PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

ANU JOSEPHIst year M.Sc (NURSING)

MEDICAL SURGICAL NURSING YEAR 2008-2010

CAUVERY COLLEGE OF NURSING# 42/2B, 2C, TERESIAN CIRCLE

SIDDARTHA LAYOUTMYSORE.

1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR

DISSERTATION

1. NAME OF THE CANDIDATE

AND ADDRESS

ANU JOSEPH

1ST YEAR MSC NURSING

CAUVERY COLLEGE OF NURSING

MYSORE .

.

2. NAME OF THE INSTITUTION CAVERY COLLEGE OF NURSING

MYSORE .

3. COURSE OF STUDY AND

SUBJECT

M. Sc. NURSING I YEAR

MEDICAL SURGICAL NURSING

4. DATE OF ADMISSION TO

COURSE

30-06-2008

5. TITLE OF THE TOPIC

DETERMINE THE EFFECTIVENESS OF

STRUCTURED TEACHING PROGRAMME ON

KNOWLEDGE REGARDING ACNE AND ITS

PREVENTION AND MANAGEMENT AMONG

ADOLESCENT BOYS AND GIRLS STUDENTS

OF ST. PHILOMENA’S COLLEGE,MYSORE.

5.1 STATEMENT OF THE

PROBLEM

A STUDY TO DETERMINE THE

EFFECTIVENESS OF STRUCTURED

TEACHING

PROGRAMME ON KNOWLEDGE REGARDING

ACNE AND ITS PREVENTION AND

MANAGEMENT AMONG ADOLESCENT BOYS

AND GIRLS STUDENTS OF ST. PHILOMENA’S

COLLEGE,MYSORE.

2

6. BRIEF RESUME OF THE INTENDED WORK:

6.1.

6.2

INTRODUCTION:

"Youth is Happy because it has the ability to see beauty. Anyone who keeps the ability to                                         -Franz Kafka                  

"Beauty is only skin deep, but it is valuable asset if you are poor and have not any sense".                                               - Kin Hubbara 1  

            Skin is the largest organ system of the body and it is indispensable for human life.2

Each person's unique appearance is established through the skin and Once it was thought to reflect the "normal aging process" it plays a critical role in person's mental and physical health and always integral to self-esteem. Proper skin care can prevent dermatological disease and can enhance the beauty. A good and healthy skin is always essential for the proper development of all faculties of the individual.3              

Acne is common skin disorder of the oil glands when overactive sebaceous (oil) glands secrete too much oil (sebum) in the skin which leads to the plugged pores and outbreaks of lesions called Pimples/zits. This is characterized by the recurring formation of blackheads, white heads and pimples. Acne lesion occurs primarily on the face and sometimes on the back, shoulders, chest and arms. The incidence of acne is greatest during puberty, adolescence, and when hormones influencing the secretion of oil glands are at their peak level of activity such as during stress, emotional problems, menstruation menopause and exercising.4 Nearly, 17 million people in the United States have acne, making it the most common skin disease. Although, acne is not a serious health threat, severe acne can lead to disfiguring, permanent scarring, which lead can be upsetting to people who are affected by the disorder. 5          

The term acne derives from the Greek word 'acme' from the writings of Actius Amidennus, he use this term "acme" in the sense of skin eruption" and vulgaris indicate the meaning "common" Acne. Vulgaris or common acne is the most experienced acne among teenagers. 6           

Acne vulgaris is commonly called as pimples and symptoms include presence of open and closed comedones, pus pockets, raised red areas of skin, pustular lesions most commonly on face, neck, back and chest. Apart from these, pain, soreness, itching and scarring may occur overtime and the condition may worsen before menses due to hormonal changes.7

NEED FOR THE STUDY  

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Acne vulgaris is a common skin disease affecting at least 85% of adolescents and young adults. This disorder often dismissed by the medical community and general population as superficial affliction associated with growing up, however scientific evidences has illustrated that the effects of condition are far more than skin deep.8           

Acne vulgaris affect roughly 80% of female and 90% male adolescents. In generally worse is adolescent male and tends to subside as people reach their late 20's. 3% of man and 12% of women over the age of 30 are still plagued by the disease (Erlich and Kabn, (2004)). Furthermore, 20% of newborn develop acne, 25% of suffers will have permanent scars and only 16% of adolescents seek medical treatment for their skin (Arnold, (2006)).9           

Seventeen million Americans or 85% of people 12-24 years of age affecting with acne. Whereas, Canada has least prevalence (2,081,742 million) compared to USA. While Indians are moderately having acne approximately 66,566,912 million.10            

Kilkenny M, Merliss K, Plasket S, Marks R ( 1998  ) conducted a study on the prevalence of common skin conditions in Australian School student; acne vulgaris. They accessed by a randomized sample of 2491 students (aged 4-18 yrs) throughout the State of Victoria in Australia. The prevalence rate between the age group of 16-18 was 95% (c 189.6-96-9). This result shows that acne is a common problem especially adolescents.11           

Tan, H. H, Tan, A.W, Barkhan T, Yas X.Y, Zbum ( 2007 ) done a community based study of acne vulgaris among adolescents aged 13-19 years. In this cross sectional study 88% of teenagers themselves reported as having acne out of 1045 participants.12

Today society has a long standing prejudice against skin disease that need to be dispelled. Historically, skin disease has been perceived as divine punishment for being spiritually and physically unclean. Subtle punishment of skin disease still exists because of ignorance, so, it became as urgent need to provide accessible and accurate health education or structured teaching programme to change their beliefs and attitudes.3            

Al-Hoquail, I. A, (2001) revealed a study on knowledge, beliefs and through the help of questionnaire. This study vehimently pointed out that misconception and false beliefs on acne are wide spread and enduring among the youth. Health education programme on acne is needed to improve their understanding of the conditions.13   

Al Robaee, (2005) as conducted a study on prevalence, knowledge beliefs and psychosocial impact of acne in university students in central Saudi Arabia. The sample size was 717 students and chi-.square test was used. At last, the researchers found that health education is necessary to improve their knowledge as well as change their beliefs

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and misconcepts about acne. 14           

According to WHO "Health is a state of complete, physical, mental and social well being and not merely an absence of disease or infirmity".15 But, Acne significantly effects physical and psychosocial wellbeing.16 Clients who have visible chronic skin problems often withdraw from social situations and have altered interpersonal relationships and increased social isolation. When their clients seek professional care for skin problems psychosocial as well as physical concerns need to be met.3            

Even though relevant scientific researches discuss potential effect of acne beyond its dermatological manifestation. It includes effect on psychiatric health, psychological well being and quality of life. Acne has been implicated psychiatric and psychological process more than other dermatological conditions and they report greater level of anxiety and depression. In spite, feelings of embarrassment, shame, guilt, social phobia can develop secondary to acne vulgaris.            

The University of Western Ontario's Department of psychiatry done a recent study on depression among 480 patients with dermatological disorders. They found that 5.6% of patients with non cystic facial acne had suicidal ideation.8            

Karaoha C I, Taylor, Gol, Anctor J, et al.( 2004 ) conducted a study on demographic features, beliefs and socio psychological impact of acne vulgaris among its suffers in two town in Nigeria. The sample size was 174 facial acne suffers and used a self administered questionnaire some of them experienced psychological abnormalities included social inhabitation, depression and anxiety. At last, the researches came to the conclusion that they need to improve the understanding of the disorder in Nigeria though health education programme.17            

Gil Yosipovitch, M. D .( 2007 ) done a study among the secondary school students in Singapore with the age of 14-19 years to understand the interplay between the factors that exacerbate acne and he used a 14 item, self questionnaire, and perceived stress scale. And 92%of the girls and 95% of the boys reported having acne. Finally he suggests that acne severity and stress has an association.16           

Krejci-Manwaring, et al. (2006) conducted an American survey of 479 patients between the age of 16 and 63 and found that acne severity was significantly associated with poor social interactions and lower quality of life. 9           

The investigator has found that, when there are pimples on any face, it has a negative impact on their self esteem and one tiny zit feels like it's the size of a volcano. From the experience of researcher, people having acne unable to face mirrors and feel themselves like a vampire. Because the mirror shows the direct result of acne, the fact is,

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people with acne generally hate the way they look. "I don't like mirrors, I am like a vampire. I shy away from the mirror. I comb my hair using my silhouette on the wall to show the outline of head I have not looked myself in the years, and is painful not to be able to do that and that is direct result of acne, the acne scarring" this quotes come from the heart of investigator's friend. These painful words are the motivational or influencing factors for the investigator to do the dissertation on particular topic. This negative psychosocial effect can have crippling impact discouraging patients pursuing life's opportunities-socially on the job or at school or college.            

When assessing acne, is not just a skin disease but wide spread and socially frustrating conditions. So it is important to take all embracing approach and examine carefully for both clinical and psychological effect of the disease process. Moreover people have to know the causes and prevention of acne.            

Exact cause of acne often unknown others include family or genetic history hormonal activity, inflammation, stress hyperactivity of sebaceous glands, any medicines and chemicals.   

                                            "Prevention is better than cure"          

Simple remedies will always helps to get rid of acne and its complications. It includes,

Keep face clean Drink plenty of water

Increase the intake of citrus fruits  

Avoid

Squeezing and picking of pimples Use of oily cosmetics

Excessive hair oil

Stress factor

Infected acne lesion by touching with hands. 19      

6.2. REVIEW OF LITERATURE:

Review of literature is a key in research process. This will help to make a

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stepping progress of the study .The literature reviewed under the following headings. 

1. Prevalence of acne. 

2. Etiological factors of acne. 

3. Management of acne. 

1.Studies related to the Prevalance of acne 

        Menon C,Gipson K, Bowe WP , Hoffstad OJ, Margolis DT(2008) performed a

study on validity of subject self report for acne among university students. They used

acne questionnaire and the validity of self report was measure by sensitivity, specificity,

positive predictive value and negative predictive value and the agreement was measured

by Cohen's Kappa and correct classification percentage. Validity of self report was

moderate at best agreement was fair, indicating that college students accurately report that

they have acne.20  

     Tan H.H, Tan A.W, Barkham T, Yan X.Y, Zhun (2007) revealed a community

based study of acne vulgaris among adolescents in Singapore. The sample size was 1045

adolescents aged 13 to 19 years.  Among that 88% reported having acne and need

assessable and accurate education on acne.12  

   Al Robaee, A.A,(2005) conducted a study on prevalence, knowledge, beliefs,

psychosocial impact of acne in university students in Central Saudi Arabia. The sample

size was 717 students and use Chi-square test. To conclude Acne is a common skin

disease among Qassim university students and need health education to encourage people

to seek medical help.14 

2. Studies related to the Etiological factors of acne 

    Xu S.X , Wang H.L , Fan X. et al. (2007) revealed a study on the familial risk of

acne vulgaris in Chinese Hans ethnic group. It was a case controlled study and he include

volunteers of 975 acne cases and 580 controls. The final result said that the risk of acne

vulgaris occurring in a relative of patient of acne vulgaris was significantly greater than

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for the relative of an unaffected individual [odds ratio 4.05, 95% confidence interval

{ CI} ; 3.45-4.76, p<0.001]21 

     Huba A.T, Zawar, V, Wong, W.C.W, Lee, A. (2007) presented a study on the

association of smoking and acne in men in Hong Kong and India. The setting was 3

primary care practices in Hong Kong and 1 primary care practice in India and used a

retrospective case control study. They collected a data from 632 records of patients with

acne seen in the previous five years and they concluded that smoking is likely to bear a

positive correlation with acne for men.22   

   Wu T.Q, Mei S.Q, Zhing J.X et al.(2007) did a study on the prevalence and risk

factors of facial acne vulgaris among Chinese adolescents. The sample size was 3163

students between the age of 10 to 18 years from 7 schools and used self administered

questionnaire and physician examinations. At last they found that significant risk factors

of acne vulgaris included age, skin type, insufficient sleep and cosmetic make up use.23  

         A cross sectional study was conducted (2007) on prevalence of acne and related

psychological health among 600 participants of high school students and the

questionnaires consisted of General Health Questionnaire [GHQ] and Rosenberg Self-

Esteem scale [RSES]. Finally they found the factors implicating the causes for acne were

food, bad skin hygiene and hormones in increasing frequency.24  

       Parker Magin, Dimity Pond, Wayne Smith, Alan Watson et al [2007] performed a

study on a systematic review of the evidence for 'myths' and 'misconceptions' in acne

management is diet, face washing and sunlight. Original studies were done by the

searchers of the Medline EMBASE, Amed, CINAHL, Cohrane and DARE  data base.

The result had shown little evidence exists for the efficacy or lack of efficacy for dietary

factors, face washing and sunlight exposure in the management of acne.25

    Jemec GB, Linnerberg A, Nielson N.H et al [2002] did a study on "Have oral

contraceptive reduced the prevalence of acne?" a population based study of acne vulgaris,

tobacco smoking and oral contraceptives among Danish adolescents and used a random

sample of 186 population of 15 to 22 years old. To summarize they proved that the use of

oral contraceptive was associated with significantly lower prevalence of acne while the

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use of tobacco and smoking was not significantly associated with acne.26 

3.Studies related to the Management of acne  

    Rustom Tehrani(2004) revealed a study on the management of premenstrual acne

with Cox –2 inhibitors in the dermatology outpatient department of tertiary care hospital

in Karnataka. The sample size was 80 women with premenstrual acne and used Refecoxib

[ a cox-2 inhibitor or Placebo] for ten days for 2 cycles and determined that refecoxib was

more effective than placebo.27 

      Sanjana P.H (2003) performed a post marketing surveillance study to assess the safety

and efficacy of Aadapalene gel 0.1%[adaferin] in acne vulgaris. The sample size was 571

patients from 21 centers across India and used multicentre, open label, non comparative

study for twelve weeks between January and September[2002]. At the ends of therapy

96.3% of patients show improvement. They concluded that Adapalene gel 0.1% is a safe

and effective topical agent and it can be used as the combination of topical and oral anti

acne agents.28 

       Webster GF did a study on safety and efficacy of Tretin-X compared with Retin-A

in patients with mild to severe Acne vulgaris. Webster used double-blind, three-treatment

and parallel group studies randomly assigned 1642 adolescents and adults 12 to 14 years

of age. Finally the study concluded that Tretin-X and Retin-A behave similarly in patients

with mild to severe acne both treatment were well tolerated.29     

      Gravelink JM, White VR conducted a study on Concurrent use of laser skin

resurfacing and punch excision in the treatment of facial acne scarring. The sample size was

21 patients with skin type’s I-III with mild to severe acne scarring and photographs were

taken for each stage. Finally they had seen a range of clinical improvement in patients with

facial acne scarring by the use of laser skin resurfacing with the concurrent use of Punch

excision.30

6.3STATEMENT OF THE PROBLEM :

A STUDY TO DETERMINE THE EFFECTIVENESS OF STRUCTURED TEACHING

POGRAMME ON KNOWLEDGE REGARDING ACNE AND ITS PREVENTION AND

9

MANAGEMENT AMONG ADOLOSCENT BOYS AND GIRLS STUDENTS OF

ST. PHILOMENA’S COLLEGE , MYSORE.

6.4. OBJECTIVES OF THE STUDY:

1. To assess the knowledge of students regarding acne management 

2. To determine the effectiveness of structured teaching programme about prevention

and management of acne in students of selected college.

3. To find out the association between the level of knowledge (scores) and their socio-

demographic data

6.5. OPERATIONAL DEFINITIONS:

DETERMINE - An activity to estimate the outcome of structured teaching programme on

knowledge regarding acne, its prevention and management.  

EFFECTIVENESS - Refers to gain in knowledge scores achieved by college students

regarding acne , its prevention and management.

KNOWLEDGE  - Information received to identify acne and its management.

 STRUCTURED TEACHING PROGRAMME -   It is a formal education regarding acne,

its management and prevention for the college students. 

ACNE - It is a small inflamed lump on the skin usually occurs in red color with pus

formation.

ADOLOSCENTS - Refers to students those who are at the age from 17 to 20.

COLLEGE – It refers to a degree college, which come under an university.

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6.6 ASSUMPTIONS:

It is assumed that :-

1. The college students will have less knowledge regarding acne, its prevention and

management.

2. The structured teaching programme will help to improve the knowledge of college

students about acne its prevention and management.  

6.7 DELIMITATIONS:

1. Study is limited to only those who are studying in St. Philomena’s college.

2. Study is limited to age group from 17 to 20.

3. The sample size of the study is 50 college students   

6.8 PROJECTED OUTCOME:

1. This study will promote the knowledge of college students regarding acne, its

prevention and management.  

 

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA COLLECTION Data will be collected from the students studying

in the selected college of Mysore. 

7.2.1. SAMPLING CRITERIA

INCLUSION CRITERIA

1. Those students who are willing to

participate in the students.     

2. Those who can understand and speak

English. 

3. Students with the age group of 17 to 20

years.

1.

2.

EXCLUSION CRITERIA 1. Students who have not given consent.

2. Students who are not available during the

time of study.

3. Students those who are not willing to

participate in the study.

5 Students who have not given consent.

6 Students who are not available during the

7 Students those who are not willing to

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4 Students who previously exposed to similar

research.

8 Students who previously exposed to similar

7.2.2. RESEARCH DESIGN The research design adopted for the study is pre-

experimental design.

7.2.3 VARIABLES UNDER STUDY: Independent variable       

Structured teaching programme on acne, its

prevention and management. 

Dependent variable     

  Knowledge of college students regarding

acne, its prevention and management.   

7.2.4. SETTING OF THE STUDY Study will be conducted in St. Philomena’s

college, Mysore.

7.2.5. SAMPLING TECHNIQUE Convenient method will be used to select the

sample for the study

7.2.6. SAMPLE SIZE The sample size proposed for the present study is

50.

7.2.7. TOOL OF RESEARCH A structured questionnaire in which include the

following sections.

Section I- Pre test questionnaire prepared by

investigator.

Section II- post test questionnaire to

determine the effectiveness structured teaching

programme on adolescents.

The structured questionnaire will be developed by

the help of extensive literature and expert’s

opinion

7.2.8. COLLECTION OF DATA 1. A prior formal permission will be 7.

12

obtained from concerned authority.

2. The purpose of the study will be explained

3. Consent of the participants will be

obtained to involve in the study.

4. A pre- test questionnaire will be

administered.

5. A post test questionnaire will be given

after the intervention.

6. The duration of data collection will be 30

days.

8.

9.

10.

11.

7.2.9 METHOD OF DATA ANALYSIS

AND PRESENTATION

It includes descriptive and inferential

statistics.   

Descriptive statistics                

Demographic variables and level of pre test

and post test knowledge (scores) will be given

in frequencies with their percentage.           

Pre test and post test average scores will be

given using mean and standard deviation.   

Inferential statistics     

Pre test and post test differences will be

analyzed using student paired t-test and

Mc.Nimar Chi-square test .     

Association between the levels of post test

scores with demographic variable will be

analyzed using Pearson Chi-square test  

7.3. DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO

13

BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO,

PLEASE DESCRIBE BRIEFLY.

Yes, the study will be conducted on students of St. Philomena’s colleges at Mysore. This

study has the structured teaching programme as intervention.

7.4. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN

CASE OF 7.3?

Yes, informed consent will be obtained from the institution authorities and subjects.

Privacy, confidentiality and anonymity will be guarded. Scientific objectivity of the study

will be maintained with honesty and impartiality.

8.LIST OF REFERENCES:

1. M.M Divakaran. Great thoughts of great thinkers, H&C Publishing house, Trissur

2. Brunner and Suddarth’s Text book of Medical and Surgical Nursing,Anatomic and

Physiological Overview, 10th Edition, Lippincott William and Wikins Publication, 1639

3. Joyce.M.Black Esther Matassarin-Jaccobs Medical Surgical Nursing,clinical

management for continuity of care, 5th Edition, Saunders Publication, Vol. 2, 2174

4. An article, Questions and Answers About Acne, Skin problems and treatment in Health

centres, retrived from webmd.www.betterinformation.better health on 28th November.

5. Journal Articles “Acne’ published on 2006 January, retrived from http;||

www.nians.nib.gov|health-info|acne|default.asp.

6. Acne- Origin? Retrieved from http:| www.acne-pen.com|whatisacne.php on 15 | 11 |08 at

12pm

7. Treatment for acne or pimples, do acne normally occur in teenagers? 2008 september 06

artricle retrieved from http:| www.clickindia.comdetail.php? id=389429

8. Vaneer Meeen, Vander Schar WW,Vander Hab CM. The Psychological impact of severe

Acne,Cutis 1985, 36:84-6

14

9. An article Epidemiology and psychological implication of Acne Vulgares, an attack on

the skin and psyche retrieved from http;||meducatar.org.php|issue 20006 november,

vol.22, p 60-70.

10. Net Information ‘Statistics by country for Acne’, obtained from http.||

www.wrongdignosis.com.

11. Kilkenny M, Merlin K, Plunkett A, Marks R, The prevalence of common skin conditions

in Australian school students; Acne vulgaris, British journel. 1998 November; 139 (5);

840-5

12. Tan HH, Tan AW, Barkhan T, Yan XY. Zhu M., Community based study of acne

vulgaris in adolescents in Singapore, British journel Dermato 2007 september;(157) (3);

547-51 Epub 2007 July 26

13. Al-Hoquil IA. Knowledge beliefs and perception of youth towards acne vulgaris, Saudi

Med Journel 2003 july; 24(7); 765-8

14. Al Robaee AA. Prevalence, Knowledge, beliefs and Psychosocial impact of acne in

university students in Central Saudi Arabia, Saudi Med journel 2005 December;26(12):8-

61

15. K Park Preventive and Social Medicine,1 7th Edition, Banarsidas, Bhanot Publishers, P-

12.

16. Science news. Link Found between Teens Stress levels and acne severity, science daily

2007 March 06.

17. Karaoha CI, Taylor GOL , Anetor JI et al. Demographic features, beliefs and socio-

psychological impact of acne vulgaris among its sufferers in Two Town in Nigeria,

Department of Internal Medicine, Siraz E-Medical journel 2004 oct, vol.5, No.4

18. An article Acne vulgaris received from http;||en.wikipedia.org. on 2008 November 27.

15

19. An article ‘Do acne normally occur in teenagers, treatment for pimples/acne, 2008, sep.

06. Retrieved from http|www.clickindia.com. on 2008 Nov. 13th..

20. Menon C, Gipson K, Bowe WP, Hoffslad OJ, Margolis DJ validity of subject self report

for acne dermatology (2008);217(2);164-8

21. Xu SX, Wang HL , Fan X et al. the familial risk of acne vulgaris in Chinese Hans: case-

control study. J Eur Acad Dermato, Venereol 21(5); 602-5

22. Chuh A.A.T , ZAWAR V , WongW C W, Lee A. The association of smoking and acne in

men in Hong Kong and in India: A retrospective case control care settings Med know

Publications. 2007

23. Wu TQ, Mei SQ, Zhang JX, et al. Prevalence and risk factors of acne vulgaris among

Chinese adolescents. Int Adolesc med health 2007oct-dec 19(4):407-12.

24. Journal compilation, ‘Acne, Adolescents, Prevalence and Psychological health.’

European Academy of Dermatology and Venereology, Published on 2007 dec 20.Volume

22, issue 4, p 462- 469.

25. Parker Margin, Dimity Pond, Wayne Smith, Alan Watson. A systematic review of the

evidence for ‘myths and misconceptions in acne management: diet, face washing and

sunlight 2007.

26. Jemec G B, Linnerberg A,Nielsen N H et al. Have oral contraceptives reduced the

prevalence of acne?a population based study on acne vulgaris , tobacco smoking and oral

contraceptives , Dermatology 2002 .204(3):179-84

27. Rustom Teherani. Management of premenstrual acne with Cox-2 inhibitors. A placebo

controlled study, Indian journal Dermatol Venerol leprol (2004) 70:345-8.

28. Sanjana PH. Safety and efficacy of Adapelene gel 0.1% in acne vulgaris: result of post

marketing survillance study, Indian journal of dermatology, venerology and amp.

Leprology 2002 vol.69,(No:4)277-280

29. Webster GF. Safety and efficacy of Tretin-X compared with Retin-A in patient with mild

to severe acne vulgaris.

16

30. Grevelink T M, White V R,’ Concurrent use of laser skin, resurfacing and punch excision

in the treatment of facial acne scarring, 1998 may; 24(5); 527-30.

17