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Simplified cellular grafting for treatment of vitiligo and piebaldism: the "6-well plate" technique new erectile dysfunction drugs 2014 cheap vimax online visa. Four compartment method as an efficacious and simplified technique for autologous noncultured epidermal cell suspension preparation in vitiligo surgery: A randomized erectile dysfunction at age of 20 generic 30 caps vimax with amex, active-controlled study. Autologous grafting with non cultured melanocytes: A simplified method for treatment of depigmented lesions. Double-blind placebo-controlled study of autologous transplanted epidermal cell suspensions for repigmentingvitiligo. Long term results of non cultured epidermal cellular grafting in vitiligo, halo nevi, piebaldism and nevus depigmentosus. Clinical features and histological findings are potential indicators of activity in lesions of common vitiligo. Long-term follow-up study of 142 patients with vitiligo vulgaris treated by autologous, non-cultured melanocyte-keratinocyte cell transplantation. Melanocytekeratinocyte transplantation procedure in the treatment of vitiligo: the experience of an academic medical center in the United States. Clinical and treatment characteristics determining therapeutic outcome in patients undergoing autologous non-cultured outer root sheath hair follicle cell suspension for treatment of stable vitiligo. It is a disease with no mortality but significant psychosocial effects [3], especially in dark-skinned races, that greatly impacts quality of life [4]. Several hypotheses have been put forward to describe the pathogenesis of vitiligo-autoimmune, biochemical, self-destructive, genetic, and neural hypotheses are noteworthy. However, the etiology of vitiligo seems to be multifactorial, with all the factors playing significant roles in the pathogenesis [5]. To date, there is no complete cure for vitiligo, but many treatments are available that can prevent disease progression and help in repigmentation. Surgical methods represent an alternative therapeutic approach to treating patients with stable vitiligo [11,12]. The surgical techniques used for repigmenting vitiligo lesions are broadly classified in two types: tissue grafting and cellular grafting, based on the nature of the grafts. Tissue grafting includes transferring of whole skin tissue grafts containing epidermis and dermis to the depigmented recipient skin [11,13]. Cellular grafts, on the other hand, employ the autologous melanocyte rich cell suspension (noncultured technique) [14,15] or the cultured melanocyte (culture technique) to the recipient skin [16]. Both these methods are based on the same principle of selective refilling of melanocytes at the recipient stable vitiligo lesions. The epidermis and dermis were detached from each other with the help of sterile forceps. Thorough pipetting was done to detach the cells from epidermis to prepare the single-cell suspension. The acquired suspension of cells was centrifuged for 5 minutes at 1000 rpm and the obtained cell pellet was used for the culturing of melanocytes. Cultures were routinely examined for the contamination, and every 2 days the medium was changed. The epidermal cell suspension technique by trypsinization for vitiligo transplantation was first reported by Gauthier and SurleveBazeille in 1992 [17]. The technique of transplantation of cultured autologous melanocytes was reported by Olsson and Juhlin in 1993 [16]. Autologous cultured pure melanocyte suspension is an efficacious therapy for stable vitiligo patients who have failed to respond to clinical treatments, particularly for patients with stable localized vitiligo [18]. Transplantation of cultured melanocytes is a complex, but it provides the best donor-to-recipient size ratio of greater than 1:10 to up to 1:60 [19]. A study [20] demonstrated progressive repigmentation of depigmented skin by both methods of epidermal cell suspension and the cultured melanocyte method. Another study was conducted to determine the relative effectiveness of the autologous transplant of noncultured cell suspension technique and the melanocyte culture technique in the repigmentation of stable vitiligo, which revealed an outstanding response in 62. In another comparative study, the efficacy of noncultured epidermal cell suspension transplantation, cultured melanocytes transplantation and blister roof grafting in the repigmentation of macules in stable vitiligo was checked [22].

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Evaluation of patients with hereditary hemorrhagic telangiectasia with video capsule endoscopy: a single-center prospective study erectile dysfunction drugs not working generic vimax 30 caps. Treatment of bleeding gastrointestinal vascular malformations with oestrogen-progesterone erectile dysfunction medication for sale buy cheap vimax 30 caps line. Blue rubber bleb nevus syndrome: surgical eradication of gastrointestinal bleeding. Indications, detectability, positive findings, total enteroscopy, and complications of diagnostic doubleballoon endoscopy: a systematic review of data over the first decade of use. Comparison of capsule endoscopy and enteroscopy with the double-balloon method in patients with obscure bleeding and polyposis. Management of obscure occult gastrointestinal bleeding: a cost-minimization analysis. Relative frequency of upper gastrointestinal and colonic lesions in patients with positive fecal occult-blood tests. Esophago-gastro-duodenoscopy is not indicated in patients with positive immunochemical test and nonexplanatory colonoscopy. Accuracy of screening for fecal occult blood on a single stool sample obtained by digital rectal examination: a comparison with recommended sampling practice. The clinical utility and diagnostic yield of routine gastric biopsies in the investigation of iron deficiency anemia: a case-control study. Gastric as well as duodenal biopsies may be useful in the investigation of iron deficiency anaemia. Gastrointestinal causes of refractory iron deficiency anemia in patients without gastrointestinal symptoms. Small bowel mucosal injury is reduced in healthy subjects treated with celecoxib compared with ibuprofen plus omeprazole, as assessed by video capsule endoscopy. Duodenal diverticulum at endoscopic retrograde cholangiopancreatography, analysis of 123 patients. Impact of endoscopy in the management of duodenal diverticular bleeding: experience of a single medical center and a review of recent literature. Provocative angiography in patients with gastrointestinal hemorrhage of obscure origin. Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a standard endoscope. Laparotomy and intraoperative enteroscopy for severe obscure gastrointestinal bleeding before and after the era of video capsule endoscopy and deep enteroscopy: a tertiary center experience. A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease. Diagnostic yield of wireless capsule enteroscopy in comparison with computed tomography enteroclysis. Capsule endoscopy or push enteroscopy for first-line exploration of obscure gastrointestinal bleeding Capsule endoscopy or angiography in patients with acute overt obscure gastrointestinal bleeding: a prospective randomized study with long-term follow-up. The role of wireless capsule endoscopy in investigating unexplained iron deficiency anemia after negative endoscopic evaluation of the upper and lower gastrointestinal tract. Although jaundice is commonly viewed as a sign of liver and biliary tract disease, the differential diagnosis is broad, and identifying the cause of jaundice and how best to treat it have challenged clinicians for millennia. Clinical descriptions of disorders associated with jaundice appeared as early as the treatises of Hippocrates. By the latter part of the 20th century, parallel revolutions in molecular biology and clinical imaging led, respectively, to elucidation of fundamental mechanisms of bilirubin metabolism and transport and to technical approaches that made it possible to pinpoint the cause of jaundice in most cases. Despite these advances, an effective management strategy for the jaundiced patient still requires careful selection of appropriate diagnostic and therapeutic tools on the basis of an assessment of the likelihood of possible underlying causes. Much of the literature concerning the metabolism of this hydrophobic and potentially toxic substance was published in the latter part of the 20th century, as reviewed in detail. Most bilirubin (70% to 80%) results from catabolism of hemoglobin released from senescent erythrocytes.

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Cytogenetic aberrations involving chromosomes 6 popular erectile dysfunction drugs buy vimax 30caps on line, 7 do herbal erectile dysfunction pills work purchase vimax 30 caps with mastercard, 12, and 14 constitute the major chromosome abnormalities seen in leiomyomata [1]. The potential effects of fibroids on pregnancy and the potential effects of pregnancy on fibroids are frequent clinical concerns, since these tumors are common in women of reproductive age. Most pregnant women with fibroids do not have any complications during pregnancy related to the fibroids. Pain is the most common problem, and there may be a slightly increased risk of obstetrical complications such as miscarriage, premature labor and delivery, abnormal fetal position, and placental abruption. Several factors make it difficult to assess the impact of fibroids on pregnancy outcome and to identify specific fibroid characteristics that are important. The prevalence of fibroids increases with age and is higher in African American women than in white or Hispanic women [3]. Increasing parity and prolonged duration of breastfeeding are associated with a small, but statistically significant, reduction in prevalence [4]. Changes in Size during Pregnancy and Postpartum Pregnancy-related increases in estrogen and progesterone levels, uterine blood flow, and possibly human chorionic gonadotropin levels, are believed to affect fibroid growth. Most studies that have sonographically monitored the size of fibroids across pregnancy have refuted the commonly held belief that fibroids 45 46 Fibroids and Reproduction increase in size throughout gestation [5]. Inconsistent data on the effect of pregnancy on fibroid growth may be due to the gestational age of the ultrasound assessments, since the pattern of fibroid growth during pregnancy is probably not linear [5]. For example, in those fibroids that increase in size, most of the growth occurs in the first trimester, with little if any further increase in size during the second and third trimesters [6,7]. Larger fibroids (greater than 5 cm in diameter) are more likely to grow, whereas smaller fibroids are more likely to remain stable in size [4]. The mean increase in fibroid volume during pregnancy is 12%, and very few fibroids increase by more than 25% [6,7]. In symptomatic women, symptoms include pain, pelvic pressure, and/or vaginal bleeding. Most patients have only localized pain, without other signs and symptoms, although mild leukocytosis, fever, and nausea and vomiting can occur [10,11]. Fibroid pain typically presents in the late first or early second trimester, which corresponds to the period of greatest fibroid growth and, in turn, propensity to degeneration. Pain also may result from partial obstruction of the vessels supplying the fibroid as the uterus grows and changes its orientation to the fibroid [12], or from torsion. Complications Uterine fibroids have long been implicated as a cause of adverse pregnancy events [13]. However, there are no well-designed studies that provide high-quality data on the relationship between fibroids and pregnancy outcome. Most pregnant women with fibroids do not have any complications during pregnancy related to the fibroids [14]. When complications occur, painful red degeneration is the most common complication. There also appears to be a slightly increased risk of complications such as miscarriage, premature labor and delivery, abnormal fetal positions, and placental abruption, but all studies do not show an increased risk of adverse events. As discussed earlier, pain is one of the most common symptoms of fibroids in pregnant women and is typically due to fibroid degeneration or, rarely, torsion. Rapid growth of fibroids can result in a relative decrease in perfusion, leading to ischemia and necrosis (red degeneration) and release of prostaglandins [15]. Pedunculated fibroids are at risk of torsion and necrosis, but this is much less common than degeneration. In some patients, submucosal fibroids appear to adversely affect implantation, placentation, and ongoing pregnancy. The effects of intramural fibroids are more controversial, while fibroids that are primarily subserosal or pedunculated are unlikely to cause adverse outcomes.

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Binge eating disorder treatment: a systematic review of randomized controlled trials erectile dysfunction vacuum pumps reviews buy 30 caps vimax with visa. Efficacy of family-based treatment for adolescents with eating disorders: a systematic review and meta-analysis impotence from priapism surgery order vimax 30caps fast delivery. A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-year follow-up. Psychological therapies for adults with anorexia nervosa: randomized controlled trial of outpatient treatments. Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa. A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Comparison of group and individual cognitive-behavioral therapy for patients with bulimia nervosa. Group cognitive-behavioral therapy and group interpersonal psychotherapy for the nonpurging bulimic individual: a controlled comparison. A critical evaluation of the efficacy of self-help interventions for the treatment of bulimia nervosa and binge-eating disorder. Effectiveness of spouse involvement in cognitive behavioral therapy for binge eating disorder. A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with bingeeating disorder. The empirical status of the third-wave behavior therapies for the treatment of eating disorders: a systematic review. Dieting and the development of eating disorders in obese women: results of a randomized controlled trial. A randomized comparison of cognitive behavioral therapy and behavioral weight loss treatment for overweight individuals with binge eating disorder. Gastric emptying in patients with restricting and binge/purging subtypes of anorexia nervosa. Rectal prolapse: a possibly under-recognized complication of anorexia nervosa amenable to surgical correction. Incidence of laxative abuse in community and bulimic populations: a descriptive review. Digestive complication in severe malnourished anorexia nervosa patient: a case report of necrotizing colitis. Death due to neurogenic shock following gastric rupture in an anorexia nervosa patient. Death due to duodenal obstruction in a patient with an eating disorder: a case report. Foam bezoar: Resection of perforated terminal ileum in a 17-year-old with sickle beta+ thalassemia and pica. Overview of the treatment of rumination disorder for adults in a residential setting. Transdiagnostic cognitivebehavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. Eating disorders-core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. Short-term cognitive behavioral treatment does not improve outcome on a comprehensive very-low calorie diet program among obese women with binge eating disorder. Effect of a very low calorie diet on the diagnostic category of individuals with binge eating disorder. Efficacy and predictors of longterm treatment success for cognitive-behavioral treatment and behavioral weight-loss-treatment in overweight individuals with binge eating disorder. Exercise augments the effects of cognitive-behavioral therapy in the treatment of binge eating. Binge eating disorder and obesity in 2003: could treating an eating disorder have a positive effect on the obesity epidemic The effect of atypical antipsychotic medications in individuals with anorexia nervosa: a systematic review and meta-analysis. Double-blind placebocontrolled administration of fluoxetine in restricting- and restricting-purging-type anorexia nervosa. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. Effect on bone health of estrogen preparations in premenopausal women with anorexia nervosa: a systematic review and meta-analyses.

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Reintervention rates vary depending on the length of follow-up and initial patient characteristics erectile dysfunction only at night buy vimax 30 caps lowest price. A meta-analysis of four randomized controlled trials found a similar number at 5-year follow-up [9] erectile dysfunction medicine for heart patients buy vimax from india. Those with larger uteri and greater fibroid burden at baseline are at higher risk of failure [10,11]. Unilateral embolization, which occurs in approximately 5% of patients, is consistently seen as a risk factor for failure. Risks Postprocedural pain appears to increase with the volume of fibroid embolized. Up to 20% of patients will report vaginal discharge that can last for up to 6 months after the procedure [12]. Ovarian failure is directly related to age at time of procedure and is more likely to occur with age older than 45 years. There did not appear to be a difference on preterm delivery, intrauterine growth restriction, or malpresentation. Further studies are needed to detect a statistical difference in obstetric outcomes. One recognized benefit of directed fibroid treatment is that there is no effect on ovarian tissue and no risk of ovarian failure. Conversely, if each fibroid must be treated individually, there are natural limits to fibroid size and number than can be reasonably approached via this method, and the procedure can be lengthy. Because ultrasound waves do not pass through air, the abdomen is submerged in water, or an ultrasound gel pad is placed between the patient and the transducer. A phased-array transducer delivers ultrasound pulses of thermal energy to a specified point, termed a sonication. Thus, multiple sonications or more than one treatment session are required to 98 Fibroids and Reproduction treat a single fibroid. Fibroids are commonly classified into type 1, 2, or 3 fibroids based on the signal intensity of pretreatment T2-weighted images, where type 1 has a low-intensity image comparable to skeletal muscle, type 2 has an intensity lower than myometrium but higher than skeletal muscle, and type 3 has an image intensity higher than or equal to the surrounding myometrium. The greatest change in fibroid size and symptom relief occurs in the first 3 months after the procedure [17,19]. At 6 and 12 months after the procedure, 71% and 51% of participants met the targeted efficacy in quality of life measures. Similarly, symptom severity scores improved with a 39% and 36% reduction at 6- and 12-month time points. There was a 75% response rate from 239 women who had the procedure at least 3 years earlier and an 87% response rate from 180 women who had the procedure 5 years earlier. This time restriction significantly limited early treatment completion and success. Most women reported mild pain during the procedure and mild-moderate pain that may last for up to 5 days. Minor complications described with this procedure include urinary tract infection, urinary retention, vaginal bleeding, transient buttock pain, and febrile morbidity. More serious complications are rare and may include fibroid expulsion, skin burns, and neuropathy. Thermal injury to surrounding viscera or nerves is an important but rare complication. Ultrasound energy is focused on the fibroid; however, lower levels are transmitted both forward and aft of the target. For example, sacral nerve palsy has been described occurring after sonication of a posterior fibroid that was near the pelvic bones [21]. Thus, it is imperative that the operator has a clean path to the target fibroid to minimize this risk. Ideal candidates are women who have a fibroid that leans up against the abdominal wall. The procedure cannot be done if the bladder, bowel, or nerves fall between the path of the ultrasound waves and the fibroid, or if the fibroid is directly apposed against any of these structures.

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It has been suggested that 10% of the larger congenital naevi develop malignant melanoma impotence caused by medication buy vimax 30 caps low price. The most deforming congenital melanocytic naevi are those that cover large areas of skin in the pelvic region and adjoining back (bathing trunk naevi) or over the shoulder region and upper limb erectile dysfunction doctors cheap vimax 30 caps otc. Acquired naevi (mole, naevocytic naevus, cellular naevus) Acquired naevi appear after birth, usually during adolescence or young adult life. Potential difficulty arises when an adult notices a brown lesion for the first time. If the cluster remains in dermo-epidermal junction it is known as junctional naevus and migration of some of the cells to dermis gives rise to compound naevus. This type of mole is seen most frequently on the palms and soles, especially in children. It is presumed that these lesions are intermediary in development between the junctional naevus and the dermal cellular naevus. Dermal cellular naevi They are fawn or light-brown or just skin-colored papular or nodular lesions. In some, there is a deep component with many spindle-shaped naevus cells that may superficially resemble the cellular component of a neurofibroma. In the elderly, when there is a little pigment, they may be misdiagnosed as basal cell carcinoma. Degenerative changes in naevi Naevus cell naevi gradually become fewer during the ageing process and it is believed that moles develop involutional changes before disappearing. Some develop lipid vacuoles in their substance, others develop a type of foamy change, and others appear to calcify before finally disappearing. Dermal (blue) naevi Cellular blue naevus the melanin pigment and the bulk of the naevus cells are in the mid and deep dermis. The striking blue color given by the pigment is due to the red wavelengths being filtered out by the superficial dermis and epidermis known as the Tyndall effect. It occurs as a greyish discoloration over the sacral area in the newborn, becoming less prominent in later life. The dermal melanocytes in persistent Mongolian spots have an extracellular sheath and are frequently associated with disorders of inborn errors of metabolism and vascular birthmarks. Naevus of Ota Blue-grey to brown pigmentation affecting face usually unilaterally in the area supplied by the ophthalmic and maxillary divisions of the trigeminal nerve. Naevus of Ito Similar to naevus of Ota but situated in the distribution of posterior supraclavicular and lateral brachial cutaneous nerves. Dysplastic naevus syndrome (atypical mole syndrome) Recognition of this syndrome is important because of the increased frequency of malignant melanoma associated with it. These patients should be reviewed regularly and any suspicious moles removed for histological examination. It is helpful to take detailed clinical photographs and dermatoscopy photographs of their moles for future comparison. Clinical features the lesions are variable in number and may be quite large compared with ordinary moles. In such a scenario, dermoscopy is a useful tool for the evaluation of skin lesions. It has increased sensitivity and specificity for melanoma, allowing detection at an early stage. It acts as a bridge between clinical suspicion and biopsy, thereby reducing the number of unnecessary biopsies of naevi. Spitz naevus (juvenile melanoma) this is an uncommon, benign lesion of childhood and adolescence; its alternative name derives from its histological appearance, which may look frighteningly like a melanoma to the uninitiated. Epidermal naevus Epidermal naevi are an uncommon, localized malformations of the epidermis, composed of keratinocytes and classified as hamartomata. They are congenital in origin, represent genetic mosaicism, and are usually present at birth. Histologically, there is regular epidermal thickening and hyperkeratosis, often in a church-spire pattern. Sometimes they track along with a limb and adjoining trunk and are extensive and disfiguring.

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Although the number of study cases was small and the follow-up period was short (only 12 weeks) erectile dysfunction causes drugs order 30 caps vimax visa, smash grafting was found to be a simple erectile dysfunction causes heart disease cheap vimax 30 caps online, easy to learn, and cost-effective one-stage procedure with gratifying results for extensive areas of vitiligo with no surgical complications as compared to other surgical methods [9]. The authors concluded that smashed skin grafting is a there was more pigment spread and cost of the procedure was low as compared to punch graft (Table 37. Repigmentation after autologous miniature punch grafting in segmental vitiligo in North Indian patients. Flip-top pigment transplantation a novel transplantation procedure for the treatment of depigmentation. Comparative study of flip-top transplantation and punch grafting in stable vitiligo. Smash grafting in stable vitiligo: A case study of 30 cases in a tertiary care hospital in north India. The advantage of this technique is that it allows coverage of large body surface areas with a smaller graft. Meshing can also be done manually by making cuts in the graft using a sterile blade. Once the recipient site is cleaned and dermabraded, the graft is transferred and bandaged with saline soaked 238 Tissue Grafting Techniques Chapter 37. Over the past decades multiple treatment modalities comprising of topical/systemic immunosuppressives, phototherapy, excimer laser, and surgical grafting (splitthickness skin grafting, suction blister, punch grafting, follicular unit, and melanocyte transfer) have been successfully tried [2]. The pathogenesis of vitiligo has led us to understand that the destruction of the melanocytes of the epidermis and hair follicles leads to depigmented patches and leukotrichia, respectively. As we already know that a vitiliginous patch with leukotrichia is considered to have a poor prognosis, this finding suggests that repigmentation of vitiligo is linked to hair follicles, and this in turn is the principle of follicular unit transplantation in vitiligo. These cells possess the ability to supply the hair matrix with transient amplifying cells and eventually mature into melanocytes producing melanin [11]. This reservoir of inactive melanocyte stem cells is present in the lesional epidermis of patients with vitiligo, even after disease of 25 years duration [12]. There are several advantages of hair transplantation in treatment of vitiligo over other methods. The melanocyte to keratinocyte ratio in a follicular unit is 1:5, which is much higher than the epidermal melanin unit (1:36) [16,17]. Furthermore, anagen hair bulb melanocytes are larger, more dendritic, more active, have extensive Golgi and rough endoplasmic reticulum, and produce larger melanosomes [17]. These melanocytes also have an amazing replicative ability and potential for producing a larger quantity of melanin and are immunologically less susceptible to autoimmune destruction due to their protected localization [17]. The hair follicle is an immunologically privileged site not subject to immune surveillance besides follicular melanocytes below the arrector pili muscle, which show reduced expression of class I major histocompatibility molecules. For these reasons follicular melanocytes are more resistant to immune destruction. Although the appearance of pigmentation is delayed as compared to other modalities, the color match is much more acceptable due to stem cell migration from the graft and the specific location that amplifies cell proliferation. These inactive melanocytes move up along regenerated epidermis, leading to perifollicular pigmentation, and downward toward the hair matrices where on maturation they synthesize melanin on activation by ultraviolet light or removal of epidermis following dermabrasion [3,6,7]. In 1992, noncultured melanocyte transfer was introduced by Gauthier and Surleve Bazeille [8]. In the case of body hair transplantation, the advantage is that hair does not require frequent trimming as is required with scalp hair. They found almost complete (>90%) repigmentation in three of five patients with vitiligo, around 50% repigmentation in one patient, and less than 10% repigmentation in one patient. Their technique is simple; however, the cell yield is less in the case of plucked hair follicles, and optimization of cell harvest from the hair follicular unit needs to be standardized for optimum yield. In the era of cell-based therapies, the future may involve culturing melanocytes to treat a variety of pigment disorders, such as albinism and vitiligo. Cultivation of melanocytes in vitro can increase the cell number dramatically, and cells from a small piece of normal skin can be used to treat large depigmented areas. Mesenchymal stem cells inhibit T-cell proliferation and induce T-cell apoptosis [21].