So, today was the last day of class and we had our last round of presentations. What's left is this summary entry and the research report.

Overall I think I've enjoyed the module a lot. I enjoy the lecture style delivery of info, then immediately followed by activities to apply what we've learnt during those classes. The content isn't so heavy and I can relate it to the current trends/happenings based on my experiences. Also it's different from my major because it isn't so technical and detail intensive. It's a lot about application.

E-reflections
E-reflections is new for this batch of GEK1036 students. Overall, I think it's a really good idea, because it forces you to apply what you've learnt and relate it your life/experiences. It's like being forced to review your material to get a good grasp of what was being taught. Personally, I wouldn't read my lecture material till much later (usually before tests) so it was good for me. It was only when I started thinking of what to write, that I realised it had to much to do with pharmacy, which is really my passion.

Sometimes I think it is quite difficult to have to critically comment on another person's blog because I read blogs for fun, just to have an idea on what's going on with my friends' lives. I don't read blogs to critically evaluate them, it's more of a social thing rather than an academic evaluation. Having said that, I admit that it's nice to have people comment on your blog. At least you know people bother to read all that you've written, whether they're forced to or not.

Research Project
I had fun doing my project, although I have to say it was really very hard work. I enjoyed analysing my results because pharmacy is really my passion. Also, because of the experiences I had, I could better explain my findings.

For the presentation, I was really proud to be able to wear my white coat and present my findings to the class. I had so much to explain and I had to keep cutting and cutting my slides because of the time limit. I think there's a big problem with the time limit, because for a group project, the only difference is more literature reviews and a larger sample. This doesn't give them the need to have extra time to present their ideas. And it doesn't mean that a solo project would have less evaluation to do. Yet, I recognise that each person needs to have enough time to be evaluated on his presentation. For my presentation, I was almost freezing at the start. I wasn't nervous, but I was very cold. Thankfully it got better as I got on with the presentation. I exceeded the time limit even though I had quite a few rehearsals completed on time. However, it came to a point in time where all I wanted to do was to share my findings with the class and spend more time to explain the nature of the study and what the real situation is like for us pharmacists, simply because I really worked very hard and I was very passionate about this project. The presentation grade just seemed secondary. I was glad when the questions came in because it gave me an opportunity to explain further my own feelings and the point of view taken in the report. I really really hope everyone enjoyed my presentation!

I enjoyed listening to the wide variety of studies done by my classmates. Some people did stuff on topics which I never even knew could be analysed. Some studies were simpler than others, while some managed to defend their studies better than others. Overall, I think it really shows when a person does a presentation on something close to his heart. I could tell the from the enthusiasm displayed. I also think that those who overshot the time limit really shouldn't be penalised, because their topics were more technical and the longer introduction was very necessary to explain the technical terms and to allow us to appreciate the findings. Nonetheless, I enjoyed listening to all the presentations.

Conclusion
Alright, I don't exactly know what else I can say besides to thank everyone and especially Dr Deng. I think he was very flexible throughout the course and it is something that I appreciate, because at least it shows that even the prof is willing to compromise and actively listen to our feedback. Not every module has coordinators like that. Well done!

All in all, I had great fun in this module and I would definitely recommend it to my friends. Big thanks to my wonderful classmates for making the module so enjoyable. All the best for your exams!

Before class, I never realised how the English language was sexist. Personally, I don't see a Ms as more professional than a Miss. And I happen to be one of those whose impression of a Ms was someone who was divorced. Additionally, I did think about whether the Chinese language was as sexist as the English language and I read up a little. (I saw some Chinese words on the whiteboard when I came to class late but haven't found out what was said)


Mandarin Terms used in Marriage
I feel that certain situations and practices are so rooted in culture that it didn't matter anymore whether it was sexist or not. Regarding how a woman had to be 'given away' by their father to their husband during a marriage, I've asked a few friends and they don't think much about it. Although they had never thought about a marriage ceremony in this manner, they felt it didn't affect the status of the marriage or how the couple would live their life. Come to think about it, even in mandarin, a lady 嫁给(gets married to) a guy. However, a guy 娶 (gets married to) a lady. In Chinese, 给 means "give/given to". However, the impression of 娶 is such that the lady is married into the guy's family. Does that sound sexist to you?

Bachelor's Degree?
Also, most of us are studying for our Bachelor's degree. Haven't heard of a Bachelorette's degree yet. However, because it is so rooted in tradition, does anyone really bother making a fuss out of it? Or perhaps we are just too passive?

Discourse in Mandarin - Sexist or Not? Or a mixture of both?
The prescription of generic masculine terms has led to many debates about linguistic sexism in English. However, such a problem does not seem to occur in oral Chinese discourse because the third person in oral Chinese does not distinguish females from males. The Chinese words “他” (ta), meaning “he” and “她” (ta), meaning “she” are pronounced exactly the same so there is no need in oral Chinese to distinguish a male from a female when referring to a third person singular. However, this “gender neutrality” in the oral discourse does not occur in written discourse because the Chinese language distinguishes a female from a male. The generic masculine “他” (ta) in Chinese, like the word “he” in English, generally stands for all human beings in communication.

Gender-related Order in Expressions
The arrangement of male and female syntactic ordering, in many cases, appears largely fixed in Chinese. If we look at the simple examples I thought of (sorry my Chinese vocabulary is very limited), we realise that the "male" component in many cases comes before the "female" component.

男女 (nan nu) - men and women
父母 (fu mu) - father and mother
兄弟姐妹(xiong di jie mei) - brothers and sisters
儿女 (nu er) - son and daughter
夫妻 (fu qi) - husband and wife
太阳月亮 (tai yang yue liang) - sun and moon

To reverse the syntactic order by placing female ahead of male would render the phrases very odd or even wrong to native Chinese speakers.

For example, let's take the phrase 男女 nannu, (men and women). If the order was reversed, 女男 nu nan (women and men) would sound incorrect to the speakers of Chinese language. Another example would be if you change the order of the phrase 儿女 er nu (sons and daughters) into女儿 nu er (daughter), the meaning is totally changed. For the second phrase, if you change the order of the two characters 父母 fu mu (father and mother) into 母父 mu fu (mother and father), the term sounds grammatically wrong. A check of the Chinese dictionary I used for my exams in secondary school does not even have the phrase 母父 inside. Interestingly, if the above set phrases are in English and put in a reversed order, they are quite acceptable even to a native English speaker.

So, the Chinese language is sexist as well, not just the English language!

Have a good week everyone! And all the best with your research reports.

This week's class was so much more familiar to me. It felt much easier to grasp the theories. I think I could interpret the internet lingo and abbreviations almost instantly, and definitely much faster than Dr Deng. =)


The thing that left an impression on me most was the analysis of the MM or FF instant messenging logs. Although I've never seen a FF conversation, it became so obvious from all the emoticons and the expressions of emotion. Things like using the terms "pressie" to mean "present", it's just so.....girl.

The Webcam Pharmacy
Anyway during class, what came to my mind was how CMC was reaching the pharmacy world. Guardian pharmacy is now introducing the webcam pharmacy, where if a pharmacist was not present to attend to a patient, he would be able to speak to a pharmacist at another location through a high definition broadband webcam, or so they call it. To ensure that the correct medication is being dispensed to the patient, a "well trained" store assistant would have to show the "online pharmacist" the medication before giving it to the customer. The only requirement is that customers need to have a proof of their identity and age (it is a legal requirement that customers purchasing Pharmacy-only items need to be 18 years and above). All these information will be recorded.

Personally, I am highly doubtful about the effectiveness of this strategy. CMC has its pros and its cons. Of course, the pros are that when a pharmacist is not at the counter, the patient will always have access to a healthcare professional to get the advice he requires. However, I personally feel that patient safety is being compromised. I wouldn't trust a sales assistant to pack the correct medication for the patient. Also, what makes a patient counselling session successful is the ability of the pharmacist to connect with the patient. If I were a patient, I wouldn't feel good speaking to a flat computer screen to tell him my exact ailment. Also, what if I have a sensitive issue that I need to speak to the pharmacist about? What if it were certain women's issues that we frequently (without a webcam) lead the patient into the counselling room where there is more privacy? I doubt that the pharmacist can be "transferred to another computer in the counselling room. In fact, most counselling rooms don't even have computers. Having said all that, if I simply want to buy some over-the-counter medications and I'm not interested in what the pharmacist has to say, then I'd support the idea. But wouldn't we be sacrificing the quality of our services to ensure the patient gets the right medication while understanding the correct side effects/precautions?


Webcam Hospital?
Then again, I read some articles on the web and I realised that even hospitals are using CMC to connect with patients from the rural areas who cannot afford to travel, but are still covered by Medicare and Medicaid, the US Health System's health insurance plans.

source: 10/14/09 - St. Anthony, OSU make rural medicine wireless: Health care: Doctors will be able to work via webcam, bus in remote towns [The Oklahoman, Oklahoma City]

Webcams to Solve the Long Queues at Polyclincs?
It's amazing how people around the world are using webcams and CMC in general to communicate. It's even spreading to the healthcare world. Perhaps in a few years time, we could have doctors communicating with patients in their own homes using webcam technology. Wouldn't that solve the problem of long queues at the polyclinics?

(Come to think of it, that would decrease compliance of medication. Patients might not even bother to collect their medication from the pharmacy, and I doubt the pharmacy has enough resources to deliver medication to our patients' homes. What's more, with the greying population of Singapore, it is highly recommended for the elderly to get some "exercise" by making their way to the polyclinics to see their doctors. Once again, the pros and cons of computer-mediated communication.)

Have a wonderful week everyone =)

E-Learning is tough for a module like this. I don't like it at all.


Anyway, this week's lecture notes are about the different politeness maxims, as proposed by Leech (1993).

It didn't take long for me to realise how important those politeness maxims are, especially in a hospital/community pharmacy setting.

1. The Tact and Generosity Maxim
One way that the tact maxim is used is through minimizers - reducing the implied cost to the hearer. To our patients, we will always say, "please hold on for a moment while I help you prepare your medication". In actual fact, with all the checking/labelling/packing, it always takes more than "a moment". However, I guess by saying that, it gives us a lot of room to maneuver because "a moment" to us (pharmacists) may be different to the patient's "a moment". As such, we didn't lie, yet didn't tell the full extent of the term. Also, we would usually "maximise cost to self" in the Generosity Maxim and verbally state that we will help our patients prepare their medication. It would be terrible to say "Just take this and this and mix it on your own. Then pay at the cashier". It would be seen as a customer service disaster.

2. The Approbation Maxim
This generally is to heap praise on our patients first before we make a request or inform the patient on a change of medication. It is done even when it was a really bad reading compared to the most recent reading in the previous month. For example, a pharmacist would say "Mr Tan, your blood pressure is better since I first saw you many years ago. However, there are lots of room for improvement this month and so we have to increase the dose of your medication". Here, we attempt to "maximise praise" and "minimise dispraise" to the patient.

3. The Modesty Maxim
This is slightly more sensitive because this sign of modesty could be interpreted as not being professional enough to know our drugs and the relevant knowledge. For example if we made a mistake in our recommendation, we could never "maximise dispraise" to ourselves and say, " Oh how could I make such a stupid mistake!"

4. The Agreement Maxim
We always try to agree with our patients to a certain extent, to give them encouragement about their knowledge of their medication and to continue adherence to the regimen, especially for long term medications. For example,

Patient: Why are there so many medications! How on earth can I remember so many drugs?
Pharmacist: Mr Tan, I agree that there are many drugs. However, all these medications are good for you and prevent multiple organ failure due to your heart failure.

Here, the pharmacist tries to "maximise agreement" with the patient to show concern and provide some assurance and encouragement to the patient.

5. The Sympathy Maxim
The sympathy maxim aims to "maximise sympathy between self and other" or to "minimise antipathy between self and other". It is one of the most important steps in patient counselling, because it gives the patient confidence that you can understand how difficult it is for the patient to be in the situation that he is in. That would lead to greater confidence in your recommendation and increased compliance to your proposed drug regimen. It is simply done by acknowledging what the patient says or repeating part of the description he had narrated to you.

Patient: The headache is killing me! I can't eat, I can't sleep, I can't do anything I want to do!
Pharmacist: I'm so sorry to hear that, Mr Tan. It must have been a difficult time for you.

6. On/Off the record
If we were preparing medications and needing to cut blister packs in the pharmacy, and I wanted to borrow a pair of scissors from a fellow colleague, there are many ways I could do that.

Off the record: How come I keep losing my pair of scissors when I need to prepare medication?

Bald on record: Lend me your scissors please.

Face saving act - Positive Politeness: Hey bro, could you lend me your scissors please?

Face saving act - Negative Politeness: Sorry to keep troubling you, but erm...could you lend me your scissors for one more time?

Haha so yeah there are so many things that can be applied to a pharmacist's life and his interaction with his patients. Every week I seem to be able to link the lessons to my life in pharmacy.

That's all for now, see you at class on Wednesday!

Oh dear i forgot to click publish until now -_-


Anyway, class this week was interesting! Especially for the videos in the front =).

Singapore is a Low Uncertainty Avoidance country? Nah.
This week we learnt about the different components and representation of cultural systems. It's interesting to see where Singapore was placed in the various categories according to Hofstede's dimensions of cultural variability. The one I disagree the most is that Singapore is a low uncertainty avoidance country. Personally, I feel that most Singaporeans are not big risk takers, even the government had to step in provide incentives for Singaporeans to venture out and become entrepreneurs. I personally don't feel comfortable taking huge risks, especially now since times are really bad. Just a sudden thought: Could certain situations force a country to go against their "pre-existing level" of uncertainty avoidance? For example, in the times of the economic downturn, won't most people be focusing on getting a secure job first rather than risking their family savings to start a business?

Anyway back to my point about Singapore's standing on the "uncertainty avoidance" chart. Based on the slides,

1. I don't think Singaporeans are comfortable in ambiguous situations. Most risks taken are calculated risks.

2. Tradition plays an important role in the rules taught to children. Since young, I was taught that I couldn't do lots of stuff. And the rules were laid very clear to me: No sticking your chopsticks upright in your food (because it looks like joss sticks and considered unlucky), no cursing and swearing etc. Of course, I don't strictly follow it now. I think it's like that for most families, just that some are stricter than others. Whether the children obey the rules is one thing, but for most chinese parents, they are quite strict and firm on what should/should not be done, especially when dealing with a child.

3. I think students in Singapore are more concerned with getting the right answers rather than good discussion. It's a result of the culture being so results and grades - oriented. Take me for example. I really really enjoy the process of studying and doing my projects, interviewing people, analysing stuff. However, most of my classmates are different. They hate the discussions, they hate people beating around the bush, they think doing role plays (which was meant to liven up classes ) is a waste of time. All they want is the correct answer for the question, they go back, memorise the steps, practise practise practise, and tada. CAP 5. Me? lol. Fighting to get honours. It doesn't pay off, does it? (alright i'm sure that there are other factors involved)

4. With my usual coursemates, teachers who say "I don't know" are seen as being weak and unfit to teach. Unless it's a totally ridiculous question, they're expected to know everything, or else they're a bad teacher and they probably don't know what they're teaching and what's in their slides. To me, I do admit I do feel like that sometimes, especially when it is a basic question. However, I'd rather a teacher say he doesn't know the answer and that he'd get back to us later, rather than beat around the bush to escape the question. We know when it happens and that's the end of his reputation.

5. This is one point which I agree that Singapore is a low uncertainty avoidance country. I think the statement that Singaporeans are comfortable feeling when lazy and hardworking only when needed is very true! Most people wouldn't work if they could. Probably it is due to the fact that standards of living are going up and that there is no choice but to work. It is even more so if you have a family. If someone had an abundance of money to retire early, I'm pretty sure he would. It's only when they need to work to kill time that they appear in desperate search for a job.

6. Citizen protests are NOT acceptable to this current Singaporean government. Protests and demonstrations are banned. There is so much red tape before anyone can speak at Speaker's Corner. The only way we can speak up is through the newspaper forums. Even so, lots of sensitive stuff are censored, for example sensitive racial and political comments.

As such, I don't feel that Singapore is really low uncertainty avoidance. One must really ponder about the methodology of this survey, or how outdated the study was.

Is It the White Coat Syndrome or are Asians Simply More Collectivist by Nature?
Just final thought about something pharmacy-related. I did mention in my blog posts previously about the differences between Asian and Caucasian consumers visiting a pharmacist at a community pharmacy. Just a slight recap, it's about how Caucasian customers are more outright with their questions for the pharmacist and are more inquisitive and upfront with their comments and criticisms, while Asians are more obliging and generally accept what the pharmacist says. I also mentioned about the white coat syndrome where patients don't dare to criticise the pharmacist just because he/she is wearing a white coat and is seemingly more in power. Could it be due to the "Western" countries generally being more Individualist and being more concerned about themselves, rather than being concerned about "maintaining harmony" and "avoiding direct confrontations", which are more characteristic of the Collectivist "Asian" countries? Or is it that Asians generally experience the white coat syndrome more?

That's all for now! Have a good e-learning week!

All along, I have never enjoyed analysing texts. When i realised that the topic for this week was written discourse, I was like "uh-oh". Luckily class was quite interesting, with all the activities and the discussions. It was also interesting to know that people actually analyse texts and classify them through the different styles, especially the English and Oriental styles which I could much more easily identify with. Having said that, I still don't like analysing texts.


Writing Chinese Essays in English Style
Anyway, having learnt about the Chinese and English ways of writing, it does bring to my mind about writing English and Chinese essays during my primary school, secondary school and junior college days. I have always struggled with writing Chinese essays, and my grades were always borderline passes. When I went to my teachers and asked them why I fared so badly, all they could tell me was that besides my limited Chinese vocabulary, my style of writing was just so English, and it felt like a direct translation from English. And that was it. I asked which aspect of it was so "English", and none of them could give me a satisfactory answer. The typical answer was, "Just read your friends' essays and more Chinese story books." And that obviously didn't help me much, because I still couldn't see the difference. Maybe I should write to the Ministry of Education (MOE) to request them to send all their teachers to attend GEK1036.

Patient Information Leaflets - Are They Written in the English or Oriental Style?
With regards to pharmaceuticals, it also came to my mind the way that patient information leaflets (found inside medication boxes) are phrased actually follows the "English" style of writing. It is more direct, with a main topic before elaboration or supporting points. And to me, that's really important. If it followed the "Chinese" style of writing with all the "peripheral" information before coming to the main point, I wonder how many patients will actually bother to read till the end.

Let's take for example a paragraph I extracted from the package insert of a paracetamol suppository box. Just to provide some simple background information, paracetamol is the active ingredient in the painkiller Panadol, and the dosage form that we are most familiar with is the tablet form. However, there are many other dosage forms of paracetamol, including syrups, suspensions, pessaries, injections, and suppositories. Suppositories are little bullet shaped dosage forms containing the active ingredient and it is inserted into the rectum (or anus). It has a much quicker onset of action than the regular tablet form, and that means it works faster.

This is what it looks like in the information leaflet:

FOR RECTAL USE ONLY
This medication is for rectal use only. Do not consume orally or mix with other solvents. If you are unsure on how to use this medication, please consult your healthcare professional for further advice.

It goes straight to the point, telling patients that it is not to be consumed orally, before elaborating with more information. This is extremely important, because for a patient who just purchased such a product, he might assume that it is to be consumed orally. Especially for a person who's having a splitting headache, all he wants is to take something to quickly relieve his discomfort. I don't think a "Chinese" style of patient information would suit him. Imagine if it were like this (and yes it follows Text B of Activity 2) :


"Of all the ways that paracetamol can be administered in the world, some are more popular than others. Sean Ang likes the tablet form, and Fabius Chen prefers the sweet and tasty syrup form. Ever since paracetamol came to the market, people all over the world favour the tablet form. This box however, favours the suppository form because it works much faster and is just as potent as the tablet form. It is cone shaped, yellow, and wrapped in foil. The longer it stays refrigerated, the longer it lasts. Every suppository stands upright and firm. It is best to insert it into your rectum, but not eat it."

OH MY GOODNESS. If I were the patient who was suffering and I had no idea what a suppository was, I would stop reading after the first 2 lines and just consume the suppository orally and treat it as a larger sized pill. (and yes, it has happened many times before all over the world)

Having said that, perhaps if I was educated in the Chinese form of writing, I would learn to interpret all that at a glance. Then again, when it comes to medication, I'm not so sure that I would want my patient to interpret on his own what the information on the leaflet was trying to say. For me, it has to be writer responsible. It would be disaster to have a reader-responsible patient information leaflet.

As such, it is my guess that patient information leaflets that have "Chinese" as the main language actually follow an "English" style of written discourse. This is mainly functional, with patient safety of utmost importance, rather than sticking to the traditional style of writing.

That's all for this week, happy mid sem break!




Class this week was interesting for me, especially for the part where we composed a short story. My group managed to come up with that little poem which I'm very proud of, and I was very excited to present it to the class. Well done, team!


The part about spoken discourse was a little confusing for me though. I got it mixed up with a speech event. I hope I got the concept right in some of my thoughts penned below.

Anyway, while reading about the telephone openings and trying to figure out what the topic was all about, something related to pharmacy came to my mind again. It is once again about a pharmacist's interactions with the patient.

Pharmacists' Interactions with Asian and Caucasian Patients

In my experience doing my attachment at the polyclinics and the hospital, a pharmacist speaks differently to a caucasian, as compared to an asian who typically nods at everything the pharmacist says, whether or not he really does understand the instructions. I personally feel that this is due to a stereotype that healthcare professionals (including doctors, nurses and the allied health professionals) have with regards to the attitudes of our patients.

For example, let's compare a typical scenario where a caucasian patient and an asian patient comes to collect his medications.

(Ding dong) - queue number flashes
Pharmacist: Good morning sir.
Patient: Good morning to you.
Pharmacist: May I have your name and identification number.
Patient: (states his name and identification number)
Pharmacist: Any drug allergy?
Patient: Yes/No.
Pharmacist: (If yes, probes further for allergy. If no, pharmacist thanks the patient.)
Pharmacist: Alright, here's your medication for today (pharmacist goes on to explain the medication regimen)

The difference comes here, in how the pharmacist asks the patient for confirmation on whether he understands his condition, how his medication helps him, and how he is supposed to take his medication. Both have taken their medication before and are here to collect a resupply.

Caucasian

Pharmacist: Mr Connery, can you quickly tell me which medication is for your cough and which medication is for your high blood pressure?
Patient C: (picks up the bottled dextrometorphan cough syrup) this... cough. (picks up an amber bottle containing hydrochlorothiazide tablets) this... high blood pressure. But how does this one (hydrochlorothiazide) work to lower my blood pressure?
Pharmacist: This drug is a diuretic and it works by removing excess water from your body. That helps lower your blood pressure.
Patient C: And that's why this drug will cause me to visit to loo more often!
Pharmacist: That's right, Mr Connery.

Asian

Pharmacist: Mr Ang, can you remember how to take this medication? (picks up hydrochlorothiazide bottle)
Patient A: yes.
Pharmacist: This is for your high blood pressure right?
Patient A: ya, correct.
Pharmacist: This will make you go to the toilet more often ok?
Patient A: ya, i know.

We can see a stark difference in the way the counselling is done. In our practice, it is known that caucasians are generally much more inquisitive about their medications as compared to asians. Asians are also generally more silent during counselling sessions, as compared to caucasians, and it is far more difficult to probe for an answer to a question from them. Based on that knowledge, I feel that the pharmacist unconsciously generalises these 2 groups of patients and the way they counsel the patient reflects that problem.

For the caucasian, he is more responsive and the pharmacist feels more comfortable asking very open-ended questions. This naturally gives the patient more room to answer.

For the asian, because of this stereotype, the pharmacist asks close-ended questions and doesn't seem to even bother to try asking an open ended question. These are generally yes/no answers. Also, the pharmacist makes use of "response solicitations" like "ok?" and "right?" to encourage the patient to respond in some way. Personally, this does not convince me that the patient understands his medication. This situation could also be due to the fact that asians are reluctant to "embarass" a healthcare professional by further enquiring about their medications, since it implies that the healthcare professional did not do a good job in his explanation. In contrast, the caucasian wants to take ownership and control of his own medication regimen. Empowerment is important to the caucasian.

This stereotype has been passed down for many many years based on past experiences. However, in this day, with the popularity of the internet and its seemingly limitless resources on drug information, patients have become more informed and are more concerned about their own medication. Also, with current policies, the education level is much higher among patients as compared to say, 20 years ago. In school, we are taught that the "right" way to counsel a patient is as for the caucasian.

As such, isn't it time to consider a change in the way we counsel our patients? Could this be the time to drop the stereotype and treat everyone like the more "educated" caucasians, for the benefit of all our patients?

Reference
Jennifer Watermeyer, Claire Penn, 'Tell me so I know you understand': Pharmacists' verification of patients' comprehension of antiretroviral dosage instructions in a cross-cultural context, Patient Education and Counseling, Volume 75, Issue 2, May 2009, Pages 205-213.  Retrieved 13 September 09, from Science Direct.