Managing Acute Post-Surgery Pain

Agony is a multi orientated and complicated incident that numerous individuals experience the ill effects of and it can diminish one's personal satisfaction of life (Ashelford et al. 2019). The International Association for the investigation of torment (1994) depicts it as a psychological and perceptible upsetting experience, connected to genuine or prospective harm of tissues, or portrayed on the basis of induced harm. Moreover, torment is seen distinctively by people and is frequently hard to assess (Bridgestock, and Rae, 2013). Patients after operation regularly encounter intense agony that should be monitored effectively to prevent it from turning into an interminable torment. Intense agony is legitimately connected to harm of delicate tissues and is the kind of torment that keeps going under three to a half year (Wittink, and Carr, 2008). It is ordinarily connected with a serious abrupt beginning and can be delayed and proceed until the recuperation happens (Linton, 2015). Heath care practitioners (HCP) perform a significant job in dealing with patient's agony; understanding the discernment, dissemination and translation of torment, is central so as to give powerful treatment for torment (Dobson, 1997). Additionally, for those engaged in healthcare research, seeking healthcare dissertation help can enhance their understanding of pain management practices and improve outcomes in clinical settings.

This task shall investigate the pathophysiology along with medication with regard to dealing of intense agony experienced after operation identifying with the mentioned situation. Talab Abbas is a man of 68 years of age who has serious osteoarthritis and experienced an absolute right hip substitution (THR) medical procedure. This assignment shall be partitioned in parts A and B. Section A will fundamentally talk about the pertinent symptomatic manifestations of intense agony after operation and part B shall examine the pharmacology and issues concerning the management of drugs of morphine sulfate which belongs to the category of controlled medication for management of torment (PCA).

Because of the procedures of surgery, Talab is encountering a nociceptive torment, which is a torment that happens when the strands of torment are enacted by harm of delicate tissues, otherwise called nociceptors. As indicated by Ashelford et al. (2019) there are four phases engaged with nociceptive torment. They are transduction, transmission, comprehension and regulation. Transduction begins when the fringe nociceptors of C filaments and A-delta strands, are depolarized by irritating stimuli or factors, for example, warm, mechanical and chemical vitalities. At the point when the ion channels are invigorated it directs opening of the receptors of pain, permitting calcium and sodium particles into the cells and action potential is produced (Bridgestock, and Rae, 2013). During transmission, the endings of nerve of A-delta and C filaments ends in the dorsal horn of the spinal line where two fundamental excitatory synapses (glutamate and substance P) are discharged in the synaptic split, that ties to explicit receptors in the nociceptive dorsal horn neurones. The impulses of nerves arrive at the brain by means of two fundamental nociceptive pathways, the spinoparabrachial and spinothalamic pathway (Calvino, et al, 2006).

Sensation of torment is the point at which the neuronal action with regard to torment transmission finishes and agony turns into a cognizant multidimensional encounter (Maigne, and Vautravers, 2003). The foremost cingulate cortex, when enacted, is related to psychological and persuasive parts of agony, and the somatosensory cortex is connected to perceptible discriminative parts of torment (Leo, 2007). Ultimately, the modulation alludes to an expansion or decline of Talab's feeling of agony. So as to clarify how various variables impacts upon individuals' understanding of torment, Moayedi, and Davis, (2013) communicated the “gate control” hypothesis of agony. They recommended that the dissemination of torment responses could be diminished after reaching the dorsal horn of the spinal cord. Therefore, the openings within the dorsal horn would unlock or nearly diminish or increment the measure of torment response arriving at the cerebrum (Melzack and Wall, 1965). Damage to tissues would unbolt this entryway yet it could then be shut with the aid of pain reducing medication, rubbing the region showing the indications of pain and altering the mental condition of Talab. In spite of the fact that there are other notable speculations of agony, the gate control hypothesis remains the most exact with respect to the physical and biological parts of torment discernment (Macintyre and Schug, 2015).

It is critical that torment following operation has to be regulated overall so as to keep away from any confusion for recuperation of Talab. As indicated by Wood (2010), if postoperative agony isn't overseen accurately, the patient's recuperation can be extensively influenced, bringing about ceaseless intense torment or even demise in extraordinary cases. Moreover, torment after operation which is beyond controlled enacts the sympathetic nervous system adding to grimness and death. It might disturb myocardial ischemia and localized necrosis by the enhanced utilization of oxygen by the myocardial, or by diminishing the supply of oxygen to the myocardial via the mechanism of vasoconstriction of coronary artery (Shorten, et al. 2006). It can likewise prompt reduction of respiratory functioning of Talab, causing expanded pace of respiration, disease of the chest, low oxygen and pneumonia (Wood, 2010).

Torment which is beyond control following operating procedure can also hinder gastrointestinal framework of Talab, deferring gastric and excretory capacity (Liddle, 2013). Portability of Talab would likewise be undermined, preventing him from carrying out his physiotherapy work out. As per Lucas (2008), satisfactory help to alleviate the discomfort is fundamental while recuperating from an overall hip substitution medical procedure, as it allows the patient to prepare as quickly as time permits after operation. A reduction in versatility of Talab would put him in danger of growing an aspiratory embolism and deep vein thrombosis. An Anti Embolism Stockings (AES) was worn by Talab as LeMone, and Burke, (2008) clarifies with usage of AES after operation, can diminish the danger of growing deep vein thrombosis impressively. In addition, unregulated agony after operation can drop the immune capacity of Talab. According to Ashelford et al. (2016) it might empower poor recuperation from injury and infection at the site of operation. Furthermore, it can likewise influence mental state of Talab causing sleep deprivation, nervousness, decrease in psychological capacity, bewilderment and psychological disarray (Layzell, 2008). The other contemplations, for example, late release from medical clinic, counter admission and disappointment of patient are likewise impacts of unrelieved torment after operation.

So as to control agony of Talab viably, the healthcare practitioner must have the option to lead a far reaching and comprehensive evaluation. Evaluating the agony of patient can be a difficult errand as torment has an exceptionally abstract characteristic. In any case, a report stated by patient self, has been demonstrated to be the most ideal route for surveying the presence and remission of torment (LeMone, and Burke, 2008). As indicated by Adams, (2010), psychological, persuasive, social and emotional elements can impact the agony observation. The HCP in charge of Talab condition evaluated agony level utilizing the numerical rating scale device (NRS), where 1 is determined as no torment and 10 as the most exceedingly terrible conceivable torment. Swann (2010), accepts that NRS is the most fitting apparatus to survey intense agony following operation, as it is a basic and clear instrument. Notwithstanding, Talab's level of torment will fluctuate more within one day observation, along these lines torment evaluation must be normally and efficiently directed and being recorded precisely by an able HCP (Department of Health, DH, 2010). During the utilization of NRS, healthcare practitioner should likewise think about the severity, area, length and features of agony (Wood, 2010). As per Vickers et al. (2009) torment must be evaluated alongside other essential signs, as agony has been delegated the fifth fundamental sign.

HCP assume a significant job during taking care of torment as they are the individuals from the human services group with patients every hour each day, for seven days per week. HCP are considered specialists in evaluations, providing instruction and organization of medication, Pasero (2009), recommends that because of the above mentioned qualities, they are viewed as the essential torment carer for patients. As per The Code (NMC, 2015), so as to give great mind and to provide best service to patients, the HCP must work depending on the finest proof accessible. The HCP must discuss successfully with their patients while evaluating their degree of torment and when patients can't impart vocally, a non-vocal signs have to be utilized (Booker, and Herr, 2016). Moreover, patients must be likewise watched for different signs of torment, for example, change an in fundamental signs, anxiety and diaphoresis (Pudner, 2010). A pointer of excellent practice is when a HCP having the option to perceive the torment that a patient is encountering, particularly when he can't illustrate the agony and its seriousness (DH, 2010).

However, believing and following up on the report stated by patient concerning torment can be troublesome as agony can't be demonstrated; HCP are dependent upon wrong and false statements on torment (Linton, 2015). In this regard, Booker, and Herr, (2016) accepts that HCP are qualified for their sincere beliefs and questions; nonetheless, it must not meddle with effective patient consideration. Along these lines, a complete torment appraisal must be led routinely and patients and their families should be taught on the most proficient method to utilize the agony evaluation apparatus accurately (LeMone, and Burke, 2008). Medical professionals must likewise consider the socially based reactions of a patient towards torment, individual’s feelings concerning sense of torment. Interestingly, it has been noticed depending on examines that individuals convey their torment contrastingly and anticipate that others should react to the message in various manners (Ohrbach, 2016). Along these lines it is central that HCP must comprehend the effect of culture with regard to torment report of patient, giving socially touchy consideration (Ohrbach, 2016).

As per Linton, (2015) the best therapeutic option for agony following operation incorporates the pharmacological mediation utilizing an assortment of analgesics. The patient Talab has a morphine analgesia pump which can be regulated by patient (PCA) in advancement. Morphine sulfate is for the alleviation of mild to severe types of nociceptive agony, such as following operation (Weiss, 2010).

The following part will basically examine the applicable pharmacology and the management of prescriptions for morphine sulfate PCA.

Morphine sulfate is categorised as the potential model pain killer and is acquired from the opium poppy (Nute, 2014). Opioid demonstrates as agonists of receptors of opioids. These medications bind to the receptors of cell and produce an impact that is equivalent to typical substance of the body (Weiss, 2010). The three principle kinds of agonist receptors are mu, kappa and delta, they are broadly available in the CNS, fringe nerves and in the cells of GI tract (LeMone, and Burke, 2008). The narcotics provoke the receptors in the neural connection within dorsal horn of the spinal cord and hinder the carrying of impulse, in this way lessening signals of torment (Linton, 2015). They are likewise liable for the enactment of downward pathways of torment from the frontal and midbrain so as to adjust torment (Layzell, 2008). As indicated by Weiss, (2010), the mu receptors demonstrate elevated attraction for binding and are the ones answerable for the vast majority of the pain relieving impacts of narcotics, as well as the undesirable impacts.

The patient is accepting the drug via intravenous (IV) route. IV medications reach the circulatory system, accomplishing the impacts much quicker (Nobre, et al. 2016). It is viewed as the most accurate path for administration to accomplish restorative effect during intense agony (O'Connor, 2013). Notwithstanding, there are dangers, for example, the site of administration subjected to contamination, the medication showing nearby adverse responses, and demonstrating distress to the patient (Wicker, and Bocos, 2010). Other affirmative component of administering IV morphine is the medication enters the blood stream straightway and bypasses the digestion step within the liver, accomplishing a 100% bioavailability quickly as because there is no requirement for ingestion (Nobre, et al. 2016). The morphine is quickly dispersed inside the body, also within cerebrum; nonetheless, because of its low dissolvability in lipid it crosses the blood-brain boundary with trouble (Pudner, 2010). It is then chiefly processed within liver through glucuronidation into the metabolites morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G). As per Wicker, and Bocos, (2010), a portion of the drug is likewise utilized within mucosal cells of the small intestine. The other parameters such as the age, nutrition, sex and the utilization of different prescriptions can impact the digestion of the medication for Talab (Nobre, et al. 2016).

The metabolites are both totally wiped out by the renal system and discharged through bile and urine. Pudner, (2010) clarify that the residues can collect within renal system in the event of renal inadequacy when the dosage routine has to be diminished to maintain a strategic distance from gathering of the dynamic residues (Pudner, 2010). Around 90% of the morphine is discharged via urine inside twenty-four hours of last dosage administered; the other 10% is discharged via defecation and by means of bile (Wicker, and Bocos, 2010). Wicker (2010) clarifies that morphine has a generally moderate pace of activity with top plasma concentration achieving within 20 minutes after IV application and has a small half-life of roughly 120 minutes. Because of its short half-life, the drug has to be given on a successive premise (Wicker, and Bocos, 2010).

The patient can manage by self a bolus of 1 mg for each mL of morphine, having a lock out time of 5 minutes. This permits Talab to get an aggregate of 12mgms of the medication every hour. HCP associated with observing, providing, recommending and applying drugs should contact the British National Formulary (BNF, 2016) so as to choose a secured and viable medication for singular patients. The Joint Formulary Committee (2016) demonstrates that the medical clinic trust nearby convention should be followed for morphine sulfate applied by means of PCA implantation. As indicated by Kang, (2014), the standard beginning dosage for intravenous PCA morphine sulfate is 50 mgms for each 50 mL; 1 mg for every mL bolus has lock out for 5 minutes. PCA of pain is broadly utilized for the controlling of intense torment, via self regulation of little portions of morphine (Lewis et al. 2011). Talab will keep up adequate degrees of the medication in the circulation system so as to keep himself torment free.

An investigation demonstrated patient's inclination for utilizing PCA as they could titrate the pain relieving impact against the reactions and have more command over the their utilization for alleviating pain (Kang, et al. 2014). In any case, so as to accomplish a compelling remedial target, Talab must comprehend the idea of PCA, be agreeable and also must have his consistency checked routinely (Wicker, and Bocos, 2010). Additionally, Talab should likewise be intellectually and bodily ready to utilize the PCA apparatus (Lewis et al. 2011). The HCP must ensure protection while permitting Talab to self-direct enough medication. Moreover, HCP should teach Talab on the best approach to utilize PCA securely and guarantee the nearby conventions and techniques are being followed. However, additionally they need to watch him for contradictions and hazardous occasions (Nobre, et al. 2016).

Morphine sulfate is seen an amazing narcotic pain reliever, but there are antagonistic impacts that can restrict its utilization. Talab should be checked for indications of respiratory suppression; narcotics decline the sensation of the focal chemoreceptors for CO2, in this manner breathing isn't invigorated to its highest state (Ashelford et al. 2019). Talab did not pass his entrails since the day of the medical procedure; however, constipation is another reaction due to receptor specific for narcotics present in the rectal passage diminishing the GI motility (Kang, et al. 2014). Lobby (2009) stated it is crucial that purgatives are endorsed while starting a narcotic therapy. Talab has not grumbled about sickness and spewing, nonetheless, it can be an exceptionally regular reaction of narcotics usage. The narcotics provoke the trigger chemoreceptors zone, causing queasiness and spewing. Anti emetic medication must be administered so as to forestall these side effects (Tomala, 2005).

Talab is encountering mellow pruritus in the back and trunk; Kang, et al. (2014) clarify that gentle pruritus may grow, though, it is not considered as hypersensitive response. On the off chance that pharmacotherapy therapy is requested, antihistamines are the favoured alternative for management (Swegle and Logemann, 2006). Besides, the patient may encounter neurological symptoms, for example, unsteadiness, psychoses, tipsiness, uneasiness, dread, mental trips and narrowing of pupils of eye. It might happen because of the incitement of the narcotic receptors within brain, hypothalamus and limbic framework (Karch, 2010). At the point when manhandled, morphine can cause physiological reliance in certain patients, yet it is to a lesser degree a difficult when utilized for intense torment or malignancy torment (Ashelford, 2016). The lock out of 5 minutes within PCA guarantees that Talab is getting standard little portions when needed. This is for security and means he can't overdose. It is basic that the HCP in charge of Talab screens his fundamental signs, the recurrence of monitoring may differ contingent upon nearby conventions, however it should incorporate pace of respiration, heartbeat, score of sedation, area of torment, torment score, measure of medication utilized and contradictions of PCA (Wicker, and Bocos, 2010).

Notwithstanding the morphine sulfate, Talab was additionally recommended 1gm of paracetamol (acetaminophen) after 6 hours via oral route, within limit of 4 grams every day (BNF, 2016). Paracetamol is viewed as outstanding amongst other known analgesics (Bennett, 2013). Multimodal torment reliever is frequently offered so as to decrease morphine associated contradictions (McDaid, et al. 2010). The various methods of activity for paracetamol and morphine sulfate permit more noteworthy torment relief to be kept up with lower portions of morphine, along with reduced morphine associated contradictions (McDaid, et al. 2010). Tomala, (2005) clarifies that paracetamol can be considered for fundamental structure o torment relief following operation regimens as it will decrease the utilization of morphine necessity after surgery.

So as to securely manage drugs to the patient, the HCP should possess sound information concerning the pharmacology of those medications. This will empower the HCP to comprehend the therapy of patient and have the option to screen him adequately and know about any symptoms (McDaid, et al. 2010). The HCP will likewise have the option to talk about the patient successfully with different individuals from a multi proficient group (McDaid, et al. 2010). Kaufman, (2016) clarify that from the viewpoint of security, it is their obligation to never prescribe any drug without recognizing its function, method of activity and the probable reactions. The Code (NMC, 2015), mentioned that enlisted HCP have a legitimate obligation to give a worthy standard of care, continually performing to greatest advantage of patient. Moreover, HCP must recognize their impediments, in regards to information and aptitudes and work inside the mentioned constraints (NMC, 2015).

Prior to regulation of drugs it is fundamental that HCP must follow the six standards of safe medication prescription as totally enlisted professionals are lawfully liable for the right management of medications (Nute, 2014). So as to guarantee successful consideration, it is significant that professionals exhibit safe work on sticking to rehearse rules at each phase of the medication prescribing process (Kaufman, 2016). The norms for prescriptions (NMC, 2008), express that individuals can confide to the HCP to work inside lawful and moral systems that support secured and compelling drugs. Besides, all able grown-ups reserve the privilege to acknowledge or decline medications, the attendant thinking about the patient should regard their choice (Wicker, and Bocos, 2010). Conversely, if a patient capacity is limited, the law acknowledges the giving of medication via a carer who will act in accordance to finest interest for the wellbeing of patient (Nute, 2014).

To finish up, torment is a multi oriented encounter that is seen distinctively by people and can be to a great extent affected by persuasive, psychological and social variables. Postoperative patients frequently experience intense agony, which is straightforwardly connected to harm of delicate tissues and can turn into a constant torment if not monitored accurately. Professionals assume a significant job in dealing with patients' agony, which means a comprehension about the pathophysiology of torment is fundamental so as to give the correct torment treatment. Uncontrolled postoperative agony can likewise cause undesirable impacts, deferring patient's recuperation. An all encompassing and far reaching appraisal must be directed, notwithstanding the utilization of a proper agony evaluation device, so as to give a compelling relief from discomfort. HCP should consistently think about self reports of patient present state and severity of agony. Be that as it may, they are dependent upon wrong and false statements of agony.

It is clear that the best agony treatment following surgery incorporates the utilization of different torment relievers. Though it has unfriendly impacts for patients, morphine sulfate through PCA implantation is viewed as the most proper treatment for intense agony following surgery. At the point when given related of paracetamol as a multidimensional pain reliever, it can keep up more prominent relief with lower dosages of morphine, just as diminishing morphine associated symptoms. Professionals must recognize the pharmacology of the medications to be regulated, as because it shall empower the HCP to screen patient viably and have a superior comprehension of their healing. Besides, HCP should consistently perform in accordance with The Code (NMC, 2016), working inside the restrictions and giving an adequate standard consideration, while continually acting to greatest advantage for patients.

References:

Ohrbach, R., Michelotti, A., Al-Harthy, M., & List, T. (2016). The effect of culture on pain sensitivity. Journal of oral rehabilitation; 2, 43.

Ashelford, S., Raynsford, J., & Taylor, V. (2019). Pathophysiology and Pharmacology in Nursing. Learning Matters.

Nute, C. (2014). Reducing medication errors. Nursing Standard (2014+), 29(12), 45.

Bennett, S. (2013) Pharmacology of paracetamol and prescribing considerations, Nurse Prescribing, 11 (1), pp. 28-33.

Adams, K. (2010). Indigenous cultural competence in nursing and midwifery practice. Australian Nursing Journal: ANJ, The, 17(11), 35.

Maigne, J. Y., & Vautravers, P. (2003). Mechanism of action of spinal manipulative therapy. Joint bone spine, 70(5), 336-341.

Kang, Y. J., Eun, S. J., Park, E. W., Lee, S. Y., & Kang, J. M. (2014). Quality improvement for reducing intravenous patient-controlled analgesia self-discontinuation rate. Korean journal of anesthesiology, 67(Suppl), S118.

Wicker, P., & Bocos, A. (2010). Perioperative pharmacology. Caring for the Perioperative Patient, 101-133.

Dobson, F. (1997) Anatomy and physiology of pain, British Journal of Community Health Nursing, 2 (6), pp. 283-291.

Weiss, R. D., Potter, J. S., Provost, S. E., Huang, Z., Jacobs, P., Hasson, A., ... & Ling, W. (2010). A multi-site, two-phase, Prescription Opioid Addiction Treatment Study (POATS): rationale, design, and methodology. Contemporary clinical trials, 31(2), 189-199.

LeMone, P., & Burke, K. M. (2008). Medical surgical nursing (Vol. 1). Pearson Education India.

Joint Formulary Committee (September 2016 – March 2017) British National Formulary. 72. London: BMJ Group and Pharmaceutical Press.

Karch, A. M. (2010) Focus on nursing pharmacology. London: Lippincott Williams & Wilkins.

Layzell, M. (2008) Current interventions and approaches to postoperative pain management, British Journal of Nursing, 17 (7), pp. 414-419.

Linton, A. D. (2015). Introduction to medical-surgical nursing. Elsevier Health Sciences.

Liddle, C. (2013) Postoperative care 1: principles of monitoring postoperative patients, Nursing Times, 109 (22), pp. 24-29.

Lucas, B. (2008) Total hip and total knee replacement: postoperative nursing management, British Journal of Nursing, 17 (22), pp. 1410-1414.

Macintyre, P. and Schung, S. (2015) Acute pain management: a practical guide. 4th ed. London: CRC Press.

McDaid, C., Maund, E., Rice, S., Wright, K., Jenkins, B., & Woolacott, N. (2010). Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for the reduction of morphine-related side effects after major surgery: a systematic review. In NIHR Health Technology Assessment programme: Executive Summaries. NIHR Journals Library.

Leo, R. J. (2007). Clinical manual of pain management in psychiatry. American Psychiatric Pub.

Melzack, R. and Wall, P. D. (1965) Pain mechanisms: a new theory, Science, 150 (3699), pp. 971-979.

Merskey, H. and Bugduk, N. (eds.) (1994) Classification of chronic pain, descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle: IASP Press.

NMC. (2015). The code: Professional standards of practice and behavior for nurses and midwives. London: NMC.

O’Connor, L. (2013) Understanding individual reactions to opioids in pain management, Nurse Prescribing, 11 (5), pp. 233-239.

Nobre, K. S. S., Cardoso, M. V. L. M. L., Teixeira, J. L., Lopes, M. M. C. O., & Fontenele, F. C. (2016). Use of peripherally inserted central catheter in a neonatal unit: a descriptive study. Online Brazilian Journal of Nursing, 15(2), 215-225.

Pasero, C. (2009) Assessment of sedation during opioid administration for pain management, Journal of PeriAnesthesia Nursing, 24 (3), pp. 186-190.

Kaufman, G. (2016). CONTINUING PROFESSIONAL DEVELOPMENT. Medicines optimisation: priorities and challenges. Nursing Standard, 30(30).

Pergolizzi J., Labhsetwar S. and Puenpatom R. (2011) Exposure to potential CYP450 pharmacokinetic drug-drug interactions among osteoarthritis patients: incremental risk of multiple prescriptions, Pain Practice, 11, pp.325–336.

Pudner, R. (2010) Nursing the surgical patient. London: Elsevier.

Russell, M. (2011) Administration of medicines: safety first?, Nurse Prescribing, 9 (1), pp. 10-11.

Wittink, H., & Carr, D. B. (2008). Pain Management: Evidence, Outcomes and Quality of Life-A Sourcebook.

Bridgestock, C., & Rae, C. P. (2013). Anatomy, physiology and pharmacology of pain. Anaesthesia & Intensive Care Medicine, 14(11), 480-483.

Swann, J. (2010) Pain: causes, effects and assessment, Nursing and Residential Care, 12 (5), pp. 212-215.

Swegle, J. M. and Logemann, C. (2006) Management of common opioid-induced adverse effects, American Family Physician, 74 (8), pp. 1347-1354.

Booker, S. Q., & Herr, K. A. (2016). Assessment and measurement of pain in adults in later life. Clinics in geriatric medicine, 32(4), 677-692.

Tomala, C. (2005) Improving care of patients who have nausea and vomiting, Nursing Times, 101 (12), pp. 46.

Vickers, A. (2010) The management of acute pain, Surgery, 28 (4), pp. 175-180.

Woods, S. (2010) Postoperative pain: understanding the factors affecting patient’s experiences of pain, Nursing Times, 106 (45), pp. 10-13.

Wood, S. (2010) Postoperative pain 2: patient education, assessment and management, Nursing Times, 106 (46), pp.14-16.

Moayedi, M., & Davis, K. D. (2013). Theories of pain: from specificity to gate control. Journal of neurophysiology, 109(1), 5-12.