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November 21, 2011

Condition, Disease, Disorder

Filed under: usage — amastyleinsider @ 11:00 am
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“Disease often fortifies the system against the action of remedies.”

“Disorder often fortifies the system against the action of remedies.”

Which of these sentences is correct? As it happens, the first is an actual quote (H. C. Wood, 1879)1(p445) and so in that sense is the “correct” one. However, the question remains: What are the differences, if any, between disease and disorder? For that matter, where does the often-used condition fit in? While these terms are frequently used interchangeably, differences between them do exist and can assist the person wishing to use them in more specific senses.

Condition is perhaps the least specific, often denoting states of health considered normal or healthy but nevertheless posing implications for the provision of health care (eg, pregnancy). The term might also be used to indicate grades of health (eg, a patient might be described as in stable, serious, or critical condition). While this term is often used in medical discussions to specifically indicate the presence of pathology or illness, Dorland’s Illustrated Medical Dictionary provides no definition of the term used in this sense. Merriam-Webster’s Collegiate Dictionary, however, defines condition as “a usu. defective state of health,”2(p258) and the Oxford English Dictionary similarly opines that it denotes “[a] state of health, esp. one which is poor or abnormal; a malady or sickness.”1(p309) In lay conversation condition is sometimes used euphemistically when a discreet term is desired for reference to a state of health, either well or ill—for example, delicate condition was once commonly used to refer to either pregnancy or alcoholism. Similarly, condition understood specifically to indicate the presence of pathology or illness is sometimes used as a value-neutral term when a stronger term might not be desirable. When such considerations do not come into play, a condition conferring illness can be further classified as a disease or a disorder.

“He was full of such disease. That he may nought the deth escape” (1393).1(p445)

Disease is often used in a general sense when referring to conditions affecting a physical system (eg, cardiovascular disease) or a part of the body (eg, diseases of the foot). The term also may be used in specific senses—for example, a writer might refer in general terms to neurologic disease or in specific terms to Alzheimer disease. But disease is perhaps most often used when referring to a condition that possesses specific characteristics. In this vein, Merriam-Webster’s defines disease as “a condition of the… body or one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms…”2(p358); the Oxford English Dictionary defines the word similarly but particularly stresses structural change as a cause.1(p445) Dorland’s concurs with these sources but makes clear that the impaired functioning associated with the diseased state may constitute “any deviation from or interruption of the normal structure or function…” and further elaborates that “the etiology, pathology, or prognosis may be unclear or unknown.”3(p535)

“A Fever is the first disorder that affects the Blood and Vessels” (1725).1(p449)

Compared with disease, disorder is less restrictive: Merriam-Webster’s defines it simply as “an abnormal physical or mental condition,”2(p360) a definition with which Dorland’s largely concurs.3(p555) The Oxford English Dictionary emphasizes that disorder involves a disturbance of function but again further stresses structural change, this time in negative terms, stating that disorder is “usually a weaker term than DISEASE, and not implying structural change.”1(p449) This emphasis on functional rather than structural change has been in place since at least the late 1800s, when the Lexicon of Medicine and Allied Sciences stated that disorder is “a term frequently used in medicine to imply functional disturbance, in opposition to manifest structural change.”1(p449) Because disorder, like condition, is relatively value-neutral when compared with disease, it is often used in place of the latter term when a less stigmatizing or less alarming term is desirable—eg, a clinician might at first refer to a patient’s disease as a disorder to reduce the patient’s initial anxiety; similarly, the same patient might initially refer to his or her recently diagnosed disease as a disorder in conversations with family and friends.

In short, what distinguishes condition, disease, and disorder from one another would seem to be their relative emphases on functional change, structural change, presence of signs and symptoms, and, perhaps to a lesser extent, the gravity a writer wishes to convey:

Condition simply indicates a state of health, whether well or ill; a condition conferring illness might be further classified as a disease or a disorder—however, condition might be used in place of disease or disorder when a value-neutral term is desired.
Disease denotes a condition characterized by functional impairment, structural change, and the presence of specific signs and symptoms. As an aside, Dorland’s equates the terms illness and sickness with disease; while these are often used to indicate the state or experience of disease, they are also sometimes used as value-neutral alternatives for disease.
Disorder, in contrast, denotes a condition characterized by functional impairment without structural change and, while certain disorders or categories of disorders might be accompanied by specific signs and symptoms, their presence is not required for a condition to be termed a disorder. Like condition, disorder is sometimes used as a value-neutral term in place of disease.—Phil Sefton, ELS

1. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991.
2. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA; Merriam-Webster Inc; 2003.
3. Dorland’s Illustrated Medical Dictionary. 31st ed. Philadelphia, PA: Saunders; 2007.

November 4, 2011

Cheat Sheet for Abbreviations Style

Filed under: abbreviations,usage — amastyleinsider @ 1:07 pm
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Abbreviations are a convenience, a time saver, a space saver, and a way of avoiding the possibility of misspelling words. However, a price can be paid for their use. Abbreviations are sometimes not understood. They can be misread, or are interpreted incorrectly. … The person who uses an abbreviation must take responsibility for making sure that it is properly interpreted.—Neil M. Davis1

Abbreviations are used widely in medical articles, and great care should be taken to provide expansions that define these abbreviations. The AMA Manual of Style includes a straightforward rule regarding the use of abbreviations: Define abbreviations at first mention by providing the expanded term first, followed by the abbreviation in parentheses, and the abbreviation is used thereafter.

But for every rule, there are exceptions.

Some Exceptions:

• Avoid creating abbreviations for terms that are easy to spell out and do not take up a lot of space. For example, it is not advisable to abbreviate “catheter ablation” as “CA” or “immune response” as “IR.” Also, avoid using too many abbreviations in any one article.

• If a term is better known as an abbreviation, provide the abbreviation first with the definition following in parentheses. “The TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling) staining assay was carried out using an apoptosis detection kit.”

• It is inelegant to begin sentences with abbreviations, unless the expansion is so unwieldy that using the abbreviation makes sense. The previous example, TUNEL, also works here. Rather than begin a sentence with the cumbersome expansion, it is acceptable to begin the sentence with the abbreviation TUNEL.

• Abbreviations should not be introduced in headings. If an abbreviation is being used for the first time in a heading, expand the abbreviation in the heading; then, at first mention in the running text after the heading, expand the abbreviation again, with the abbreviation following in parentheses. Use the abbreviation thereafter.

• Some very common abbreviations do not require expanding at first mention, such as AIDS, TNM, UV, and CD-ROM. A complete list of these abbreviations is provided in section 14.11, with those that do not require expansion denoted by an asterisk.

• The efficiency of using an abbreviation is lost if the abbreviation is used only one time, so as a rule of thumb, introduce an abbreviation only if it is used at least 2 or 3 times.

Items of Note:

• Tables, figures, and abstracts are treated as separate items from the text, so abbreviated terms must be reexpanded in each of these items.

• Use the appropriate article (a or an) before an abbreviation according to the sound following the article (eg, a UN resolution, an HMO plan).

• Use a lowercase s (and no apostrophe) when making abbreviations plural (eg, NSAIDs).—Lauren B. Fischer

1. Davis NM. MEDical ABBREViations: 28,000 Conveniences at the Expense of Communication and Safety. 13th ed. Warminster, PA: Neil M Davis Associates; 2007:1.

October 25, 2011

Masterful, Masterly

Filed under: editing process,usage — amastyleinsider @ 1:49 pm
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Writers are often taught that masterful and masterly mean different things and to ensure that they are used correctly. Masterful, so such thinking goes, is taken to mean “suggestive of a domineering nature,” or “inclined and [usually] competent to act as master,”1 whereas masterly is used to denote “having the power and skill of a master.”1

However, the use of masterful to mean “skillful” is now widespread; as Bernstein, clearly a proponent of maintaining the distinction, pithily puts it, “masterly is never misused; masterful often is….”2 Moreover, it seems that the distinction has not always been observed. Whereas masterful has been used in the sense of “domineering” since the 1330s,3 it also was used to mean “skillful” as early as 1613.3 And whereas masterly was used in the sense of “skillful” since the mid 1600s,3 it also was used to mean “domineering” as early as the 1530s,3 although that use has been obsolete since the late 18th century.3

In short, both words have been used to indicate “skillful” since roughly the time of King James I of England. However, the idea that writers should distinguish between them is comparatively new1—and such a late addition of a distinction is the reverse of the more common case, in which a distinction between words ceases to hold sway as the language evolves.

The origin of the distinction? Merriam-Websters posits that it was “excogitated by a 20th century pundit”1—this “pundit” apparently none other than Henry Watson Fowler, editor of The Pocket Oxford Dictionary, coeditor of The Concise Oxford Dictionary and The King’s English, and author of A Dictionary of Modern English Usage.4 In the latter work, Fowler established a distinction between masterful and masterly that was taken up by authorities such as Bernstein2 and that continues to be trumpeted to this day.5 Fowler’s reason for introducing the distinction? Masterly has only 1 sense (at least since its use to mean “domineering” became obsolete), so masterful should be limited to a single sense as well.1

However, some also have argued for the use of masterful in place of masterly in adverbial constructions, pointing out that although masterly is properly used as an adverb as well as an adjective, its use as an adverb seems awkward, even incorrect; eg, “He paints masterly.”2 Moreover, masterly, like many words ending in “y,” is what Bernstein (who nevertheless advocates distinguishing between the words) calls a “reluctant” adverb—ie, a word that resists serving as or being turned into an adverb.6 To make matters worse, masterly takes another adverbial form, the admittedly horrid masterlily.

Where does this leave the conscientious writer? Like Fowler, several modern authorities deem the distinction a valuable one5 and often advocate recasting a sentence to allow a more mellifluous use of a reluctant adverb5,6: hence, the sentence “Its wooden gables… showed how masterly they had been carved of old”3 might be recast as “Its wooden gables… showed the masterly manner in which they had been carved of old,” or similar. “A retreat of this kind,” Bernstein maintains, “is better than clumsy bravado.”6

At least one like-minded authority, however, has conceded that the battle to maintain the distinction—whatever its merits—has likely been lost.5 The prevalence of masterful in everyday usage confirms that opinion, receiving further support from the fact that the words have developed in roughly parallel fashion over time.3 Merriam-Websters concurs, maintaining that masterful used in the sense of “skillful” “has continued in reputable use all along; it cannot rationally be called an error.”1 Moreover, it has been suggested that using masterful in its original sense might even confuse readers now accustomed to the use of masterful to mean “skillful.”7

The bottom line:

● Using masterful in place of masterly to mean “skillful”? You’re in good company, and that usage has a long history. However:

● Set on maintaining a distinction between masterful and masterly? You can’t go wrong there, either. True enough, some readers might be confused by the use of masterful in its original sense—but since when do writers shrink from using words correctly to avoid confusion?—Phil Sefton, ELS

1. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003:764.

2. Masterful, masterly. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:269.

3. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:1045.

4. Sheidlower J. Elegant variation and all that. The Atlantic Online Web site. http://www.theatlantic.com/past/docs/issues/96dec/fowler/fowler.htm. December 1996. Accessed September 16, 2011.

5. Masterful, masterly. Good English Rules! Web site. http://www.goodenglishrules.com/masterful_masterly.htm. Accessed September 16, 2011.

6. Adverbs, reluctant. In: Bernstein TM. The Careful Writer: A Modern Guide to English Usage. New York, NY: Athaneum; 1985:27.

7. Masterful vs. masterly. Grammarist Web site. http://www.grammarist.com/usage/masterful-masterly/. Accessed September 16, 2011.

September 15, 2011

Jarring Jargon

Theodore M. Bernstein, in The Careful Writer: A Modern Guide to English Usage, describes jargon as “meaningless, unintelligible speech,” which is how some people might describe their last conversation with their physician. In science and medicine, many barriers to clear communication exist, with jargon being one of them. In fact, it’s so difficult for physicians and patients to communicate clearly that a federal program has been created to promote simplified health-related language nationwide. The Health Literacy Action Plan is a “national action plan to improve health literacy.” The entire action plan is 73 pages (which is probably their first mistake) and it highlights the fact that we have a problem.

As editors, we know that jargon is to be avoided in medical literature. While jargon may evolve for the most innocuous of reasons, it is a vocabulary specific to a profession that sometimes is esoteric or pretentious and that can be confusing to those not familiar with it (sometimes to those familiar with it as well). “Inside talk” can be just that by design—it keeps outsiders out. Therein lies the source of the negative feelings about jargon.

In addition to being exclusive, some jargon is offensive and unprofessional. Have you ever seen an FLK? Probably. That’d be a funny-looking kid. “We bagged her in the ER” sounds ominous; what it means is that a patient was given ventilatory assistance with a bag-valve-mask prior to intubation in the emergency department. Hopefully the emergency department physician didn’t describe the patient as a GOMER. This means “get out of my emergency room” and could refer to, for instance, an elderly patient who is demented or unconscious and near death and who perhaps should die peacefully rather than occupy emergency department resources. In this example, jargon diminishes the complexity of a situation that should be dealt with in a more thoughtful way. As Bernstein writes, “All the words that describe the kinds of specialized language that fall within this classification [of inside talk] have connotations that range from faintly to strongly disparaging.”

Jargon also sometimes violates rules of grammar, eg, turning nouns into verbs, “The doctor scoped the patient,” or creating back-formations, like “The patient’s extremities were cyanosed,” instead of “The patient’s extremities showed signs of cyanosis.” Jargon can sometimes appear to depersonalize, by defining a person in terms of a disease. A “bypassed patient” may be one who has undergone coronary artery bypass graft surgery rather than one who has been overlooked. Sometimes, patients might be referred to by their organs, such as “the lung in room 502” instead of “the patient in room 502 with lung disease.”

The AMA Manual of Style lists examples of jargon to avoid in section 11.4, Jargon. Some other examples that we’ve collected over the years are listed here:

* Collodion baby is better phrased as collodion baby phenotype or “the infant had a collodion membrane at birth.”

* Surgeons perform operations or surgical procedures, not surgeries.

* Rather than say a patient has a complaint, describe the patient’s primary concern.

* Do not use shorthand (eg, exam for examination, preemie for premature infant, prepped for prepared).

* Euphemisms sometimes are not clear and should be avoided: “The patient died” is preferred to “The patient succumbed or expired”; the same holds true for killed vs sacrificed (in discussion of animal subjects).

* Patients aren’t “put on” medication, they’re treated with medication. Also, patients aren’t “placed on” ventilators, they’re given ventilatory assistance.

Certainly jargon does have its place. It is specialized, and those in the same field can use it to communicate precisely and quickly. However, when it comes to medical and scientific publications, jargon is best avoided. Bernstein ends his entry on “inside talk” with the following: “It must never be forgotten that the function of writing is communication.” Clear enough.—Lauren Fischer

August 5, 2011

Ventilate or Ventilation

Filed under: usage — amastyleinsider @ 12:32 pm
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“The patient was ventilated.”

“We decided to ventilate the patient.”

Such statements are commonly overheard in critical care units and other areas when clinicians discuss the care of a patient experiencing insufficient or absent respiration. Both statements use forms of ventilate in ways that—because they appear in this sense in the latest edition of Merriam-Webster’s Collegiate Dictionary—are correct and so may be used in medical journals. However, writers and editors have a valuable opportunity to ensure the continuing precision of the language through careful use of such terms and their variants, referred to as back-formations.

As discussed in the 10th edition of the AMA Manual of Style, “Back-formation is the creation of a new word in the mistaken belief that is was the source of an existing word” (see §11.3, Back-formations, in the AMA Manual of Style, p 407 in print). Back-formations are formed by the removal of a suffix (either a derivational suffix such as -ion or an inflectional suffix such as the plural -s) from a word that actually appeared first, changing its part of speech and forming a new word. Thus, the verb ventilate when used in the clinical sense may well be such a form, as suggested by its appearance in common use slightly later than the appearance of the noun ventilation (early 1900s vs 1890s, respectively).1 Interestingly, however, users of the English language had been busily back-forming for some time before that: ventilate as used in the closely related sense of exposing the blood to air, now obsolete or nearly so apart from its use in the study of physiology, likely also represents a back-formation that appeared some 50 years after ventilation as used in this sense (1660s vs early 1600s, respectively).2

Back-formation plays a valuable role in language evolution, producing neologisms that often subsequently enter common use. However, coining verbs through back-formation can result in medical jargon (see §11.4, Jargon, in the AMA Manual of Style, pp 408-409 in print) that is vague, depersonalizing, and sometimes downright comical in the images it can evoke. Taking the case in point, for example, what does “the patient was ventilated” mean, exactly? Was the patient perforated? Fitted with louvers? Left outdoors?

While it is commonly understood that the use of ventilated in this sense in spoken English denotes the use of a mechanical ventilator or other means of artificial respiratory assistance (eg, use of a bag-valve-mask apparatus), it typically refers to the former. However, in written materials, the use of mechanical ventilation should be explicitly reported when appropriate. In addition, eschewing the use of assistance altogether is perhaps advisable, and certain constructions (eg, “was” or “on” constructions) should be avoided if they lead to ambiguity such as that noted above. For example, “the patient was ventilated” and “the patient was placed on a mechanical ventilator” should be rewritten to read “the patient underwent mechanical ventilation.” In some instances, it might also be helpful to report additional information to clarify whether the intervention was invasive (ie, required endotracheal intubation, nasotracheal intubation, or tracheostomy) or nonvasive (eg, used a mechanical, sealed-mask approach such as BPAP [bilevel positive airway pressure]).

Writers and editors of medical information, then, should be vigilant when using terms coined through back-formation. Such terms should not be used if they do not appear in a current dictionary of reference. Those that do—eg, ventilated—may be used, but writers and editors should take care to ensure that they are not used in ways that are vague, depersonalizing, or unintentionally comical. Ultimately, however, a bit of back-formation is not a bad thing—for example, edit is a back-formation coined from editor.3Phil Sefton, ELS

1. Ventilate. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:2223.
2. Ventilation. The Compact Oxford English Dictionary. 2nd ed. Oxford, England: Oxford University Press; 1991:2223.
3. Back-formation. In: Hoad TF, ed. The Concise Oxford Dictionary of English Etymology. Encyclopedia.com Web site. http://www.encyclopedia.com. Accessed August 5, 2011.

July 27, 2011

Abbreviation Nation

Filed under: abbreviations,editing process,usage — amastyleinsider @ 11:28 am
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Of the reference books I use while editing the Archives journals, my favorite by far is MEDical ABBREViations: 28,000 Conveniences at the Expense of Communication and Safety, 13th Edition, by Neil M. Davis. Not only does it have the most wonderfully snarky title I’ve ever seen on a reference book, but it is the Great Decoder, the book that allows me to make sense of the myriad abbreviations I run across in my daily work.

As much as we are a nation of people who speak largely in cliches and mixed metaphors (I will save my rant about the overused and incorrect “magic bullet” for another day), we are a nation of overabbreviators. The number of organizations that are known by their abbreviation are too many to quantify (NFL, AMA, NORAD). We put out APBs, send out CVs, take our OTC meds, surf our Macs and PCs, and occasionally go AWOL. But when you think about it, do these mean anything? A National Football League is a thing. An NFL is not. What about an AC? Is it an air conditioner? An alternating current? Atlantic City? Though sometimes context can tell us what an abbreviation means, just as often it cannot, and it’s my job to sort these out.

As someone who previously tried to argue that texting is a valid and efficient method of communicating, it may seem hypocritical for me to do a mental fist pump every time I read Mr Davis’ snappy title, but I do. It’s because for every abbreviation that I find easily in my AMA Manual of Style or my MED ABBREV, there are so many that I must ask authors about. This worries me, because I don’t think authors would put these in their articles if they weren’t  routinely used. And though they and their colleagues and most of the American medical community may know exactly what they mean, will readers in Zimbabwe, Thailand, or Argentina? Those readers may have their own set of metaphors, jargon, and abbreviations that makes perfect sense to them. Or they may be students who don’t come across them every day. What happens when we let them slide, or when a journal doesn’t have finicky, know-it-all editors to question them? I worry that it will make journals less accessible, and that it will make medical discourse less accessible. I hate the idea of a medical student somewhere in the world not being able to use one of our articles in his research because I didn’t feel like finding out what something means. And believe me, sometimes I don’t feel like it. But I know I must be persistent, as annoying as it feels to harass a busy professional about something that seems so trivial. And that medical student out there better appreciate it.—Roya Khatiblou, MA

July 12, 2011

Dr Readability: Or How I Learned to Stop Worrying and Love the Pronoun

Filed under: editing process,usage — amastyleinsider @ 2:34 pm
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In academic writing, the current modus operandi seems to be: the more words the better. Why say “children” when we can say “individuals of pediatric age”? Why “time” when “period of time” sounds so much more substantial? Strunk and White1 would surely disapprove. Extraneous verbiage may make one’s writing sound lofty and important, but it can muddle one’s message. Writers should not use circuitous, rhetorical language to persuade their readers. Strong, clear writing, without extra baggage, creates a confident tone and allows the reader to more easily understand a work’s significance.

Here are a few ways to clean up one’s writing for easier reading:

Use the pronoun. Use it.

Writers often repeat nouns instead of using pronouns, as writers fear that readers won’t understand what the writers are saying. Not horrible, but is there confusion over what they refers to in this revised sentence: “Writers often repeat nouns instead of using pronouns, as they fear that readers won’t understand what they are saying”? Repeating the same word or phrase creates reading fatigue, like listening to someone beat on a drum over and over. Trust that your reader has a longer attention span than the time it takes to read half a sentence and there will be no need to use the same nouns over and over and over…

Here’s an example: “Because many people use vitamin therapy, we must determine the efficacy of vitamin therapy compared with other treatments.”

How about this instead: “Because many people use vitamin therapy, we must determine its efficacy compared with that of other treatments.”

Use the verb.

Editors are in agreement that “to be” constructions are weak and should be replaced with the actual verb. I agree!

Substituting “to be” constructions with actual verbs makes writing stronger and more confident. Researchers often use the phrase, “Our findings are indicative of…” See the “to be” hidden in there? How about “Our findings indicate…”? Were “patients in receipt of the drug” or did they “receive the drug”? Were participants “in attendance” or did they “attend”? The meaning is the same, but the writing sounds a whole lot better with the true verb.

This goes hand in hand with the passive voice. We’re not saying that the passive voice is wrong necessarily, it’s just that it is believed by some people that it is not as strong as it could be. Rather, some people believe that the passive voice is weak. In general, the active voice should be used over the passive voice, especially in cases when the “actor” is present. For example, “Patients were monitored by resident physicians” should be changed to “Resident physicians monitored the patients.”

This is another way to say: Use the delete button.

Close your eyes. Pretend you have a word limit. Now, pretend you have to follow it. Would you rather cut 100 words from the “Results” section or 100 words throughout a manuscript that add nothing of substance substantial? See what I did there?

Here are a few substitutions that reduce wordiness:

–“combined with” instead of “in combination with”
–“important” instead of “of importance”
–“most” instead of “the majority of”
–“can” instead of “is able to”
–“affect” instead of “to have an effect on”

Eliminating exaggerations can also trim one’s writing. How often is quite, very, or rather necessary (or accurate)? Writers should also avoid superlatives like profoundly and significantly when describing a study’s results.

These tips will help eliminate excess verbiage and heighten readability while preserving meaning. What is there to be afraid of fear?—Laura Adamczyk

[author’s note: Some of these ideas came from lectures by Northwestern University professor Bill Savage, PhD.]
1. Strunk W Jr, White EB. The Elements of Style. 4th ed. New York, NY: Longman; 1999.

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