretion. It may be used to dif- or another unmeasured anion is present in the urine), ferentiate between gastrointestinal and renal bicarbo- rendering calculation of urinary ammonium concen- nate losses as a cause of metabolic acidosis (see Sect. Measurement of creatinine clearance using a timed microscopic examination of the urinary sediment. However, the positive heme test on dipstick is due to hemoglob- under certain circumstances, for instance in individu- inuria or myoglobinuria, while the presence of a signif- als with exceptional dietary intake (vegetarian or vegan icant number of red blood cells confirms hematuria. Measurement of the respective heme pigment in the urine also helps differentiate between these entities. Furthermore, technical limitations may arise when posi- Myoglobin, a small protein (16,700Da), is readily tioning for the procedure in a critically ill patient who may filtered, whereas the larger hemoglobin (approximately be intubated with multiple intravenous lines. Acutely, simply examining a sample of sedation or anesthesia, and careful control of the airway the patient’s serum can differentiate between the two must all be coordinated. Preliminary treatment with conditions: the plasma will be red in hemoglobinuria, steroids, cyclophosphamide, or plasmapheresis may be but clear in myoglobinuria. In rare patients, the most often derived from food coloring or drugs such clinical circumstances may preclude immediate biopsy, as pyridium or rifampin. Polymorphonuclear leucocytes in the urine imply Renal and bladder ultrasound is a noninvasive and inflammation from infection or interstitial nephritis. Although urinary tract such as hydronephrosis, hydroureter, or other obstruc- infection must be considered in the differential of pyu- tion.