INTERNAL MEDICINE Essentials for Clerkship Students 2 pdf

AMERICAN COLLEGE OF PHYSICIANS

CLERKSHIP DIRECTORS IN INTERNAL MEDICINE ACP

INTERNAL MEDICINE

Essentials

for

Clerkship

Students

2

Patrick C. Alguire, MD, FACP

DIRECTOR

EDUCATION AND CAREER DEVELOPMENT

AMERICAN COLLEGE OF PHYSICIANS

EDITOR-IN-CHIEF

INTERNAL MEDICINE

Essentials

for

Clerkship

Students

2

Associate Publisher and Manager, Books Publishing: Tom Hartman

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Copyright © 2009 by the American College of Physicians. All rights reserved. No part of

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ISBN: 978-1-934465-13-4

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Section Editors

Thomas M. DeFer, MD, FACP

Clerkship Director

Division of Medical Education

Department of Internal Medicine

Washington University School of Medicine

St Louis, Missouri

D. Michael Elnicki, MD, FACP

Director, Ambulatory Medicine Clerkship

Director, Section of General Internal Medicine

University of Pittsburgh School of Medicine

UPMC Shadyside

Pittsburgh, Pennsylvania

Mark J. Fagan, MD

Clerkship Director

Department of Medicine

Alpert Medical School of Brown University

Providence, Rhode Island

Sara B. Fazio, MD

Assistant Professor, Harvard Medical School

Director, Core I Medicine Clerkship

Division of General Internal Medicine

Beth Israel Deaconess Medical Center

Boston, Massachusetts

James L. Sebastian, MD, FACP

Director of Student Teaching Programs

Department of Medicine

Medical College of Wisconsin

Clement J. Zablocki Veterans Affairs Medical Center

Milwaukee, Wisconsin

v

Arlina Ahluwalia, MD

Clinical Assistant Professor of Medicine

Stanford University School of Medicine

Clerkship Site Director

Palo Alto VAHCS

Palo Alto, California

Eyad Al-Hihi, MD, FACP

Associate Professor of Medicine

Clerkship Director, Ambulatory Medicine

Section Chief, Division of General Internal Medicine

Medical Director, Internal Medicine Clinics

Truman Medical Center-Hospital Hill

University of Missouri-Kansas City School of

Medicine

Kansas City, Missouri

Erik K. Alexander, MD, FACP

Director, Medical Student Education

Brigham & Women’s Hospital

Assistant Professor of Medicine

Harvard Medical School

Boston, Massachusetts

Irene Alexandraki, MD, FACP

Assistant Professor of Medicine

University of Florida College of Medicine

Jacksonville, Florida

Mark R. Allee, MD, FACP

Assistant Professor of Medicine

Department of Internal Medicine

University of Oklahoma College of Medicine

Oklahoma City, Oklahoma

Hugo A. Alvarez, MD, FACP

Associate Professor of Medicine

Sub-Internship Director

Clerkship Site Director, Department of Medicine

Rosalind Franklin University of Medicine and Science

Mount Sinai Hospital

Chicago, Illinois

Alpesh N. Amin, MD, MBA, FACP

Medicine Clerkship Director

Associate Program Director, IM Residency

University of California, Irvine

Irvine, California

Mary Jane Barchman, MD, FACP, FASN

Associate Professor of Medicine

Section of Nephrology and Hypertension

Director, Introduction to Medicine Course

Clerkship Director, Internal Medicine

Brody School of Medicine at East Carolina University

Greenville, North Carolina

Seth Mark Berney, MD, FACP

Professor of Medicine

Chief, Section of Rheumatology

Director, Center of Excellence for Arthritis and

Rheumatology

Health Sciences Center

Louisiana State University School of Medicine

Shreveport, Louisiana

Contributors

Cynthia A. Burns, MD

Assistant Professor

Clerkship Director, Inpatient Internal Medicine

Section of Endocrinology and Metabolism

Department of Internal Medicine

Wake Forest University School of Medicine

Winston-Salem, North Carolina

Amanda Cooper, MD

Assistant Professor of Medicine

University of Pittsburgh School of Medicine

University of Pittsburgh Medical Center

Pittsburgh, Pennsylvania

Nicole M. Cotter, MD

Fellow, Section of Rheumatology

Center of Excellence for Arthritis and Rheumatology

Health Sciences Center

Louisiana State University School of Medicine

Shreveport, Louisiana

Reed E. Drews, MD, FACP

Program Director

Hematology-Oncology Fellowship

Co-Director, Core Medicine 1 Clerkship

Beth Israel Deaconess Medical Center

Harvard Medical School

Boston, Massachusetts

Steven J. Durning, MD, FACP

Major, Medical Corps, US Air Force

Associate Professor of Medicine

Co-Director, Intro to Clinical Reasoning Course

Uniformed Services University of the Health Sciences

Bethesda, Maryland

Richard S. Eisenstaedt, MD, FACP

Chair, Department of Medicine

Abington Memorial Hospital

Professor of Medicine

Temple University School of Medicine

Philadelphia, Pennsylvania

J. Michael Finley, DO, FACP, FACOI

Associate Professor and Chair of Medicine

Department of Medicine

Western University College of Osteopathic Medicine

Pomona, California

Janine M. Frank, MD

Assistant Professor of Medicine

University of Pittsburgh Medical Center

University of Pittsburgh School of Medicine

Pittsburgh, Pennsylvania

Jane P. Gagliardi, MD

Assistant Clinical Professor

Department of Internal Medicine

Department of Psychiatry and Behavioral Sciences

Duke University School of Medicine

Durham, North Carolina

Peter Gliatto, MD

Assistant Professor of Medicine

Director, Medical Clerkships

Mount Sinai School of Medicine

New York, New York

Eric H. Green, MD, MSc

Course Director, Patients, Doctors, and Communities

Assistant Professor of Medicine

Montefiore Medical Center

Albert Einstein College of Medicine

Bronx, New York

Mark C. Haigney, MD

Professor of Medicine

Director of Cardiology

Uniformed Services University of the Health Sciences

Bethesda, Maryland

Charin L. Hanlon, MD, FACP

Assistant Professor of Internal Medicine

Clerkship Director, Internal Medicine

West Virginia University-Charleston Division

Charleston, West Virginia

Warren Y. Hershman, MD

Director of Student Education

Department of Medicine

Boston University School of Medicine

Boston, Massachusetts

Mark D. Holden, MD, FACP

Eagle’s Trace Medical Director

Erickson Retirement Communities

Houston, Texas

vi • Contributors

Ivonne Z. Jiménez-Velázquez, MD, FACP

Professor and Vice-Chair for Education

Geriatrics Program Director

Clerkship Director, Internal Medicine Department

University of Puerto Rico School of Medicine

San Juan, Puerto Rico

Lawrence I. Kaplan, MD, FACP

Professor of Medicine

Section Chief, General Internal Medicine

Internal Medicine Clerkship Director

Temple University School of Medicine

Philadelphia, Pennsylvania

Asra R. Khan, MD

Assistant Professor of Clinical Medicine

Associate Program Director, Internal Medicine

Residency

Medicine Clerkship Director

University of Illinois College of Medicine

Chicago, Illinois

Sarang Kim, MD

Assistant Professor of Medicine

Division of General Internal Medicine

University of Medicine and Dentistry of New Jersey

Robert Wood Johnson Medical School

New Brunswick, New Jersey

Christopher A. Klipstein, MD

Clerkship Director of Internal Medicine

Associate Professor

Department of Medicine

University of North Carolina School of Medicine

Chapel Hill, North Carolina

Cynthia H. Ledford, MD

Clerkship Director of Internal Medicine

Ohio State University College of Medicine

Columbus, Ohio

Bruce Leff, MD, FACP

Associate Professor of Medicine

Medicine Clerkship Director

Johns Hopkins University School of Medicine

Baltimore, Maryland

Fred A. Lopez, MD, FACP

Associate Professor and Vice Chair

Department of Medicine

Louisiana State University Health Sciences Center

Assistant Dean for Student Affairs

LSU School of Medicine

New Orleans, Louisiana

Anna C. Maio, MD, FACP

Division Chief and Associate Professor

Division of General Internal Medicine

Department of Internal Medicine

Creighton University School of Medicine

Omaha, Nebraska

Brown J. McCallum, MD, FACP

Assistant Professor

Co-Clerkship Director

Department of Internal Medicine

University of South Carolina School of Medicine

Columbia, South Carolina

Kevin M. McKown, MD, FACP

Associate Professor of Medicine

Co-Chief, Section of Rheumatology

Program Director, Rheumatology Fellowship

Co-Clerkship Director

Department of Medicine

University of Wisconsin School of Medicine and

Public Health

Madison, Wisconsin

Melissa A. McNeil, MD, MPH

Professor of Medicine and Obstetrics, Gynecology &

Reproductive Sciences

Chief, Section of Women’s Health

Division of General Medicine

University of Pittsburgh

Pittsburgh, Pennsylvania

Janet N. Myers, MD, FACP, FCCP

Associate Professor of Medicine

Deputy Clerkship Director, Department of Medicine

Uniformed Services University of the Health Sciences

Bethesda, Maryland

Contributors • vii

Kathryn A. Naus, MD

Chief Fellow, Section of Rheumatology

Center of Excellence for Arthritis and Rheumatology

Health Sciences Center

Louisiana State University School of Medicine

Shreveport, Louisiana

Robert W. Neilson Jr., MD

Assistant Professor

Clerkship Director

Department of Internal Medicine

Division of General Internal Medicine

Texas Tech University Health Sciences Center

Lubbock, Texas

Katherine Nickerson, MD

Vice Chair

Department of Medicine

Associate Professor of Clinical Medicine

Clerkship Director

Columbia University, P & S

New York, New York

L. James Nixon, MD

Clerkship Director

Division of General Internal Medicine

University of Minnesota Medical School

University of Minnesota Medical Center, Fairview

Minneapolis, Minnesota

Carlos Palacio, MD, MPH, FACP

Clerkship Director

Assistant Professor of Medicine

University of Florida College of Medicine

Jacksonville, Florida

Hanah Polotsky, MD

Assistant Professor of Medicine

Clerkship Director

Montefiore Medical Center

Albert Einstein College of Medicine

Bronx, New York

Nora L. Porter, MD

Co-Director, Internal Medicine Clerkship

St. Louis University School of Medicine

St. Louis, Missouri

Priya Radhakrishnan, MD

Clinical Assistant Professor

University of Arizona College of Medicine

Clerkship Director and Associate Program Director

Department of Internal Medicine

St. Joseph Hospital & Medical Center

Phoenix, Arizona

Joseph Rencic, MD, FACP

Assistant Professor of Medicine

Clerkship Site Director, Associate Program Director

Department of Internal Medicine

Tufts-New England Medical Center

Boston, Massachusetts

Kathleen F. Ryan, MD

Associate Professor of Medicine

Clerkship Director

Division of General Internal Medicine

Department of Internal Medicine

Drexel University College of Medicine

Philadelphia, Pennsylvania

Brijen J. Shah, MD

Chief Medical Resident, Department of Medicine

Beth Israel Deaconess Medical Center

Harvard Medical School

Boston, Massachusetts

Patricia Short, MD

Major, Medical Corps, US Army

Associate Professor and Associate Clerkship Director

Department of Medicine

Uniformed Services University of the Health Sciences

Bethesda, Maryland

Madigan Army Medical Center

Tacoma, Washington

Diane C. Sliwka, MD

Instructor of Medicine

Beth Israel Deaconess Medical Center

Harvard Medical School

Boston, Massachusetts

viii • Contributors

Harold M. Szerlip, MD, FACP, FCCP

Professor and Vice-Chairman

Department of Medicine

Medical College of Georgia

Augusta, Georgia

Gary Tabas, MD, FACP

Associate Professor of Medicine

University of Pittsburgh School of Medicine

Pittsburgh, Pennsylvania

Tomoko Tanabe, MD, FACP

Assistant Professor of Medicine

Associate Clerkship Director

University of California, San Diego

San Diego, California

David C. Tompkins, MD

Associate Chair

Department of Medicine

SUNY Stony Brook Health Sciences Center

Stony Brook, New York

Dario M. Torre, MD, MPH, FACP

Clerkship Director

Department of Medicine

Medical College of Wisconsin

Milwaukee, Wisconsin

Mark M. Udden, MD, FACP

Professor of Medicine

Department of Internal Medicine

Baylor College of Medicine

Houston, Texas

H. Douglas Walden, MD, MPH, FACP

Co-Director, Internal Medicine Clerkship

St. Louis University School of Medicine

St. Louis, Missouri

Joseph T. Wayne, MD, MPH, FACP

Associate Professor of Medicine

Associate Professor of Pediatrics

Clerkship Director, Internal Medicine

Albany Medical College

Albany, New York

John Jason White, MD

Assistant Professor of Medicine

Nephrology Section

Department of Medicine

Medical College of Georgia

Augusta, Georgia

Kevin D. Whittle, MD

Assistant Professor

Third Year Clerkship Director, Internal Medicine

Sanford Medical School of the University of South

Dakota

Sioux Falls, South Dakota

Contributors • ix

xi

FOREWORD ..............................................................xv

ACKNOWLEDGMENTS ..............................................xvii

I Cardiovascular Medicine

1 Approach to Chest Pain......................................3

Dario M. Torre

2 Chronic Stable Angina........................................7

Anna C. Maio

3 Acute Coronary Syndrome................................11

Patrick C. Alguire

4 Supraventricular Arrhythmias ............................15

Charin L. Hanlon

5 Ventricular Arrhythmias ....................................20

Steven J. Durning and Mark C. Haigney

6 Heart Failure ....................................................24

James L. Sebastian

7 Valvular Heart Disease ......................................28

H. Douglas Walden

II Endocrinology and Metabolism

8 Diabetes Mellitus and Diabetic Ketoacidosis ....37

Erik K. Alexander

9 Dyslipidemia ....................................................41

D. Michael Elnicki and Gary Tabas

10 Thryoid Disease................................................44

Erik K. Alexander

11 Adrenal Disease ................................................48

Cynthia A. Burns

12 Osteoporosis ....................................................52

Melissa A. McNeil and Janine M. Frank

III Gastroenterology and Hepatology

13 Approach to Abdominal Pain............................57

Priya Radhakrishnan

14 Approach to Diarrhea ......................................61

Sarang Kim

15 Diseases of the Gallbladder and Bile Ducts........64

Nora L. Porter

16 Acute Pancreatitis ............................................67

Nora L. Porter

17 Gastroesophageal Reflux Disease ......................70

Brown J. McCallum

18 Peptic Ulcer Disease ........................................72

Brown J. McCallum

19 Dyspepsia..........................................................74

Brown J. McCallum

20 Approach to Gastrointestinal Bleeding ..............76

Warren Y. Hershman

21 Viral Hepatitis ..................................................80

Carlos Palacio

22 Cirrhosis ..........................................................83

Mark J. Fagan

23 Inflammatory Bowel Disease ............................87

Brown J. McCallum

IV General Internal Medicine

24 Test Interpretation............................................93

D. Michael Elnicki

25 Health Promotion, Screening, and Prevention....96

L. James Nixon

26 Approach to Syncope......................................100

Lawrence I. Kaplan

Contents

27 Depression......................................................103

Hugo A. Alvarez

28 Substance Abuse ............................................107

Mark Allee

29 Approach to Low Back Pain............................110

Lawrence I. Kaplan

30 Approach to Cough........................................113

Patrick C. Alguire

31 Smoking Cessation..........................................116

Patrick C. Alguire

32 Obesity ..........................................................118

L. James Nixon

33 Approach to Involuntary Weight Loss ............121

Bruce Leff

34 Disorders of Menstruation and Menopause ....124

Sara B. Fazio

35 Common Dermatologic Disorders ..................128

Hanah Polotsky

36 Comprehensive Geriatric Assessment ..............133

Ivonne Z. Jiménez-Velásquez

37 Hypertension..................................................137

Thomas M. DeFer

V Hematology

38 Anemia ..........................................................143

Reed E. Drews

39 Bleeding Disorders ........................................149

Diane C. Sliwka

40 Sickle Cell Anemia ..........................................152

Reed E. Drews

41 Thrombocytopenia ........................................155

Richard S. Eisenstaedt

42 Thrombophilia................................................158

Patrick C. Alguire

43 Common Leukemias ......................................161

Mark M. Udden

44 Multiple Myeloma ..........................................164

Mark M. Udden

VI Infectious Disease Medicine

45 Approach to Fever ..........................................171

Joseph T. Wayne

46 Sepsis Syndrome ............................................174

Charin L. Hanlon

47 Common Upper Respiratory Problems ..........177

Robert W. Neilson, Jr.

48 Urinary Tract Infection ..................................180

Irene Alexandraki

49 Sexually Transmitted Diseases ........................183

Sara B. Fazio

50 Human Immunodeficiency Virus Infection ....186

Peter Gliatto

51 Health Care Associated Infections ..................189

Brijen Shah

52 Tuberculosis ..................................................193

Arlina Ahluwalia

53 Community-Acquired Pneumonia ..................197

Irene Alexandraki

54 Infective Endocarditis ....................................200

Fred A. Lopez

55 Osteomyelitis..................................................203

David C. Tompkins

VII Nephrology

56 Acute Kidney Injury ......................................209

Harold M. Szerlip

57 Chronic Kidney Disease ..................................213

John Jason White

58 Acid-Base Disorders........................................217

Tomoko Tanabe

59 Fluid and Electrolyte Disorders ......................220

Mary Jane Barchman

60 Calcium and Phosphorus Metabolism ............225

Mary Jane Barchman

VIII Neurology

61 Approach to the Altered Mental State ............231

Robert W. Neilson Jr.

62 Headache........................................................234

Eyad Al-Hihi

63 Dementia........................................................237

Mark Allee

64 Approach to Meningitis and Encephalitis ........240

Fred A. Lopez

65 Stroke and Transient Ischemic Attack ............244

Jane P. Gagliardi

66 Peripheral Neuropathy....................................247

Christopher A. Klipstein

IX Oncology

67 Breast Cancer ................................................253

Kathleen F. Ryan

68 Colon Cancer ................................................256

Kathleen F. Ryan

xii • Contents

69 Lung Cancer ..................................................259

Cynthia H. Ledford

70 Prostate Cancer ..............................................262

Eric H. Green

71 Cervical Cancer ..............................................265

Asra R. Khan

72 Skin Cancer ....................................................268

Cynthia H. Ledford

73 Pain Management ..........................................271

Patrick C. Alguire

X Pulmonary Medicine

74 Approach to Dyspnea......................................275

Mark D. Holden

75 Pleural Effusion ..............................................278

Dario M. Torre

76 Asthma ..........................................................282

Patricia Short

77 Chronic Obstructive Pulmonary Disease ........286

Carlos Palacio

78 Obstructive Sleep Apnea ................................290

Arlina Ahluwalia

79 Infiltrative and Fibrotic Lung Diseases ............293

Janet N. Myers

80 Venous Thromboembolism ..........................297

Alpesh N. Amin

81 Interpretation of Pulmonary Function Tests....301

Kevin D. Whittle

XI Rheumatology

82 Approach to Joint Pain ..................................307

Thomas M. DeFer

83 Approach to Knee and Shoulder Pain ............309

Joseph Rencic

84 Crystalline Arthritis ........................................312

Katherine Nickerson

85 Osteoarthritis..................................................315

Amanda Cooper

86 Polymyositis and Dermatomyositis..................317

Kevin M. McKown

87 Rheumatoid Arthritis ......................................319

Kathryn A. Naus and Seth Mark Berney

88 Septic Arthritis................................................322

J. Michael Finley

89 Systemic Lupus Erythematosus ......................325

Nicole Cotter and Seth Mark Berney

90 Vasculitis ........................................................328

Patrick C. Alguire

INDEX ............................................................331

COLOR PLATES..................................Back of Book

Contents • xiii

I

nternal Medicine Essentials for Clerkship Students is a

collaborative project of the American College of

Physicians (ACP) and the Clerkship Directors in

Internal Medicine (CDIM), the organization of indi￾viduals responsible for teaching internal medicine to

medical students. The purpose of IM Essentials is to

provide medical students with an authoritative educa￾tional resource that can be used to augment learning

during the third year internal medicine clerkship. Much

of the content is based upon two evidence-based

resources of ACP: the Medical Knowledge Self￾Assessment Program (MKSAP) and the Physician

Information and Education Resource (PIER); other

sources include recently published practice guidelines

and review articles. IM Essentials is updated every two

years with the best available evidence and is designed to

be read cover-to-cover during the clerkship.

Based upon student feedback, IM Essentials 2 con￾tains twice as many color plates and algorithms as its

predecessor and more than 100 extra tables to enhance

learning (and passing tests!). An index now provides

fuller subject access. The most exciting addition is the

Book Enhancement section found at the end of each

chapter. This section directs the reader to a book-relat￾ed Web site that contains nearly 500 links to additional

tables, algorithms, color plates, and patient care tools.

The Book Enhancement section also identifies specific

chapter-related self-assessment questions published in a

separate companion book, MKSAP for Students 4.

MKSAP for Students 4 consists of a printed and elec￾tronic collection of patient-centered self-assessment

questions and answers. The questions begin with a clin￾ical vignette, just as in the medicine clerkship examina￾tion and the USMLE Step 2 licensing examination. The

questions are organized into eleven sections that match

the eleven sections found in IM Essentials. Each of the

more than 450 questions has been specifically edited by

a group of clerkship directors to meet the learning

needs of students participating in the medicine clerk￾ship. Each question comes with an answer critique that

supplies the correct answer, an explanation of why that

answer is correct and the incorrect options are not, and

a short bibliography. We recommend that students first

read the appropriate chapter in IM Essentials, then

assess their understanding by answering the designated

questions in MKSAP for Students 4.

The content of IM Essentials is based upon The Core

Medicine Clerkship Curriculum Guide (available at

www.im.org/CDIM), a nationally recognized curricu￾lum for the required third-year internal medicine clerk￾ship, created and published by the CDIM and the

Society for General Internal Medicine. A collaboration

of 66 authors, all of whom are either internal medicine

clerkship directors or clerkship faculty, representing 45

different medical schools, IM Essentials 2 is unique in

that it is created by faculty who helped design the inter￾nal medicine curriculum and who are actively involved

in teaching and advising students on the internal medi￾cine clerkship.

* * * * *

Founded in 1915, the American College of

Physicians is the nation’s largest medical specialty soci￾ety. Its mission is to enhance the quality and effective￾ness of health care by fostering excellence and profes￾sionalism in the practice of medicine. ACP’s 124,000

members include allied health professionals, medical

students, medical residents, and practicing physi￾cians. Physician members practice general internal

medicine and related subspecialties, including cardi￾ology, gastroenterology, nephrology, endocrinology,

Foreword

xv

hematology, rheumatology, neurology, pulmonary dis￾ease, oncology, infectious diseases, allergy and immunol￾ogy, and geriatrics.

The Clerkship Directors in Internal Medicine is the

national organization of individuals responsible for

teaching internal medicine to medical students.

Founded in 1989, CDIM promotes excellence in the

education of medical students in internal medicine.

CDIM serves internal medicine faculty and staff by:

providing a forum to share ideas, generate solutions to

common problems, and create opportunities for career

development; participating in the development and dis￾semination of innovations for curriculum, evaluation,

and faculty development; encouraging research and col￾laborative initiatives among medical educators; and

advocating for issues concerning undergraduate med￾ical education.

* * * * *

Publication of Internal Medicine Essentials for

Clerkship Students 2 would not have been possible with￾out the invaluable and entirely voluntary contributions

of many individuals, only some of whom are listed in

the Acknowledgments. Others, not specifically named,

were representatives from a wide spectrum of con￾stituencies and organizations such as the Executive and

Educational Committees of the Clerkship Directors in

Internal Medicine and the Education Committee and

the Council of Student Members of the American

College of Physicians.

Patrick C. Alguire, MD, FACP

Editor-in-Chief

xvi • Foreword

xvii

The American College of Physicians and the Clerkship Directors in Internal

Medicine gratefully acknowledge the special contributions to Internal Medicine

Essentials for Clerkship Students 2 of Nicole V. Baptista, CDIM Policy

Coordinator, Clerkship Directors in Internal Medicine; Sheila T. Costa,

Director of Meetings and Communications, Clerkship Directors in Internal

Medicine; Rosemarie Houton, Administrative Representative, American

College of Physicians; Lisa Rockey, Education and Career Development

Coordinator, American College of Physicians; and Helen Kitzmiller, Patient

Education Project Administrator, American College of Physicians. We also

thank the many others, too numerous to mention, who have contributed to this

project. Without the dedicated efforts of them all, publication of this volume

would not have been possible.

Acknowledgments