O.O.Bogomolets National Medical University

Department of Faculty Surgery #1

“Approved”at the Methodist Faculty Surgery

Department # 1 Council“__”_____2008, protocol #_____

Head ofFaculty Surgery Department # 1

Professor _______ M.P.Zakharash

Study Guide for Practical Work for Teachers and Students

Topic: “Appendicitis”.

Course 4Foreign Students’ Medical FacultyDuration of the lesson – 45 min.

Worked out byAssistant T.Kravchenko

Kyiv2008

I. The theme actuality

About 8% of people in Western countries have appendicitis at some time during their

life, with a peak incidence between 10 and 30 years of age. Acute appendicitis is the

most common general surgical emergency, and early surgical intervention improves

outcomes. The diagnosis of appendicitis can be elusive, and a high index of suspicion

is important in preventing serious complications from this disease.

II. Student must know:

- embryology and anatomy of appendix

- historical perspective of appendicitis

- pathophysiology of appendicitis

- bacteriology of appendicitis

- diagnosis of appendicitis

- diagnostic algorithm

- treatment

III. Student must be able to:

- to interpret correctly the present manifestations of disease and investigation

results

- to differentiate appendicitis

- to diagnose and make the chart of treatment

- to apply the instrumental methods of examination

- to conduct examination of patient

- to interpret data of examinations

IV. Education aims of the study

- forming the deontology presentations, skills of conduct with the patients

- to develop deontology presentations, be able to carry out deontology approach

to the patient

- to develop the presentations of influence of ecological and socio-economic

factors on the state of health

- to develop sence of responsibility for a timeliness and loyalty of professional

actions

- to lay hands on ability to set psychological contact with a patient and his family

V. The contents of a theme

Embryology and anatomy

The appendix, ileum, and ascending colon are all derived from the midgut. The

appendix first appears at the 8th week of gestation as an outpouching of the cecum

and gradually rotates to a more medial location as the gut rotates and the cecum

becomes fixed in the right lower quadrant.

The appendiceal artery, a branch of the ileocolic artery, supplies the appendix.

Histologic examination of the appendix indicates that goblet cells, which produce

mucus, are scattered throughout the mucosa. The submucosa contains lymphoid

follicles, leading to speculation that the appendix might have an important, as yet

undefined, immune function early in development. The lymphatics drain into the

anterior ileocolic lymph nodes. In adults, the appendix has no known function.

The length of the appendix varies from 2 to 20 cm, and the average length is 9 cm in

adults. The base of the appendix is located at the convergence of the taeniae along the

inferior aspect of the cecum, and this anatomic relationship facilitates identification of

the appendix at operation. The tip of the appendix may lie in a variety of locations.

The most common location is retrocecal but within the peritoneal cavity. It is pelvic in

30% and retroperitoneal in 7% of the population. The varying location of the tip of the

appendix likely explains the myriad of symptoms that are attributable to the inflamed

appendix.

Historical Perspective

In 1886, Reginald Fitz of Boston correctly identified the appendix as the primary

cause of right lower quadrant inflammation. He coined the term appendicitis and

recommended early surgical treatment of the disease. Richard Hall reported the first

survival of a patient after removal of a perforated appendix, which launched focused

attention on the surgical treatment of acute appendicitis. In 1889, Chester McBurney

described characteristic migratory pain as well as localization of the pain along an

oblique line from the anterior superior iliac spine to the umbilicus. McBurney

described a right lower quadrant muscle-splitting incision for removal of the appendix

in 1894. The mortality rate from appendicitis improved with the widespread use of

broad-spectrum antibiotics in the 1940s. Recent advances have included improved

preoperative diagnostic studies, interventional radiologic procedures to drain

established periappendiceal abscesses, and the use of laparoscopy to confirm the

diagnosis and exclude other causes of abdominal pain. Laparoscopic appendectomy

was first reported by the gynecologist Kurt Semm in 1982 but has only gained

widespread acceptance in recent years.

Pathophysiology

Obstruction of the lumen is believed to be the major cause of acute appendicitis. This

may be due to inspissated stool (fecalith or appendicolith), lymphoid hyperplasia,

vegetable matter or seeds, parasites, or a neoplasm. The lumen of the appendix is

small in relation to its length, and this configuration may predispose to closed-loop

obstruction. Obstruction of the appendiceal lumen contributes to bacterial overgrowth,

and continued secretion of mucus leads to intraluminal distention and increased wall

pressure. Luminal distention produces the visceral pain sensation experienced by the

patient as periumbilical pain. Subsequent impairment of lymphatic and venous

drainage leads to mucosal ischemia. These findings in combination promote a

localized inflammatory process that may progress to gangrene and perforation.

Inflammation of the adjacent peritoneum gives rise to localized pain in the right lower

quadrant. Although there is considerable variability, perforation typically occurs after

at least 48 hours from the onset of symptoms and is accompanied by an abscess cavity

walled-off by the small intestine and omentum. Rarely, free perforation of the

appendix into the peritoneal cavity occurs that may be accompanied by peritonitis and

septic shock and can be complicated by the subsequent formation of multiple

intraperitoneal abscesses.

Bacteriology

The flora in the normal appendix is very similar to that in the colon, with a variety of

facultative aerobic and anaerobic bacteria. The polymicrobial nature of perforated

appendicitis is well established. Escherichia coli, Streptococcus viridans, and

Bacteroides and Pseudomonas species are frequently isolated, and many other

organisms may be cultured. Among patients with acute nonperforated appendicitis,

cultures of peritoneal fluid are frequently negative and are of limited use. Among

patients with perforated appendicitis, peritoneal fluid cultures are more likely to be

positive, revealing colonic bacteria with predictable sensitivities. Because it is rare

that the findings alter the selection or duration of antibiotic use, some authors have

challenged the traditional practice of obtaining cultures.

Bacteria Commonly Isolated in Perforated Appendicitis

1. AEROBIC

Bacteroides fragilis 80%

Bacteroides thetaiotaomicron 61%

Bilophila wadsworthia 55%

Peptostreptococcus species 46%

AEROBIC

Escherichia coli 77%

Streptococcus viridans 43%

Group D streptococcus 27%

Pseudomonas aeruginosa 18%

Diagnosis

History

Appendicitis needs to be considered in the differential diagnosis of nearly every

patient with acute abdominal pain. Early diagnosis remains the most important clinical

goal in patients with suspected appendicitis and can be made primarily on the basis of

the history and physical exam in most cases. The typical presentation begins with

periumbilical pain (due to activation of visceral afferent neurons) followed by

anorexia and nausea. The pain then localizes to the right lower quadrant as the

inflammatory process progresses to involve the parietal peritoneum overlying the

appendix. This classic pattern of migratory pain is the most reliable symptom of acute

appendicitis. A bout of vomiting may occur, in contrast to the repeated bouts of

vomiting that typically accompany viral gastroenteritis or small bowel obstruction.

Fever ensues, followed by the development of leukocytosis. These clinical features

may vary. For example, not all patients become anorexic. Consequently, the feeling of

hunger in an adult patient with suspected appendicitis should not necessarily deter one

from surgical intervention. Occasional patients have urinary symptoms or microscopic

hematuria, perhaps owing to inflammation of periappendiceal tissues adjacent to the

ureter or bladder, and this may be misleading. Although most patients with

appendicitis develop an adynamic ileus and absent bowel movements on the day of

presentation, occasional patients may have diarrhea. Others may present with small

bowel obstruction related to contiguous regional inflammation. Therefore,

appendicitis needs to be considered as a possible cause of small bowel obstruction,

especially among patients without prior abdominal surgery.

Physical Examination

Patients with acute appendicitis typically look ill and are lying still in bed. Low-grade

fever is common (∼38°C). Examination of the abdomen usually reveals diminished

bowel sounds and focal tenderness with voluntary guarding. The exact location of the

tenderness is directly over the appendix, which is most commonly at McBurney's

point (located one third of the distance along a line drawn from the anterior superior

iliac spine to the umbilicus). The normal appendix is mobile, so it may become

inflamed at any point on a 360-degree circle around the base of the cecum. Thus, the

site of maximal pain and tenderness can vary. Peritoneal irritation can be elicited on

physical examination by the findings of voluntary and involuntary guarding,

percussion, or rebound tenderness. Any movement, including coughing (Dunphy's

sign), may cause increased pain. Other findings may include pain in the right lower

quadrant during palpation of the left lower quadrant (Rovsing's sign), pain on internal

rotation of the hip (obturator sign, suggesting a pelvic appendix), and pain on

extension of the right hip (iliopsoas sign, typical of a retrocecal appendix).

Rectal and pelvic examinations are most likely to be negative. However, if the

appendix is located within the pelvis, tenderness on abdominal examination may be

minimal, whereas anterior tenderness may be elicited during rectal examination as the

pelvic peritoneum is manipulated. Pelvic examination with cervical motion may also

produce tenderness in this setting.

If the appendix perforates, abdominal pain becomes intense and more diffuse, and

abdominal muscular spasm increases, producing rigidity. The heart rate rises, with an

elevation of temperature above 39°C. The patient may appear ill and require a brief

period of fluid resuscitation and antibiotics before the induction of anesthesia.

Occasionally, pain may improve somewhat after rupture of the appendix, although a

true pain-free interval is uncommon.

Laboratory Studies

The white blood cell count is elevated with more than 75% neutrophils in most

patients. A completely normal leukocyte count and differential is found in about 10%

of patients with acute appendicitis. A high white blood cell count (>20,000/mL)

suggests complicated appendicitis with either gangrene or perforation. A urinalysis

can also be helpful in excluding pyelonephritis or nephrolithiasis. Minimal pyuria,

frequently seen in elderly women, does not exclude appendicitis from the differential

diagnosis because the ureter may be irritated adjacent to the inflamed appendix.

Although microscopic hematuria is common in appendicitis, gross hematuria is

uncommon and may indicate the presence of a kidney stone. Other blood tests are

generally not helpful and are not indicated in the patient with suspected appendicitis.

Radiography

Although they are commonly obtained, the indiscriminate use of plain abdominal

radiographs in the evaluation of patients with acute abdominal pain is unwarranted. In

one study of 104 patients with acute onset of right lower quadrant pain, interpretation

of plain x-rays changed the management of only 6 patients (6%), and in one case

contributed to an unnecessary laparotomy. A calcified appendicolith is visible on plain

films in only 10% to 15% of patients with acute appendicitis; however, its presence

strongly supports the diagnosis in a patient with abdominal pain. Plain abdominal

films may be useful for the detection of ureteral calculi, small bowel obstruction, or

perforated ulcer, but such conditions are rarely confused with appendicitis. Failure of

the appendix to fill during a barium enema has been associated with appendicitis, but

this finding lacks both sensitivity and specificity because up to 20% of normal

appendices do not fill.

Among patients with abdominal pain, ultrasonography has a sensitivity of about 85%

and a specificity of more than 90% for the diagnosis of acute appendicitis.

Sonographic findings consistent with acute appendicitis include an appendix of 7 mm

or more in anteroposterior diameter, a thick-walled, noncompressible luminal

structure seen in cross section referred to as a target lesion, or the presence of an

appendicolith. In more advanced cases, periappendiceal fluid or a mass may be found.

Ultrasonography has the advantages of being a noninvasive modality requiring no

patient preparation that also avoids exposure to ionizing radiation. For these reasons,

it is commonly used in children and in pregnant patients with equivocal clinical

findings suggestive of acute appendicitis. Disadvantages of ultrasonography include

operator-dependent accuracy and difficulty interpreting the images by those other than

the operator. Because performance of the study may require hands-on participation by

the radiologist, ultrasonography may not be readily available at night or on weekends.

Pelvic ultrasound can be especially useful in excluding pelvic pathology, such as tubo-

ovarian abscess or ovarian torsion, that may mimic acute appendicitis.

Ultrasound of a normal appendix illustrating the thin wall in both coronal (left) and

longitudinal (right) planes. In appendicitis, there is distention and wall thickening and

blood flow is increased, leading to the so-called ring-of-fire appearance.

Computed tomography (CT) is commonly used in the evaluation of adult patients with

suspected acute appendicitis. Improved imaging techniques, including the use of 5-

mm sections, have resulted in increased accuracy of CT scanning, which has a

sensitivity of about 90% and a specificity of 80% to 90% for the diagnosis of acute

appendicitis among patients with abdominal pain. Controversy remains as to the

importance of intravenous, oral gastrointestinal, and rectal contrast in improving

diagnostic accuracy. In general, CT findings of appendicitis increase with the severity

of the disease. Classic findings include a distended appendix greater than 7 mm in

diameter and circumferential wall thickening, which may give the appearance of a

halo or target. As inflammation progresses, one may see periappendiceal fat stranding,

edema, peritoneal fluid, phlegmon, or a periappendiceal abscess. CT detects

appendicoliths in about 50% of patients with appendicitis and also in a small

percentage of people without appendicitis. Among patients with abdominal pain, the

positive predictive value of the finding of an appendicolith on CT remains high at

about 75%.

CT scan of the abdomen or pelvis in a patient with acute appendicitis may reveal an

appendicolith, CT typically shows a distended appendix with diffuse wall-thickening

and periappendiceal fluid. The appendix may be described as having mural

stratification, referring to the layers of enhancement and edema within the wall and

this may also be referred to as a target sign. cecum; terminal ileum.

Should CT be used routinely in the diagnostic evaluation of patients with suspected

appendicitis? In our opinion, no. In the setting of typical right lower quadrant pain and

tenderness with signs of inflammation in a young patient, a CT scan is unnecessary,

wastes valuable time, and exposes the patient to the risks for allergic contrast reaction,

nephropathy, aspiration pneumonitis, and ionizing radiation. The latter carries

increased risk in children in whom the rate of radiation-induced cancer has been

estimated at 0.18% following an abdominal CT scan. Moreover, a negative study may

be misleading, particularly early in the inflammatory process. CT has proved most

valuable among older patients in whom the differential diagnosis is lengthy, the

clinical findings may be confusing, and appendectomy carries increased risk. Among

patients with atypical symptoms, CT scan may reduce the negative appendectomy rate

(i.e., the fraction of pathologically normal appendices that are removed). Selective use

of CT scans seems most appropriate, and as always, the study needs to be obtained

only in settings in which it has a significant potential to alter management.

The morbidity of perforated appendicitis far exceeds that of a negative appendectomy.

Thus, the strategy has been to set a low enough threshold for removal of the appendix

so as to minimize the cases of missed appendicitis. With increased use of CT scans,

the frequency of negative explorations has declined in recent years without an

accompanying rise in the number of perforations. A recent analysis of more than

75,000 patients in 1999 to 2000 revealed a negative appendectomy rate of 6% in men

and 13.4% in women.

Diagnostic Laparoscopy

Although most patients with appendicitis will be accurately diagnosed based on

history, physical exam, laboratory studies, and if necessary, imaging techniques, there

are a small number in whom the diagnosis remains elusive. For these patients,

diagnostic laparoscopy can provide both a direct examination of the appendix and a

survey of the abdominal cavity for other possible causes of pain. We use this

technique primarily for women of childbearing age in whom preoperative pelvic

ultrasound or CT scan fails to provide a diagnosis. Concerns about the possible

adverse effects of a missed perforation and peritonitis on future fertility sometimes

prompt earlier intervention in this patient population.

Diagnostic Algorithm

Patients in whom the diagnosis of appendicitis is being considered should have a

surgical evaluation. Early involvement of the surgical team in the diagnostic

evaluation of these patients may improve diagnostic accuracy and help to avoid

expensive and unnecessary diagnostic studies. Experienced clinicians accurately

diagnose appendicitis based on a combination of history, physical exam, and

laboratory studies about 80% of the time. We stratify patients based on their clinical

findings starting with the extremes, which are easier to identify. Patients with a high

probability of uncomplicated appendicitis undergo surgery. Patients suspected of

having an appendiceal abscess undergo further imaging, typically ultrasonography for

children or CT for adults. The next step in the evaluation of patients in whom the

likelihood of appendicitis is believed to be low is determined by the probability and

severity of alternate diagnoses under consideration. Many of these patients will be

discharged with a planned follow-up visit or phone call the next day. Most older

patients with abdominal pain undergo CT before discharge because of the high

prevalence of surgical pathology in this patient population. The remaining patients are

believed to have an intermediate probability of having appendicitis. Children and

pregnant women in this category typically undergo abdominal ultrasonography.

Women in their childbearing years may undergo pelvic ultrasonography or CT scan

depending on the index of suspicion of pelvic pathology. Among patients that would

otherwise be admitted to the hospital for observation, CT may reduce hospital costs by

reducing length of stay. Following the completion of imaging studies, the patient is re-

examined to determine whether pain and tenderness have localized to the right lower

quadrant. If the diagnosis remains uncertain at this point, patients either undergo

diagnostic laparoscopy, especially in fertile women, are admitted for observation and

re-examination, or are discharged with follow-up the next day.

Treatment

Most patients with acute appendicitis are managed by prompt surgical removal of the

appendix. A brief period of resuscitation is usually sufficient to ensure the safe

induction of general anesthesia. Preoperative antibiotics cover aerobic and anaerobic

colonic flora. For patients with nonperforated appendicitis, a single preoperative dose

of antibiotics reduces postoperative wound infections and intra-abdominal abscess

formation. Postoperative oral antibiotics do not further reduce the incidence of

infectious complications in these patients. For patients with perforated or gangrenous

appendicitis, we continue postoperative intravenous antibiotics until the patient is

afebrile.

Several prospective randomized studies have compared laparoscopic and open

appendectomy, and the overall differences in outcomes remain small. The percentage

of appendectomies performed laparoscopically continues to increase. Obese patients

had less pain and shorter hospital stays after laparoscopic versus open appendectomy.

Patients with perforated appendicitis had lower rates of wound infections following

laparoscopic removal of the appendix. Patients treated laparoscopically had improved

quality-of-life scores 2 weeks after surgery and lower readmission rates. As compared

with open appendectomy, the laparoscopic approach involves higher operating room

costs, but these have been counterbalanced in some series by shorter lengths of stay.

For patients in whom the diagnosis remains uncertain after the preoperative

evaluation, diagnostic laparoscopy is useful because it allows the surgeon to examine

the remainder of the abdomen, including the pelvis, for abnormalities. Our practice is

to perform appendectomies laparoscopically in fertile women, obese patients, and

cases of diagnostic uncertainty; otherwise, the approach is determined by patient or

surgeon preference.

Open appendectomy is usually easily performed through a transverse right lower

quadrant incision (Davis-Rockey) or an oblique incision (McArthur-McBurney). In

cases with a large phlegmon or diagnostic uncertainty, a subumbilical midline incision

may be used. For uncomplicated cases we prefer a transverse, muscle-splitting

incision lateral to the rectus abdominis muscle over McBurney's point. Local

anesthetic, administered before the incision, reduces postoperative pain. After the

peritoneum is entered, the inflamed appendix is identified by its firm consistency and

delivered into the field. Particular attention is paid to gentle handling of the inflamed

tissues to minimize the risk for rupture during the procedure. In difficult cases,

enlarging the incision and working down the trajectory of the taeniae on the cecum

will often facilitate localization and delivery of the appendix. The meso-appendix is

divided between clamps and ties. The base of the appendix is skeletonized at its

junction with the cecum. A heavy absorbable tie is placed around the base of the

appendix, and the specimen is clamped and divided. An absorbable purse-string suture

or Z stitch is placed into the cecal wall, and the appendiceal stump is inverted into a

fold in the wall of the cecum. Simple ligation and inversion probably have equivalent

outcomes. If the base of the appendix and adjacent cecum are extensively indurated,

an ileocecal resection is performed. The wound is closed primarily in most cases

because the wound infection rate is less than 5%.

Laparoscopic appendectomy offers the advantage of diagnostic laparoscopy combined

with the potential for shorter recovery and incisions that are less conspicuous. If a CT

scan was obtained preoperatively, it needs to be reviewed by the surgeon for useful

information regarding the position of the appendix relative to the cecum. After

injection of local anesthetic, we place a 10-mm port into the umbilicus, followed by a

5-mm port in the suprapubic midline region and a 5-mm port midway between the

first 2 ports and to the left of the rectus abdominis muscle. The 5-mm, 30-degree

scope is moved to the central port with the surgeon and assistant both on the patient's

left. With the patient in Trendelenburg's position and rotated left-side down, we gently

sweep the terminal ileum medially and follow the taeniae of the cecum caudad to

locate the appendix, which is then elevated. The mesoappendix is divided using a 5-

mm harmonic scalpel or Liga-Sure, or between clips, depending on the thickness of

this tissue. We typically encircle the appendix with two heavy absorbable Endoloops

cinched down at the base of the appendix and then place a third Endoloop about 1 cm

distally and divide the appendix. In cases in which the base is indurated and friable,

we use a 30-mm endoscopic stapler to divide the appendix. For most cases, however,

the considerable added cost of the stapler is unwarranted. Any spillage of fluid is

promptly aspirated, and similarly any identified appendicoliths are removed to prevent

postoperative abscess formation. The appendix is placed into a specimen bag and

removed with the port through the umbilical wound. Fascia at the 10-mm trocar site is

closed, and all wounds are closed primarily.

VI. Lesson topic control questions.

Key points:

- Acute appendicitis is the most common general surgical emergency, and early

surgical intervention improves outcomes.

- The diagnosis of appendicitis can be elusive, and a high index of suspicion is

important in preventing serious complications from this disease.

- Appendicitis needs to be considered in the differential diagnosis of nearly every

patient with acute abdominal pain.

- Early diagnosis remains the most important clinical goal in patients with suspected

appendicitis and can be made primarily on the basis of the history and physical exam

in most cases.

- In some cases diagnosis is not easy and includes, endoscopy, ultrasound, plain

abdominal films or CT, laboratory tests and laparoscopy

- Appendectomy remains the only curative treatment for appendicitis

Cases

(1)

A 15-year-old boy is admitted and physical findings consistent with appendicitis.

Which finding is most likely to be positive?

1. Pelvic crepitus

2. Iliopsoas sign

3. Murphy sign

4. Flank echymosis

5. Periumbilical ecchymosis

The answer is 2.

The iliopsoas sign in the lower abdomen and psoas region that is elicited when thigh is

flexed against resistance. It suggests an inflammatory process, such as appendicitis.

Crepitus suggests a rapidly spreading gas-forming infection. Murphy sign is elicited

by palpating the right upper quadrant during inspiration and suggests acute

cholecystitis. Flank and periumbilical ecchymoses suggest retroperitoneal

hemorrhage.

(2)

A 23-years-old male presents to the emergency room (ER) at night with abdominal

pain beginning the prior afternoon. The pain is described as crampy with intermittent

episodes of sharp pain, and non radiating. It is located in the right lower quadrant

(RLQ) with an intensity of 8/10 which has progressively worsened since it started. He

also has nausea and vomiting that began soon after onset of pain. He denies fever ,

chills, or dysuria. Physical examination revealed RLQ tenderness, no palpable masses,

a soft abdomen, with normal bowel sounds. He states no change in bowel habits. Lab

studies reveal negative urine analysis (UA), WBC of 13,500, and Hgb gms/dl. The

patient is taken to the operating room (OR) without obtaining a computed tomography

(CT) scan of the abdomen and pelvis. Intra-operatively, the appendix appears normal.

On further evaluation, the distal ileum appears inflamed with fat wrapping. Your

notice the cecum is not involved. What is your management at this time?

1. Perform appendectomy

2. Leave appendix and ileum as-is and close. Colsult GI

3. Perform appendectomy and distal ileum resection

4. Perform appendectomy and stricturoplasty of the terminal ileum

5. Run the small bowel to rule out Meckel’s diverticulum

Answer is 1.

The patient presented with a classic history for appendicitis. Twenty percent of all

explorations for appendicitis turn out to be negative; therefore, other sources of pain

must be sought. On exploration, the patient had classical sighns of Crohn’s disease,

including fat wrapping, which is pathognomonic for Crohn’s disease. Differentiating

Crohn’s from appendicitis is extremely difficult, especially without preoperative CT

of abdomen/pelvis. The history of previous episodes of colicky abdominal pain with

bouts of diarrhea may lead to a suspected diagnosis of Crohn’s. Management of

disease intraoperatively is to perform appendectomy if no cecal involvement in order

to eliminate possibility of appendicitis versus Crohn’s in the future. If the cecum is

involved you do not perform appendectomy because of risk of fistula formation.

VII. Supporting materials required for teaching

1. Participation in clinical duties on admission

2. Working in library

VII. Literature

1. Townsend CM, Harris JW. Sabiston’s Textbook of Surgery, 16th ed. Philadelphia,

PA: W.B. Saunders Co, 2001, vol.44

2. Schwartz SI, Schires GT, Spencer FC, Daly JM, Fischer JE, Galloway AC.

Principles of Surgery, 7th ed. New York: McGraw-Hill, 1999, vol.27

3. Bruce E. Jarrell, R.Antthony Carabasi. Surgery, 3rd ed. Williams & Wilkins, 1998