Our Story


Southwestern University School of Law. M. Diego, MD: "Order Evista online - Proven Evista online no RX".

A three part tagging system (full discount 60mg evista fast delivery menstrual cramp icd 9, in use discount 60 mg evista with amex omega 7 menopause, empty) evista 60mg lowest price women's health and wellness issues, should be utilized to indicate status of tank. To clear dust particles, crack the tank valve slightly prior to applying a regulator to a new bottle. Prior to placing non-rebreather masks on the patient, care should be taken to fully inflate the oxygen reservoir bag. A minimum of one stokes litter should be maintained with flotation devices permanently affixed. Each end of the litter shall have a minimum of 20 feet (or longer based on ship’s configuration), of 21 thread manila line permanently secured with a minimum of 4 – 5 tucks on each splice. The line will allow the stretcher to be handled from the main deck of the ship and above. A minimum of three patient securing straps shall be permanently affixed to the stretcher and stopped with twine. Each ship will be required to have on board a full allowance of Medevac Rescue Litters. G-8 Hoisting Sling and Trail Line Assembly must be purchased for hoisting operations. Item: Inventory List Adhesive Bandage, ¾”X 3” (Band Aids) Adson Tissue Forceps, 4 ½” Artificial Respiration & Mouth To Mouth Resuscitation Instruction Card Aspirin Tablets, 325mg Tabs Compress and Bandage, 4” X 4” Compressed Gauze Bandage, 2”X 6”, 4”X 6” Compressed Gauze Sponge Surgical, 2”X 2” Compressed Muslin Bandage (Cravat), 37” X 52” Eye Dressing First Aid Kit First Aid Field Dressing, 4"X 7" First Aid Instruction Sheet General Surgical Scissors, Straight 5 ½” Lipstick, Antichap Meclizine, 25 mg, Tabs Medical Chest Petrolatum Gauze 3" X 18" Povidine Iodine Solution, 10%, ½ Fl Oz Sulisobenzone Lotion U/V Screen 10% 75gm Wire Fabric 5 ¼” X 36” First Aid Kit, Carry Bag These kits should be placed throughout the vessel for emergency use. The kits should be inventoried quarterly and inspected monthly or immediately after use. Item: Inventory List Absorbent Gauze, 18" X 36" Adhesive Bandage, ¾”X 3” (Band Aids) Adhesive Surgical Tape, 1”X 5 Yards Compressed Gauze Bandage, 2" X 6", 3" X 6" Compressed Muslin Bandage (Cravat), 37” X 52” Compress and Skull Cap, Head Dressing Elastic Cotton Bandage with Rubber Wrap Threads, 3” X 4 ½ yds First Aid Field Dressing, 4” X 7”, 7 ½” X 8”, 11 ¾” Square App. These areas should be designated in writing and posted in the ships operational plan and sickbay operating plan. Health care personnel must ensure the water is secure and not being used for other purposes. Portable medical lockers contain enough medical supplies and equipment to support a large number of casualties remote from sickbay. Decontamination lockers should be maintained at or near each saltwater decontamination station as designated in the ships design. This inventory should include as a minimum, nomenclature, quantity, quality control data, and documented date of inspections. Decontamination Locker Requirements: One or two per vessel as required by ships configuration. An inventory list with expiration dates should be affixed to the outside and the locker should be sealed in such a manner to ensure that tampering has not occurred. Poison Control Center phone numbers should be posted on the outside of the antidote locker. Items annotated with a “C” are Drug Enforcement Administration designated Controlled Substances and must be stored in a safe within a secure area. G-17 Sulisobenzone Lotion U/V Screen 10% 75gm Surgical Lubricant, 4oz Transdermal Scopalomine 1. Nevertheless, the nature of sea duty is such that dental emergencies will arise periodically. While rarely serious, these emergencies can be extremely painful and can serve to debilitate any sailor. A working knowledge of the drug locker, especially antibiotic and analgesic medications, is essential in the management of dental emergencies at sea. Item: Color Chlorine - Bromine & Ph Determination Comparator Set, Dpd Method Colilert Bacteriological Water Thest Starter Kit (Cat. Worthington Oconomowoc, Wi 53066 (414) 567-4047 *(Second Unit To Be Used As Backup While Primary Unit Is Being Calibrated Or Repaired) Thermometer, Pocket Max-Registering (Part #07293) Adams-Burch, Inc. H- i Tuberculosis H-42 Typhoid Fever (Enteric Fever) H-43 Typhus Fever H-44 Undulent Fever (Brucellosis, Malta Fever or Mediterranean Fever) H-46 Whooping Cough (Pertussis) H-47 Yaws H-48 Yellow Fever H-49 App. Since the epidemiology and treatment recommendations change over time, as new antibiotics are developed and resistance to older ones evolves, more current information is available at the Centers for Disease Control and Prevention website at: http://www. Obtain immediate medical consultation when treating patients suspected of having any serious infectious disease. These may be as simple as wearing a long sleeved-shirt or applying insect repellant to prevent a tick-born or mosquito transmitted disease. Lifestyle, including sexual practices, is also linked to infectious disease transmission. Over 30 microorganisms can be sexually transmitted with many having similar symptoms. Despite this complexity, initial management (with subsequent referral) can be accomplished in many settings with a minimum of resources. The following clinical syndromes associated with sexually transmitted diseases will be discussed in this section: Urethral discharge (urethritis) App. The end of this section addresses general management issues including counseling, partner notification, referral, sexual practices, symptomatic individuals and prevention. Urethral Discharge (Urethritis) Urethritis is characterized by a discharge from the urethra and burning with urination. It is usually caused by one of two bacteria: Neisseria gonorrhoeae (which causes gonorrhea) and Chlamydia trachomatis (which causes chlamydia), both of which infect and irritate the urethra. The usual incubation period for gonorrhea is 3-5 days and the discharge is yellow or green. The incubation period for chlamydia is longer, 1-5 weeks (usually 10-16 days), and the discharge is less profuse, less purulent (often white or watery) and less painful. If a microscope is available, examination of a Gram-stain of the discharge may disclose gram-negative diplococci inside of white blood cells, diagnostic of gonorrhea and the patient should be treated for both gonorrhea and chlamydia. If the Gram stain of the exudate does not disclose white cells with gram-negative intracellular diplococci, the patient should be treated for chlamydia. If no microscope is available, it is difficult to distinguish gonococcal urethritis from chlamydial urethritis with surety and the patient should be treated for both. These women do not have a urethral discharge, but have pain with urination due to the urethral inflammation. Various antibiotic regimens have been developed to treat gonorrhea and chlamydia, separately and/or together. H-2 The epididymis, which stores sperm and is located on the posterior side of the testicle, may become infected by C. In men >35 years of age, or in homosexual men, epididymitis is frequently caused by bacteria that cause urinary tract infections. Epididymitis must be differentiated from acute testicular torsion (twisting of the testicle inside the scrotal skin, which can lead to loss of blood supply to the testicle. If torsion is suspected, based primarily upon sudden onset, excruciating pain, age under 20, and elevation of the testicle, immediate consultation should be obtained because immediate surgery may be needed. Examination of a patient with epididymitis shows tenderness of the epididymis and possible swelling. In men with sexually transmitted epididymitis, there will usually be symptoms or signs of urethritis, but this may not be prominent (particularly in men with chlamydia). If possible, a microscopic examination of the urethral secretions or urine should be performed to look for white blood cells and microorganisms.

After gy supplied with food and energy spent on physical binding with α-melanocortin evista 60 mg sale 66 menopause symptoms, receptor stimulates activity cheap evista 60 mg without prescription women's health magazine 6 week boot camp. On the con- obesity buy evista overnight delivery womens health subscription, which is a part of syndrome ñ is rare, obesi- trary, when inverse agonist ñ agouti-related protein ty is one of the phenotypic characteristics of the dis- is connected to the receptor, satiety disappears and ease, for example, in Prader and Willi syndrome it is hunger center is triggered. Frequency of monogenic obesi- in children and adults with severe cases of obesity. Higher growth and higher bone G protein-coupled receptors: abnormalities in signal transmission. Currently, a number of clinical studies are con- Regular exercise can cause increased energy con- ducted on substances that can be used as medica- sumption, cause lose weight and prevent obesity. Due to Mutations in the arginine vasopressin receptor 2 the fact that the receptors are in the brain, such drugs Vasopressin (antidiuretic hormone) is a hor- should have a good penetration of the blood-brain mone released from the pituitary in hypovolemia or barrier. Second messenger activates protein of large particles and a long N-terminal domain. The kinase A, which stimulates aquaporin type 2 to interaction of vasopressin with receptor results in move to the basement membrane of the follicle cells. They are tetrameric proteins that form in the cell, and transcellular transport, then with aquaporin cell membrane of the renal tubule channels with 3 and 4, the flow to the interstitial nephron. In obtaining a suitable concentration of urine, vaso- the inactive state, aquaporin 2 is arranged in vesicles pressin detaches from receptor, and aquaporins 2 are inside the cell. After connection to the vasopressin endocytosed or are excreted with the urine (32). In consequence, no water resorp- ed into 15 types within the 4 classes, taking into tion leads to polyuria (33). The process is illustrated account the impact of specific disorders on the sev- in Figure 1. Their role is to join and sta- centrated despite normal hormone level in the blood. In almost 90% of tion with other peptides and assistance for transport cases is inherited and passed on as a recessive disor- to the other places in the cell. These are coperons are small lipophilic compounds, which mutations in the gene encoding aquaporin 2, which penetrate through the membrane into the cell and result in the molecules that are not displaced from bind to the structurally modified, as a result of muta- the cell membrane vesicles to the collecting tubule. This 15 to 20 liters of diluted urine per day) and noctur- mechanism is presented in Figure 2. The structure include dryness and loss of elasticity of the skin and of pharmacoperons affect its efficiency, which dark circles under the eyes. In the case of giving up determines the selectivity of the target protein, treatment, among young people there is a distur- severity of the damage and the location of the muta- bance in the development and reduction of growth. So far, there was only one clinical trial age, mental retardation and problems with growth in which five patients were treated with an antago- and development (33). Vaptans class of drugs (for example and beginning of the treatment can prevent the Tolvaptan) are used in the treatment of hyperna- expansion of mental retardation. Extracellular domain binding addition, elderly patients may have difficulty in the calcium ions and other cations is characteristic for sensation of thirst or in maintaining urine. The result of activating mutation in the calcium ological level, receptor stimulates parathyroid cells receptor is its increased sensitivity to calcium ions. This hor- Therefore, the receptor does not respond properly to mone enhances calcium ions level, by affecting the the reduced concentration of calcium ions in serum bone structure, the glomerular reabsorption from the and does not stimulate secretion of parathyroid hor- initial and calcitriol synthesis in the small intestine mone (17). Children during fever may have seizures contribute to the formation of disorders manifested and be sensitive. The action of this class of drugs is to increase inflammation and allergic reactions in the course of the sensitivity of the receptor to calcium ions, which diseases such as asthma and allergic rhinitis. The drug was adminis- mainly mast cells, eosinophils, basophils, and tered at a dose of 30 mg to 60 mg once a day for macrophages. They cause bron- calcium homeostasis, which was maintained up to choconstriction and vasodilation. In three increased vascular permeability and exudation of related patients, complete disappearance of the macromolecules, swelling of the tissue is also symptoms of hypercalcemia has been shown. Mutations in genes encoding leukotriene of the patients experienced adverse reactions. Their presence also affects the Arg315Lys receptor variant and reduced agonist course of the mechanism of action of drugs, thereby potential for Met201Wal. Paradoxically, only constituting an important reference point for the fur- Met201Wal variant was observed in people with ther search for more effective pharmacologically atopy or asthma. These are lungs, pancreas, small intestine, and in a small dopaminergic, serotonergic, muscarinic and opioids extent in other organs. Dopamine is a major neurotransmitter in are widely distributed in most inflammatory cells, the central nervous system. To a properties on the two groups: D1, which includes lesser extent, it is located in the spinal cord, kidneys the D1 and D5 receptors and D2 receptors including and other organs (39). Drugs for Parkinsonís dis- leukotriene interaction with receptor is mediated by ease are dopaminergic receptors agonists, and in G protein. An example is bromocriptine, which the treatment of atopic asthma blocking leukotrienes antagonist acting to D4 receptor is two times weak- were used primarily (41). Pharmacogenetics research on response after joining agonist and their association serotonin receptors may contribute to the improve- with asthma. His265Arg and Ser268Pro, that may change the parathyroid hormone or inhibition of it secretion. Polymorphic variants receptors binding to many, different ligands, which can initiate disease or be a potential risk to their include, inter alia, hormones, neurotransmitters, and development. It is characterized by abnormal protein, which upon activation changes its confor- process of collecting and concentrate urine in the mation. They also interact mutations, which in different ways influence the with a large group of drugs inter alia in the treatment activity of the receptor (26). Mutations, which occur at to inflammatory mediators, play an important role in different levels of receptor maturation, initiate allergic reactions. This genes encoding these receptors cause many changes receptor is responsible for the process of seeing. Identify typical signs and symptoms of viral diseases spread by airborne transmission 3. Identify typical signs and symptoms of common food- borne and waterborne viral diseases 3. Nearly half of Americans sufer from at least one chronic condition, and the number is growing. Chronic diseases—such as cancer, diabetes, hypertension, stroke, heart disease, respiratory diseases, arthritis, obesity, and oral dis- eases—can lead to hospitalization, long-term disability, reduced 1 quality of life and, often, death. In fact, such persistent condi- tions are the nation’s leading causes of death and disability. According to the Centers for Disease Control and number had grown to 133 million, and by 2020, Prevention, more than two-thirds of deaths in the experts project that 157 million will be affected. Heart disease, cancer, respiratory diseases and These diseases affect more than one in two adults stroke are the leading killers of Americans; the and more than one in four children in the United top two alone account for nearly half of all deaths States. Due to the nation’s rapidly aging population and At the turn of the century, 125 million Americans a nationwide increase in risk factors for chronic had at least one chronic condition; by 2005, that disease—such as obesity—this trend shows no sign of abating.

Discount evista 60mg line. Women's Health: PCOS condition without a cure - BBC Stories.

discount evista 60mg line

cheap evista online mastercard

Endocrine: Thyroid trouble order evista overnight delivery women's health center westwood, heat or cold intolerance order evista menopause in 30s, diabetes buy evista with a visa womens health online, excessive thirst or hunger. The extent to which each system described above is reviewed will depend on the problem identified in the problem-focused health history. The health care provider will need to decide how extensive the physical examination should be. An abbreviated version of the complete physical examination will be described in this section. While the history includes subjective information from the patient, the physical examination is the objective information which is observed or measured by the health care provider. Four basic assessment techniques are involved in the physical examination that is, inspection, palpation, percussion, and auscultation. All four are employed in the head to toe systematic physical examination of the patient. The examiner uses the most sensitive parts of his or her own hands and may assess individual structures within the body cavities for position, size, shape, consistency and mobility. Percussion involves striking an object to elicit a sound or reaction of a body part. It may involve use of both hands at the same time, or the hand as a fist, or a percussion hammer. The sound that is produced is due to the vibrating structures underneath indicating the state of the structure being struck. Auscultation is the act of listening to the sounds produced by the human body, particularly those produced by the lungs, heart, and abdominal organs. The physical examination begins with an initial survey or general inspection of the patient. The health care provider observes the general state of health, level of consciousness, stature, symmetry, weight and nutritional status, mental status, speech, general skin condition, any signs of distress or disorder. Blood pressure is most commonly measured indirectly with a sphygmomanometer and stethoscope. To use a blood pressure cuff and stethoscope: Assist the patient to a comfortable sitting position, arm slightly flexed, with the forearm supported at heart level with the palm turned up. Expose as much of the upper arm as possible with no tight constrictive clothing to obstruct blood flow or interfere with reading. The patient should have rested for at least five minutes before taking the blood pressure reading. When possible, have the 1-5 patient avoid smoking for 30 minutes before taking the blood pressure reading. Position the cuff about 1 inch above the brachial artery pulsation (about at the area where the inner crease of the elbow occurs). If the cuff is too narrow, the blood pressure readings will be erroneously high; likewise, if the cuff is too wide, the blood pressure readings will be erroneously low. Relocate the brachial artery and place the diaphragm or flat piece of the stethoscope over the artery. Screw the valve tightly closed and inflate the cuff again to at least 30 mm Hg above where the brachial artery pulse was felt. Make careful note of the point on the manometer where the first clear sound is heard. Continue slowly deflating the cuff making special note of the point where the sound is no longer heard or disappears altogether. The patient’s blood pressure is the systolic/diastolic reading Keep in mind that during anxiety or stress, the blood pressure may become elevated. A single elevated blood pressure reading is an indication that the blood pressure needs to be retaken. The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommends that hypertension, elevated blood pressure, should be diagnosed only when a higher than normal level has been found on at least three consecutive readings. The systolic blood pressure is the first sound heard and is recorded as the upper level while the diastolic blood pressure is the point where sound disappears and is recorded as the lower level. The peripheral arterial pulse is a pressure wave transmitted from the left ventricle to the root of the aorta and to the peripheral vessels. This measure of peripheral pulsation gives an indication of cardiac function as well as perfusion of the peripheral tissues. The characteristics normally noted include rate, amplitude (indicating volume), rhythm, and symmetry. The rate is considered normal between 50 and 100 beats per minute as defined by the American Heart Association. Rates more than 100 beats per minute are suggestive of abnormality, particularly in the absence of physical exertion. If the rate and rhythm appear normal, count for 15 seconds and multiply times four; if the rate is unusually fast or slow, count it for a full 60 seconds. Disposable nasal specula and tongue blades must be available and appropriately disposed of after use. Wash hands before putting on gloves and after taking them off when examining each patient. Skin turgor is the degree of fullness and elasticity observed in the skin, indicating circulation and hydration status. If there are lesions present, identify the location, size, note the configuration of any grouping of arrangement of the lesions, note the color, describe any other qualities and try to identify the type of lesion. Head and Neck: The head is inspected by observing the position of the head and noting any unusual movements, size, shape, and symmetry of the skull. Assessment of muscle function is done by checking for the range of movement by flexion, extension, and lateral rotation from side to side. The patient should be able to do this freely, smoothly and without experiencing pain or dizziness. The midline neck structures are palpated for presence of masses and for enlarged lymph nodes. The thyroid may be examined with the health care provider standing either in front of or behind the patient. However, it is easiest to examine standing behind the patient and using both hands to palpate the thyroid. Ask the patient to swallow and then palpate the thyroid gland as it rises during swallowing. A palpable mass of 5 mm or larger is considered to be a nodule; and, the location and size should be described. Ears, Nose and Throat: Examine the external portions of the ear for position, size, symmetry, and presence of lumps or lesions. If gently palpating the area in front of the ear and manipulating the tip of the outer ear produces pain, the patient may have an external otitis.

However order evista 60mg with visa breast cancer nail designs, the role of Tregs cells in human hookworm infection is still poorly understood and has not been addressed yet quality 60mg evista womens health jackson wy. Introduction: Paracoccidioides brasiliensis is the agent of paracoccidioidomycosis discount evista 60 mg on-line women's health center avon nj, the most prevalent deep mycosis in Latin America. The production of eicosanoids during fungal infection has been associated with the biology of fungi, and the modulation of host immune response. Federal Fluminense University Introduction: The existence of a nervous form in the chronic phase of Chagas disease is matter of discussion. The mechanisms favoring parasite persistence in an apparent silence in the nervous tissue, while myocarditis progresses from the acute to the chronic phase of infection, remain to be understood. Introduction: Ouabain is a cardiotonic steroid identified as an endogenous substance of human plasma and has been proposed to act as an immunomodulator. Leishmaniasis are diseases caused by pathogenic species of protozoans that belong to the genus Leishmania (Leishmania) transmitted by the bite of the female phlebotomine sandfly. Despite the anti-inflammatory role of ouabain, little known about its effect on Leishmaniasis. Previous data from our group, demonstrated that ouabain produced a significant reduction in the mouse paw edema and reduced cell migration into the peritoneal cavity induced by Leishmania amazonensis. However, the mechanisms involved remain unclear Objective: Evaluate cytotoxic potential of ouabain against 2+ Swiss mice macrophages and influence of ouabain in intracellular Ca levels in Leishmania amazonensis promastigotes. Conclusion: This work demonstrated that ouabain is capable to 2+ increase intracellular Ca levels. It is unlikely that the effect observed by us resulted from cell death, as macrophages, in vitro, remained as viable in the presence of different ouabain concentrations as cells kept in medium. Macrophages are cells that play an important role in the induction and regulation of the immune and/or inflammatory response and important for controlling pathogen growth. The innate immune system is crucial in the antifungal response and macrophages are important for controlling pathogen growth. It was recently demonstrated the importance of Notch receptors in regulating the activity of macrophages and the immune system. Whereas Notch signaling may be involved in modulation of macrophage function, we evaluate the ability of P. The transcriptional analysis of Notch 1 revealed that there is an increased level of transcription in 24 hours, while there is a reduction of its ligand Delta 4 in 24 hours. These data suggested that the proteins OspC1 and OspF play a role in the inflammatory response. Conclusion: These results suggest that the effector proteins OspF and OspC1 are involved in inhibition of the inflammatory response in intestinal epithelial cells contributing with bacteria colonization and infection in the intestinal mucosa. Although the requirement of a functional cellular immune response for antimony antileishmanial action was previously V reported, the cellular and molecular mechanism of involved is still unclear. The Sb 50% inhibitory concentration for the isolates from refractory patients was 741+32 and for the sensitive patients was 381+100, p>0. Isolates from refractory patients were more infective than isolates from patients responsive to treatment, independently of these stimuli and in all times post infection. Although isolates from refractory patients produced more nitrite than those from responsive, the rate nitrite/amastigotes was six times lower in the macrophage infected by isolates from refractory patients. The aim of this study was to investigate whether the cytokine/chemokine pattern produced by peripheral blood mononuclear cells upon in vitro S. Cytokine/chemokine signatures were analyzed using the concept of low and high-cytokine producers. Faculdade de Medicina de Ribeirão Preto, Universidade de (4) São Paulo, Ribeirão Preto, Brasil. Introduction and objective: Chagas is a neglected tropical disease caused by Trypanosoma cruzi (T. Galectin-1 (Gal-1) is a multifunctional lectin that participates in several biological processes, including modulation of the immune response. Thus, this work aimed to investigate the role of endogenous Gal-1 during the course of experimental T. Introduction: Malaria is characterized by intense activation of the immune system that seems to contribute to protection against infection and to clinical manifestations related to disease. Kinetics of phagocytic cells in the spleen of these infected animals was determined by flow cytometry, in relation to number of cells and cell death. In addition, the percentage of leukocytes cell death found in spleen in the same day was lower in knockout group (12. Conclusion: Mice lacking the P2X7R seem to be more susceptible to the exacerbated immune response that is responsible for clinical symptoms, thus, presenting more severe pathological parameters for more time. Introduction: Macrophages (MØ) display heterogeneous phenotype according to the distribution to different tissue and the cytokine-chemokine networks. Fragments of the footpad, popliteal lymph node, liver, spleen and kidney were submitted to determination of the fungal load. Overtime, they exhibited a reduction of fungal load and, the percentage of this subset returned to normal levels. These data suggest a recompartmentalization of effector cells with cytotoxic activity, which may play a pivotal role in T. Introduction: The Chagas‟ disease is an illness highly neglected caused by Trypanosoma cruzi parasite. Here we study the effects of Zileuton treatment on some parameters of immune response and development of myocarditis during T. Results: We found reduced parasite load in mice treated with Zileuton compared with untreated mice. Furthermore, the Zileuton treatment resulted in lower leukocyte infiltration in cardiac tissue and our electrophysiological analyses, using the patch-clamp technique, demonstrated that the treatment also resulted in the protection of cardiomyocytes activities, including decreased in the repolarization time. Conclusion: Therefore, our results suggest that Zileuton treatment could be a “powerful tool” in the therapeutic field to modulate the development of cardiomyopathy in Chagas‟ disease. However, the role of these receptors in canine visceral leishmaniasis is not yet clear. To check if the apoptosis in T cell is dependent on 6 cell contact, macrophages were infected with 5x10 promastigotes of L. Data were acquired in the cytometer EasyCyteMini and analyzed with the Cytosoft ® software. The results were compared using the Mann-Whitney test, with significance level of 5%. As apoptosis is an important mechanism regulating the activation of lymphocytes, we decided to study the role of lymphocytic apoptosis during a non complicated malaria attack. However, the lack of correlation among apoptosis and parasitemia, number of past malaria attacks and low cellular response, specially against malaria antigens, suggest that apoptosis associated to uncomplicated malaria could be a physiological reaction of the immune system to control polyclonal activation and maintain the balance of these cellular population densities. After last immunization, sera and draining lymph node were collected for serologic tests and quantification of cytokine, respectively.