WPC0 Jiu _ Z,,.\j˕j_Sz#pHcrCQ眤~Y(BLFTϐ?͂w)S2ڊ+.&b(QBVꏔ!Ą NlV[A lRn\/jb3.a(f(5G(z%L`!fkՍ6$2h\lL KdKg@5x&f\,Fwx6yCq Yzm6r&[ԯc24??@۵8̵# 0~ƴU/ݞ>.Normal  2( 4 <DL22( 4 <DL2   \ &*   _    63  ((3$ U!     ")   _99A]#) xdE9Wf!A X @XgXXX Exercise5:ErythrocyteSedimentationRate #XgXX@Xg#*5+5 (_24  ) <DL)23  ..) <DL)  ((3$ U!   *2+2 (_23 ` &<<DL&23  ..&<<DL& ` */+/ (_22  #DL#23  ..#DL#  *,+, (_21   DL 23  .. DL  *)+) (_20 h DDL23  ..DDL h *&+& (_19  L23  ..L  *#+# (_18   L23  .. L  *>> (_17  2( 4 <DL223  Ԁ2( 4 <DL2  *DD (_16   ," <DL,23  Ԁ," <DL,   *55 (_15  ) <DL)23  Ԁ) <DL)  *22 (_14 ` &<<DL&23  Ԁ&<<DL& ` *// (_13  #DL#23  Ԁ#DL#  *,, (_12   DL 23  Ԁ DL  *)) (_11 h DDL23  ԀDDL h *&& (_10  L23  ԀL  (## &_9   L23  Ԁ L  (>> &_8  2( 4 <DL223  2( 4 <DL2  (DD &_7   ," <DL,23  ," <DL,   (55 &_6  ) <DL)23  ) <DL)  (22 &_5 ` &<<DL&23  &<<DL& ` (// &_4  #DL#23  #DL#  (,, &_3   DL 23   DL  ()) &_2 h DDL23  DDL h (&& &_1  L23  L  &## $_   L23   L  TABLE A.\  `"TimesNewRoman$359=AEIMQ111111111TABLE B(O;$0  2#  a  .3  0` (#(#TABLE A(b$0  0` (#(#2#   .3  0 ` (#` (#(9 Z(Times New Roman (xir$0  0` (#(#0 ` (#` (#2#(  0  )3  0 (# (#($0  0` (#(#0 ` (#` (#0 (# (#2#(  a  )3  0h(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#2#(   )3  0h(#h(#($0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#2#  0  )3  0(#(#({$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#2#  a  )3  0p(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#2#     )3  0p(#p(# CFHIJKLxWZ3MQUY]aeiBullets ListNM d((3$ U!   )!dxdx( $ Figure  1  Level 1Level 2Level 3Level 4Level 5 U!   _XN`XXXGXgXXXN`?XX $!  <( 4 <DLX<8N`XXdd8EXERCISE5:ERYTHROCYTESSEDIMENTATIONRATEESR,SEDRATE X  Textbook:0  None  0     0%% Skills:0  10points%%  Objectives:    (#33 ( "3"  32#  1  .3  0    StatetheprincipleoftheErythrocytesSedimentationRateESR.3E݌%% Ќ  "3"   ( 3"2#  2  .3  0    ListtwofactorswhichmayaffecttheresultsobtainedintheESR.3"[݌t%% Ќ  "3"   ( 392#  3  .3  0    ListoneredcellandoneplasmafactorandhowitwillimpacttheresultsoftheESR.39r݌ `%% Ќ  "3"   ( 3d2#  4  .3  0    ListtwosampleswhichareacceptablefortheESRandstatetheadvantageonehasoverthe  L  other.3d݌ 8 %% Ќ  "3"   ( 32#  5  .3  0    Listanddescribethethreestageswhichoccurduringthesedimentationoftheredbloodcells.3݌| $ %% Ќ  "3"   ( 32#  6  .3  0    StatetheclinicalsignificanceoftheESR.3 ݌h  %% Ќ  "3"   ( 3 2#  7  .3  0    ListthreediseaseswhichmayhaveamarkedlyelevatedESR.3  ݌T %% Ќ  "3"   ( 3 2#  8  .3  0    StatethelengthoftimeasamplemaybeusedfortheESRbasedonstoragetemperature.3 + ݌@ %% Ќ  "3"   ( 3 2#  9  .3  0    StatethenormalvaluesfortheESRformenandwomenusingtheproperunits.3 W ݌, %% Ќ  "3 "   ( 3@ 2#  10  .3  0    ListninesourcesoferrorwhichmaycauseerroneousresultsintheESR.#XN`XXGXgV#GXgXXXN`3@ y ݌%% Ќ  "3 "   ( 32#  11  .3  0    PerformanESRutilizingpropertechniqueandequipment.3݌%% Ќ  Discussion   Theerythrocytesedimentationrate(ESR)isasimpleandinexpensivelaboratorytest.Itiscommonlyusedto p assesstheacutephaseoftheinflammatoryresponseandtohelpdiagnoseconditionsassociatedwithacute \ andchronicinflammation,includinginfections,cancers,andautoimmunediseases.ESRissaidtobe H nonspecificbecauseincreasesdonottellthedoctorexactlywhereinflammationisinthebodyorwhatis 4 causingit,andalsobecauseitcanbeaffectedbyotherconditionsbesidesinflammation.Forthisreason,ESR x  istypicallyusedinconjunctionwithothertests. d  The principle oftheESRisbasedonthefactthatwhenwellmixedvenousbloodisplacedinaverticaltube, < theredbloodcells(_RBCs_)willsettleoutoftheplasmaandfalltowardsthebottomofthetubeandthepale ( yellowliquid(plasma)risestothetop.After60minutes,measurementsaretakenofthedistancetheredcells  traveledtosettleatthebottomofthetube.  Thelengthofthefallofthetopofthecolumnofredbloodcellsinagivenintervaloftimeistheerythrocyte   sedimentationrateESR.Normallyredcellsdon'tsettlefartowardthebottomofthetube,theyfallslowly,  l! leavinglittleclearplasma.Manydiseasesmakeextraorabnormalproteins(suchasfibrinogenor !X" immunoglobulins,whichareincreasedininflammation)thatcausetheredcellstomoveclosetogether,stack "D # up,andformacolumn(rouleaux).Inagroup,redcellsareheavierandfallfaster.Thefastertheyfall,the #0!$ furthertheysettle,andthehighertheESR. t$"% Erythrocytesedimentationisaffectedbytwomajorphysiologicalfactors#XN`XXGXg>#GXgXXXN`:redcellsurfacechargesand L&#' frictionalforcesaroundtheredcell.Theerythrocytesnormallyhavenetnegativechargesand,therefore, 8'$( repeleachother.Highmolecularweightproteins,especiallywhenpositivelycharged,increaseviscosityand $(%) favorrouleauxformationandthuswouldraisetheESR.Rouleauxisaconditioninwhichthe_RBCs_Ԁclump )&* togetherlikestacksofcoins.Asthestackincreases,itbecomesheavierandtendstofalltothebottomfaster. )'+ Fibrinogen,themostabundantacutephasereactant,hasthegreatesteffectontheelevationofESRwhen *(, comparedwithotheracutephaseproteins._Paraproteins_Ԁarepositivelychargedmoleculesandwhen +|)- abundantlypresentasinmultiplemyelomaor_Waldenstrom_s_macroglobulinemia_ԀwillincreasetheESR ,h*. levelsbyenhancingrouleauxformationandelevatingplasmaviscosity. -T+/ ЇOntheotherhand,achangeinthefrictionalforcesaroundtheredbloodcellcanaffecttheESR.Anemia X causesafalselyincreasedESRbecausethechangeintheRBCtoplasmaratiodecreasesthefrictionalforces D whichfavorsrouleauxformation,causingthe_RBCs_Ԁtofallquickly.Withthehematocritreduced,thevelocity 0 oftheupwardflowofplasmaisalteredsothatredbloodcellaggregatesfallfaster.Macrocytosiswithasmall  surfacetovolumeratiohavechargerelativetotheirmassandthussedimentmorerapidly.  SomeauthorsprefertolistredcellandplasmafactorswhichaffecttheESR:  *D]Eddd Xdd Xdd X%%,*dd ,N dd +  $ ` ` $@@ww FactorsTendingtoLowerESR '  " 'FactorsTendingtoRaiseESR   " RedCellFactors  D  ! ! NCFHIJKLM(WZy3 "3"  3!2WZ3  0    ݀_polycythemia_ <    3!!݌ 0  Ќ  "3"  3"2WZ3  0    abnormalredcells,_eg_Ԁ_spherocytosis_,_microcytosis_, t   sickle0cells3""݌  `  Redcellfactors  D  "3"  3\$2WZ3  0    anemia3\$$݌   0 $$ PlasmaFactors   Ѐ*_cryoglobulins_ t Ѐ*lowfibrinogen  ` PlasmaFactors   Ѐ*increasedfibrinogen t Ѐ*increasedglobulins ` Ѐ*_paraproteins_ L Ѐ*lowalbumin 8 Ѐ*coldagglutinins |$ Ѐ*certain_hyperlipidaemic_Ԁstates h  MechanicalandTechnicalfactorscanalsonegativelyaffectthetest.Propertechniqueandcorrectuseofthe p equipmentiscriticalforvalidresults.Caremustbetakentofollowproceduralinstructionsexactlyas \ temperatureswhicharetoohighorlow,vibrationsonthecounter,unbalancedrack,improperdilutionof H blood,useofsamplesolderthanrecommendedcannegativelyimpacttheresults. 4 Thesedimentationrateof_RBCs_Ԁtakesplaceinthreestages:    "3"  3|)2WZ3  0 (   FirstStageDuringthefirst10minutesrouleauxform,withslowsedimentation.3|))݌"(%(% Ќ  "3"  3*2WZ3  0 (   SecondStageForthenext40minutescellssettlerapidly,withmostofthesettlingoccurringduring x# thisperiod.3**݌d$(%(% Ќ  "3"  3+2WZ3  0 (   ThirdStageduringthelast10minutes,packingoccurs,sedimentationrateisslowbecauseofthe  P% accumulationof_RBCs_Ԁinthebottomofthetube.3++݌!<&(%(% Ќ  Sample  l#!( TwosamplesareacceptablefortheESR,EDTAandtheblackstopperedtube.AnEDTAsampleis D%"* appropriatebutrequiresdilutionofthebloodpriortotesting.Theblackstopperedhastheadvantageof 0&#+ havingthecorrectamountofanticoagulantanddiluentsothatthetestcanbeperformeddirectlyfromthe '$, bloodinthetube.TheblackstopperedtubeMUSTBEcompletelyfilled.Usingtheblackstopperedtube (%- decreasesthechancesoferrorduetoanimproperdilutionoftheEDTAsample. (&. Ifthesampleisstoredat roomtemperature (2025C)theESRshouldbe setupwithintwohours ofblood *t(0 collection.EDTAspecimens storedintherefrigerator at4Cfor 24hoursorless maybeused. +d)1  .,,4  ClinicalSignificance X  TheESRisanonspecificindicatorofinflammationandnecrosis.Itreflectsmainlytheincreaseinproduction 0 ofacertainproteinproducedinresponsetonecrosisorinflammation.Thesechangesoccurinmanyacute  andchronicinfections,tumorsanddegenerativediseasesautoimmunediseasessuchasrheumatoidarthritis..  DoctorsdonotbasetheirdecisionssolelyonESRresults.Youcanhaveanormalresultandstillhavea  problem.TheuseoftheESRatthepresenttimeisasanindicationofthepresenceofactivedisease.This t testmayhelpdetecttheexistenceofdiseasebutnotitsseverity.  ` ESRishelpfulindiagnosingtwospecificinflammatorydiseases,temporal_arteritis_Ԁand_polymyalgia_  8  _rheumatica_.AhighESRisoneofthemaintestresultsusedtosupportthediagnosis.Aphysicianusually | $  ordersanESRtest(alongwithothers)toevaluateapatientwhohassymptomsthatsuggest_polymyalgia_ h   _rheumatica_Ԁortemporal_arteritis_,suchasheadaches,neckorshoulderpain,pelvicpain,anemia,unexplained T  weightloss,andjointstiffness.Therearemanyotherconditionsthatcanresultinatemporaryorsustained @  elevationintheESR.Itisalsousedtomonitordiseaseactivityandresponsetotherapyinbothofthese ,  diseases.    0     ModeratelyelevatedESRoccurswithinflammation,butalsowithanemia,infection,pregnancy,andoldage.  AmarkedlyincreasedESRusuallyhasanobviouscause,suchasamarkedincreaseinglobulinsthatcanbe p duetoasevereinfectionor_iflammation_.Thedoctorwilluseotherfollow-uptests,suchascultures, \ dependingonthepatientssymptoms.OtherconditionswhichmayhaveamarkedlyelevatedESRinclude: H "3"  3$:2WZ3  0 (   ݀Rheumatoidarthritis,anautoimmunediseasecausingsevereinflammationofthejoints.3$:Q:݌4(%(% Ќ  "3"  36;2WZ3  0 (   Multiplemyelomaor_Waldenstrom_s_macroglobulinemia_Ԁ(tumorsthatmakelargeamountsof x  immunoglobulins)typicallyhaveveryhigh_ESRs_Ԁeveniftheydon'thaveinflammation.36;c;݌d (%(% Ќ  "3"  3=2WZ3  0 (   _Polymyalgia_Ԁ_rheumatica_Ԁ3=H=݌P(%(% Ќ  "3 "  3.>2WZ3  0 (   Temporal_arteritis_.3.>[>݌<(%(% Ќ  AlthoughalowESRisnotusuallyimportant,itcanbeseenwith_polycythemia_Ԁ(aconditionwhereapatient  makestoomanyredbloodcells),withextreme_leukocytosis_Ԁ(patienthastoomanywhitebloodcells),and  withsomeproteinabnormalities.Somechangesinredcellshape(suchassicklecellsinsicklecellanemia)  alsolowertheESR.   ArisingESRcanmeananincreaseininflammationorapoorresponsetoatherapy;adecreasingESRcan !X" meanagoodresponse. "D # AnotherlaboratorytestcalledtheCReactiveProtein(_CRP_)testisamuchbetterindicatorofinflammation t$"% andnecrosisthantheESR._CRP_Ԁistheproteinwhichisactuallyproducedandthistestcandetectand `%#& quantitatetheamountofproteinpresentandisnotaffectedbyanemiaorabnormalserumproteins.However, L&#' theESRremainsaverypopulartesttoindicatethepresenceofinflammationandnecrosis.ESRand 8'$( C-reactiveprotein(_CRP_)arebothmarkersofinflammation.Generally,ESRdoesnotchangeasrapidlyas $(%) does_CRP_,eitheratthestartofinflammationorasitgoesaway._CRP_Ԁisnotaffectedbyasmanyotherfactors )&* asisESR,makingitabettermarkerofinflammation.However,becauseESRisaneasilyperformedtest, )'+ manydoctorsstilluseESRasaninitialtestwhentheythinkapatienthasinflammation. *(,  -T+/ Ї NormalValues  X 0 ( Adults(_Westergren_Ԁmethod):0(%(% 0 (  (%(% 0 ( *Menunder50yearsold:lessthan15mm/hr.(%(% 0 ( *Menover50yearsold:lessthan20mm/hr.(%(% 0 ( *Womenunder50yearsold:lessthan20mm/hr.(%(% 0 ( *Womenover50yearsold:lessthan30mm/hr.t(%(% 0 (  (%(% 0 ( Children(_Westergren_Ԁmethod): L (%(% 0 (  (%(% 0 ( *Newborn:0to2mm/hr.| $ (%(% 0 ( *Neonataltopuberty:3to13mm/hrh  (%(%  SourcesofError @   SourcesoferrorwhichmayadverselyaffecttheresultsoftheESRinclude:    ! ! (#3y NCFHIJKLM"3"  3J2#  1  .3  0 (   Iftheconcentrationoftheanticoagulantisgreaterthanrecommended,theESRwillbeerroneously  high.Thisisespeciallycriticaliftheblacktop,whichcontainsthediluentforthetest,isused.EDTA  samplesmaybeusedfortheESRandaredilutedpriortoperformingthetest.3JK݌p(%(% Ќ  "3"  3L2#  2  .3  0 (   IftheESRstandsformorethan60minutes,theresultswillbefalselyelevated.Ifthetestistimedfor \ lessthan60minutes,falselylowvaluesareobtained.3L+M݌H(%(% Ќ  "3"  3|N2#  3  .3  0 (   AnincreaseordecreaseinroomtemperaturemayleadtoincreasedordecreasedESRresults.The 4 temperatureshouldbewithintherangeof2025C.3|NN݌x (%(% Ќ  "3"  3O2#  4  .3  0 (   Thetubesmustbemaintainedinanuprightpositionduringthetest.Allsedimentationracksused d  shouldbeequippedwithlevelingscrewsandaspiritbubble.TiltingoftheESRtubeincreasesthe P sedimentationrate.3OP݌<(%(% Ќ  "3"  3Q2#  5  .3  0 (   Bubblesinthebloodtubewhenfillingwillleadtoerroneousresults.3QQ݌((%(% Ќ  "3"  3R2#  6  .3  0 (   Fibrinclotspresentinthebloodinvalidatethetestresults.3RR݌(%(% Ќ  "3"  3S2#  7  .3  0 F   Ifthesampleisstoredat roomtemperature (2025C)theESRshouldbe setupwithintwohours   ofbloodcollection.EDTAspecimens storedintherefrigerator at4Cfor 24hoursorless maybe  used.3ST݌ F%F% Ќ  "3"  3U2#  8  .3  0 F   Ifsamplehasbeenstoredintherefrigeratorallowtowarmuptoroomtemperaturebeforetesting.3UU݌ t!F%F% Ќ  "3"  3V2#  9  .3  0 F   Thesamplemustbewellmixedpriortouse.3VW݌!`"F%F% Ќ  References: #8!$ ! !  (#33 "3"  3X2#  1  .3  0 F   TheErythrocyteSedimentationRate:OldandNewClinicalApplications,dateunknown, h%#& Constantine,_Saadeh_,MD T&#' http://_www.mechatronics.nl_/technics/_esr_/_the_erythrocyte_sedimentation_rate_by_c_saadeh_md.pdf_3XX݌@'$(F%F% Ќ  "3"  3Z2#  2  .3  0 F   LabTestsOnline,http://_www.labtestsonline.org_/understanding/_analytes_/_esr_/_test.html_3Z[݌,(%)F%F% Ќ  "3"  3p\2#  3  .3  0 F   ClinicalUtilityoftheErythrocyteSedimentationRate,MalcolmL.Brigden,M.D.,_B.C_,AmFam )&* Physician1999;60:1443-50,http://www.aafp.org/afp/991001ap/1443.html%%O%F%F%/ / 3p\\݌ *'+ Ќ   F     N      V      ^  ,p*. _  EXERCISE5:ERYTHROCYTESEDIMENTATIONRATE  X <( 4 <DLX< Specimen:    (#3 3X (#33 "3"  3`2#  1  .3  0 F   FreshwholebloodcollectedinEDTAanticoagulant3``݌F%F% Ќ  "3"  3a2#  2  .3  0 F   Checkallspecimensforclotswithapplicatorsticks3aa݌F%F% Ќ  "3"  3b2#  3  .3  0 F   Specimenshouldbeassayedwithin2hoursifkeptatroomtemperatureor24hoursifrefrigerated. 3bb݌F%F% Ќ  Equipment:   ` ! ! (#33"3"  3d2#  1  .3  0 F   Sedratetube3dd݌ 8 F%F% Ќ  "3"  3oe2#  2  .3  0 F   Reservoirprefilledwithdiluent   V      ^    @ 3oee݌| $ F%F% Ќ  "3"  3f2#  3  .3  0 F   Disposablepipettes3ff݌h  F%F% Ќ  "3"  3g2#  4  .3  0 F   Sedraterack3gg݌T F%F% Ќ  Procedure:  ,  ! !"3"  3h2#  1  .3  0 F   Removethebluecapontheprefilledreservoir.3hh݌F%F% Ќ  "3"  3i2#  2  .3  0 F   Usingadisposablepipette,fillthevialtotheindicatedfilllinewithapproximately0.8mlsofwell  mixedwholebloodtomaketherequired4:1dilution.3ii݌F%F% Ќ  "3"  3k2#  3  .3  0 F   Replacethepiercablestopperandgentlyinvertseveraltimestomix.3kJk݌pF%F% Ќ  "3"  3+l2#  4  .3  0 F   InsertsedratetubethroughthepiercablestopperusingatwistingpushingmotionintotheCand \ autozerotothe 0position.3+lXl݌HF%F% Ќ  "3"  3m2#  5  .3  0 F   Placethevialinitsrackonalevelsurface.3mm݌4F%F% Ќ  "3"  3n2#  6  .3  0 F   Setthetimeforexactlyonehour.3nn݌x F%F% Ќ  "3"  3oo2#  7  .3  0 F   Afteronehour,readthenumericalresultsoftheESRin millimeters attheplasmameniscus.3ooo݌d F%F% Ќ  "3"  3p2#  8  .3  0 F   Recordtheresultsonthelogsheet.GKXGXg3pp݌TF%F% Ќ  #GXgXGKDq#  ,   EXERCISE5:ERYTHROCYTESEDIMENTATIONRATE X  Name_________________________________ 0 *]?ddfdd * dd N D]E%%, dd ,$dd +    PatientName  D   D  PatientIDNumber   l     l   StartTime  D     D    StopTime   l     l   Results(usecorrectunits)  D   D    Dotheseresultsfallwithinthenormalrange(circleone): YESNO $      EXERCISE5:ERYTHROCYTESEDIMENTATIONRATESTUDYQUESTIONS X  Name____________________________Date___________________ 0 Points:17   F    ! !"3"  3v2#  1  .3  0 F   StatetheprincipleoftheErythrocyteSedimentationRate(ESR).1point3vHv݌ `F%F% Ќ  "3"  34w2#  2  .3  0 F   WithinwhattimeframeofsamplecollectionshouldtheESRbesetup?Besuretostatethespecific  temperatureofstorageforbothroomtemperatureandrefrigeration.(2Point)34waw݌F%F% Ќ  "3"  3x2#  3  .3  0 F   Statethetwofactorswhichaffectthesedimentationrate.(2points)3xx݌4F%F% Ќ   F A. d   F B. ( "3"  3 z2#  4  .3  0 F   Fillinthefollowingchart(2points)bylistingonefactorwhichmayaffecteachitemlisted.3 zMz݌F%F% Ќ  * ]Bdd dd  dd $]?%%,` dd ," dd , dd +      < ! LowerESR '< "" 'RaiseESR < #" RedCellFactors  !d$   !d%   !d& PlasmaFactors  <# '   <# (  <# )  "3"  3V}2#  5  .3  0 F   Describethethreestageswhichoccurduringthesedimentationrate(1.5points).3V}}݌0&#+F%F% Ќ   F A. (%-  F B. *t(0  F C. -8+3  |.$,4 "3"  3~2#  6  .3  0 F   List2sampletypeswhichmaybeusedfortheESR.(1point)3~ ݌XF%F% Ќ  "3"  32#  7  .3  0 F   Ofthe2sampleswhichmaybeappropriatefortestingstatetheadvantagethatonehasovertheother.  (1point)3(݌F%F% Ќ  "3"  3M2#  8  .3  0 F   StatetheclinicalsignificanceoftheESR(1point)3Mz݌ L F%F% Ќ  "3"  3N2#  9  .3  0 F   Listthreediseases/conditionswhichmayhave markedlyincreased ESRresults(1.5points).3N{݌@ F%F% Ќ  "C; "  C;~0 F 2#  a  .3  0F%F%  C;~݌%% Ќ  "C; "  C;\0 F 2#  b  .3  0F%F%  C;\݌%% Ќ  "C; "  C;:0 F 2#  c  .3  0F%F%  C;:g݌p%% Ќ  "3 "  32#  10  .3  0 F   ListfoursourcesoferrorintheESRtestwhichmayadverselyaffecttheresults(2points).3F݌4F%F% Ќ  "C; "  C;A0 F 2#  a  .3  0F%F%  C;An݌d %% Ќ  "C; "  C;!0 F 2#  b  .3  0F%F%  C;!N݌%% Ќ  "C; "  C;0 F 2#  c  .3  0F%F%  C;.݌ l!%% Ќ  "C; "  C;0 F 2#  d  .3  0F%F%  C;݌t$"%%% Ќ  "3 "  32#  11  .3  0 F   StatethenormalvaluesfortheModifiedWestergrenESRformalesandfemales(2point).3݌$(%)F%F% Ќ  #XN`XXGXg#