Sarah Gamble PhD

• Lecturer, Interdisciplinary

https://publichealth.berkeley.edu/people/sarah-gamble/

Upon withdrawal medicine 503 order prochlorperazine 5mg visa, sleep difficulties and unpleasant dreams have been reported lasting for several weeks symptoms nicotine withdrawal order prochlorperazine 5mg online. Consistent with their respiratory depressant effects medications in canada purchase 5mg prochlorperazine with amex, opioids exacerbate sleep apnea treatment breast cancer order 5 mg prochlorperazine fast delivery. During acute intoxication medications hyperkalemia generic prochlorperazine 5mg overnight delivery, sedative-hypnotic drugs produce the expected increase in sleepiness and decrease in wakefulness medicine 773 cheap generic prochlorperazine canada. Chronic use (particularly of barbiturates and the older nonbarbiturate, nonbenzodiazepine drugs) may cause tolerance with subsequent return of insomnia. Sedative, hypnotic, or anxiolytic drugs with short durations of action are most likely to produce complaints of rebound insomnia, whereas those with longer durations of action are more often associated with daytime sleepiness. Sleep disorders induced by amphetamine and related substances and other stimulants are characterized by insomnia during intoxication and excessive sleepiness during withdrawal. During withdrawal from chronic stimulant use, there is both prolonged nocturnal sleep duration and excessive daytime sleepiness. Multiple sleep latency tests may show increased daytime sleepiness dur ing the withdrawal phase. Individuals who smoke heavily may experience regular nocturnal awakenings caused by tobacco craving. Development and Course Insomnia in children can be identified by either a parent or the child. Often the child has a clear sleep disturbance associated with initiation of a medication but may not report symptoms, although parents observe the sleep disturbances. Help-seeking behavior for the sleep disturbance in these age groups is limited, and thus corroborative report may be elicited from a parent, caregiver, or teacher. Older individuals take more medications and are at increased risk for developing a substance/medication induced sleep disorder. They may interpret sleep disturbance as part of normal aging and fail to report symptoms. Risk and Prognostic Factors Risk and prognostic factors involved in substance abuse/dependence or medication use are normative for certain age groups. They are relevant for, and likely applicable to , the type of sleep disturbance encountered (see the chapter "Substance-Related and Addictive Disorders" for descriptions of respective substance use disorders). Culture-R elated Diagnostic issues the consumption of substances, including prescribed medications, may depend in part on cultural background and specific local drug regulations. The same amount and duration of consumption of a given substance may lead to highly different sleep-related outcomes in males and females based on, for example, gender-specific differences in hepatic functioning. All-night polysomnography can help define the severity of insomnia complaints, while the multiple sleep latency test provides information about Uie severity of daytime sleepiness. Sleep diaries for 2weeks and actigraphy are considered helpful in confirming the presence of substance/medication-induced sleep disorder. Drug screening can be of use when the individual is not aware or unwilling to relate information about substance intake. Functional Consequences of Substance/iVledication-induced Sleep Disorder While there are many functional consequences associated with sleep disorders, the only unique consequence for substance/medication-induced sleep disorder is increased risk for relapse. Monitoring of sleep quality and daytime sleepiness during and after withdrawal may provide clinically meaningful information on whether an individual is at increased risk for relapse. A substance/medication-induced sleep disorder is distinguished from another sleep disorder if a substance/medication is judged to be etiologically related to the symptoms. Once treatment is discontinued, the sleep disturbance will usually remit within days to several weeks. If symptoms persist beyond 4 weeks, other causes for the sleep disturbance-related symptoms should be considered. Not infrequently, individuals with another sleep disorder use medications or drugs of abuse to self-medicate their symptoms. If the substance/ medication is judged to play a significant role in the exacerbation of the sleep disturbance, an additional diagnosis of a substance/medication-induced sleep disorder may be warranted. Many individuals with other medical conditions that cause sleep disturbance are treated with medications that may also cause sleep disturbances. Difficulties with sleep that clearly preceded the use of any medication for treatment of a medical condition would suggest a diagnosis of sleep disorder associated with another medical condition. If the disturbance is comorbid with another medical condition and is also exacerbated by substance use, both diagnoses. Restricted to nonrestorative sleep: Predominant complaint is nonrestorative sleep unaccompanied by other sleep symptoms such as difficulty falling asleep or remaining asleep. The other specified hypersomnolence disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for hypersomnolence disorder or any specific sleep-wake disorder. The other specified sleep-wake disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific sleep-wake disorder. These cases may include, but are not limited to , conditions in which lack of knowledge about effective stimulation prevents the experience of arousal or orgasm. In many individuals with sexual dysfunctions, the time of onset may indicate different etiologies and interventions. Lifelong refers to a sexual problem that has been present from first sexual experiences, and acquired applies to sexual disorders that develop after a period of relatively normal sexual function. In addition to the lifelong/ acquired and generalized/situational subtypes, a number of factors must be considered during the assessment of sexual dysfunction, given that they may be relevant to etiology and/or treatment, and that may contribute, to varying degrees, across individuals: 1) partner factors. Clinical judgment about the diagnosis of sexual dysfunction should take into consideration cultural factors that may influence expectations or engender prohibitions about the experience of sexual pleasure. Sexual response has a requisite biological unde inning, yet is usually experienced in an intrapersonal, interpersonal, and cultural context. In many clinical contexts, a precise understanding of the etiology of a sexual problem is unknown. If the sexual dysfunction is mostly explainable by another nonsexual mental disorder. If the problem is thought to be better explained by the use/misuse or discontinuation of a drug or substance, it should be diagnosed accordingly as a substance/medication-induced sexual dysfunction. Acquired: the disturbance began after a period of relatively normal sexual function. Diagnostic Features the distinguishing feature of delayed ejaculation is a marked delay in or inability to achieve ejaculation (Criterion A). Associated Features Supporting Diagnosis the man and his partner may report prolonged thrusting to achieve orgasm to the point of exhaustion or genital discomfort and then ceasing efforts. Some men may report avoiding sexual activity because of a repetitive pattern of difficulty ejaculating. Some sexual partners may report feeliAg less sexually attractive because their partner cannot ejaculate easily. Each of these factors may contribute differently to the presenting symptoms of different men with this disorder. Prevalence Prevalence is unclear because of the lack of a precise definition of this syndrome. By definition, acquired delayed ejaculation begins after a period of normal sexual function. The prevalence of delayed ejaculation appears to remain relatively constant until around age 50 years, when the incidence begins to increase significantly. Men in their 80s report twice as much difficulty ejaculating as men younger than 59 years. Age-related loss of the fast-conducting peripheral sensory nerves and age-related decreased sex steroid secretion may be associated with the increase in delayed ejaculation in men older than 50 years. Culture-Related Diagnostic issues Complaints of ejaculatory delay vary across countries and cultures. Such complaints are more common among men in Asian populations than in men living in Europe, Australia, or the United States. This variation may be attributable to cultural or genetic differences between cultures. Functional Consequences of Delayed Ejaculation Difficulty with ejaculation may contribute to difficulties in conception.

Finally medications given to newborns buy cheap prochlorperazine 5 mg line, they are recruited to the tissue where they 186 Concise Guide to Hematology Table 16 medicine stick buy generic prochlorperazine. Blood cells develop in the bone marrow medicine 014 order cheap prochlorperazine online, and the earliest cells (progenitor cells) become committed to a speci c type of blood cell medications 4 times a day discount 5mg prochlorperazine visa. Four kinds of granules are seen in neutrophils: azurophilic symptoms of the flu order prochlorperazine, speci c treatment 10 purchase online prochlorperazine, gelatinous, and secretory vesicles. Commitment begins in the bone marrow at the myeloblast stage, and proliferation occurs through the promyelocyte and myelocyte stages. Classes of granules include primary or azurophilic; secondary or spe ci c; and tertiary (Figure 16. All three classes of granules have speci c enzymes as well as different staining characteristics on blood smears. Primary granules of neutrophil (azurophilic granules) contain elastase, myeloperoxidase, defensins, and a variety of other proteins (Figure 16. Secondary granules are secretory granules acquired at the transition to the myelocyte stage. Secondary granules (speci c granules) contain lactoferrins, transcobalamin 1, and metalloproteinases. Tertiary gran ules (Gelatinase granules) contain gelatinase and are formed during later 188 Concise Guide to Hematology stages of neutrophil development. Eosinophils Eosinophils are distinguished from neutrophils at the early myelocyte stage. They contain large, bright-staining orange-red granules that are composed of major basic protein, peroxidase, and other lysosomal enzymes (Atlas Figure 6). These receptors, which are not found in neutrophils, play a role in killing parasites. In nonallergic people, the blood eosinophil count is usually less than 400/ L, and averages 120/ L. Basophils and mast cells Basophils and mast cells are the circulating and tissue-bound forms of cells, respectively, that are related but develop from separate precursor cells. They share cytoplasmic basophilic gran ules, high af nity IgE receptors, and histamine release upon stimulation like basophils, but are considered distinct. Both types of cells are believed to play a critical role in host defense against parasites and participate in atopic processes. Monocytes Once monocytes reach the tissue, they differentiate into macrophages and remove microorganisms and noxious agents. They also generate toxic oxygen metabolites that play a role in killing microorganisms. They may occur in the production of white cells, in the maturation of granules, in the expression of proteins that are necessary for critical function, or in the recruitment of cells from the circulation. Disorders in the numbers of circulating neutrophils Evaluation of these disorders includes a complete blood count and determina tion of the percentage of each class of white blood cells. Because underlying disease or medication may affect the neutrophil count, this information must be linked to the clinical evaluation. For example, the lower limit of the normal blood neutrophil count is 1500/ L in most populations; African Americans have a lower neu trophil limit, approximately 1000/ L. Neutrophilia is present when the neutrophil count exceeds the upper limit of the normal range by two standard deviations from the mean value for normal individuals. The value is higher in children than in adults, and the percentage can be higher than normal even if the total count is within the normal range. When the neutrophil count is 500/ L, the patient has considerable susceptibility to infection with endogenous organisms in the skin, oropharynx, and intestine. Infections with Gram-positive cocci, especially Staphylococcus aureus, are common in these patients. If the patient has been receiving antibacterial agents for a long period while neutropenic, suppression of 190 Concise Guide to Hematology bacterial ora facilitates fungal overgrowth and infections due to Candida or Aspergillus species arise. Medications can have a speci c effect on myeloid production producing isolated neutropenia (agranulocytosis) or general bone marrow suppres sion of all three cell lines; granulocytes, red cells, and platelets. In these patients, neutropenia may be caused in part by decreased neutrophil production in the bone marrow. In cyclic neutropenia, neutrophils disappear from the circulation at regular 3-week intervals. Several congenital neutropenia are associated with mutations in the neutrophil elastase gene. Structural and functional defects in neutrophils Neutrophils are recruited from the circulation in response to chemotactic agents that are released at the site of infection. Chemotactic agents are pep tides and proteins that diffuse from the site of tissue injury, bind to speci c receptors on the cell surface, and stimulate neutrophils to attach (adhere and roll) and migrate though the blood vessel wall (Figure 16. After neutrophils move from the circulation and cross the endothelial cell barrier, they phago cytize invading organisms, and with the help of granules, destroy them. Disorders of neutrophil function impair the ability of neutrophils to move from the circulation, phagocytize particles, or degranulate. Several inherited disorders have been de ned at the molecular level, and these disorder have shed light on critical steps of neutrophil function (Table 16. Leukocyte adhesion de ciency are a group of rare diseases that have led to the understanding that recruitment across the endothelial cell barrier occurs as a result of speci c protein protein or protein carbohydrate inter actions and neutrophil activation is mediated by integrin action. These disorders are characterized by recurrent bacterial and fungal infections as well as by neutrophilia. The Bombay erythrocyte phenotype is the expression of a nonfucosylated form of the H antigen of red cells. This antigenic variant represents the failure to form certain fucose carbohydrate linkage. These patients have an impaired ability to form sialyl Lewisx carbohydrate structures on neutrophils and other cells. This leads to improper sialylated selectins which are not able to tether by-passing neutrophils to endothelium and promote their rolling. This rolling is the initial step in the recruitment of neutrophils from the circulation. If this action does not occur, then neutrophils do not cross the endothelium and cannot localize to the site of infection. These infections occur because of an impaired ability to kill bacteria after they are phagocytized. These patients have a relative de ciency of speci c granules that contain the enzymes that are necessary for the migration and delivery of receptors to the cell surface. As a result, patients with this disease have impaired migration of neutrophils and recurrent infections of the skin, sinuses, and lungs. This transcription factor regulates expression of certain genes activated during granulocyte differentiation. This abnormality results in a giant coalesced azurophil/speci c granules in neutrophils resulting in ineffective neutrophil production, neutropenia, and impaired chemotaxis and killing of microorganisms. These patients also have oculo-cutaneous albinism and cranial and peripheral neuropathy. Hereditary myeloperoxidase syndrome occurs at a rate of approximately 1:2000 to 1:4000. This syndrome is usually found incidentally on morpho logic examination of neutrophils. The major nding is intact phagocytosis of bacteria and fungi, but impaired ability to kill fungi such as Candida and Aspergillus. The eosi nophil count can decrease as a result of infection or administration of corticosteroids, prostaglandins, or epinephrine. However, unlike neutrope nia, this condition is usually transient and is not associated with a signi cant risk of infection. Eosinophilia Eosinophilia is characterized by an absolute eosinophil count of greater than 500 cells/ L. These patients have to have organ in ltration by eosinophils leading to dysfunction of the heart, central nervous system, kidney, lungs, gastrointestinal tract, and skin. Most eosinophil function is associated with degranulation and release of major basic protein. This protein kills parasites, but is also toxic to the skin, intestine, tracheal epithelial cells, and other mononuclear cells. A low basophil count is associated with glucocorticoid treatment and hypersensitivity reactions. The basophil count is increased in patients who have allergic conditions, infection, endocrinopathy, and myeloproliferative disorders. Systemic mastocytosis is a disorder associated with mast cell in ltration of the skin or other organs also occurs. Systemic mastocytosis, a mast cell in ltrative disorder, is associated with symptoms related to excess histamine and include urticaria, hives, and dizziness. The average circulating monocyte count is 300/ L and can range from 0 to 800 cells/ L. Monocytopenia occurs in response to stress, endotoxemia and after glu cocorticoid administration. The members of this series exhibit variations in number in response to disease or infection. An understanding of the regulation of their blood levels and functions aids in understanding the clinical picture of a patient. Although the information provided appears exhaustive, a considerable amount about the function of each of these cells has yet to be uncovered. Eosinophilia, eosinophil associated diseases, chronic eosi nophil leukemia, and the hypereosinophilic syndromes. Overview Bone marrow is a semi-solid gelatinous tissue which resides within the bony cavities of the axial skeleton. It contains hematopoeitic cells (red marrow), stromal cells, and fat (yellow marrow). Bone the bone that surrounds the marrow is composed of a thick layer of compact bony material referred to as cortical bone. The medullary cavity itself contains a lattice-like network of thin bone referred to as trabecular or cancellous bone. Structure of b one (a) Woven bone is tissue in which the normal parallel brillar structure of the bone has not been fully created. Cellular c omponents of b one (a) Osteoblasts: (i) Osteoblasts are bone forming cells of mesenchymal origin that syn thesize glycosoaminoglycans and collagen bers (osteoid or non mineralized bone) forming the basis of bone structure. The remod eling is carried out by osteoclasts resorbing bone followed by osteoblasts producing osteoid, which then becomes mineralized. Bone m arrow s troma (a) the bone marrow stroma is the supporting matrix for hematopoietic cells. Marrow fat secretes cytokines that can in uence granulopoiesis and T cell and monocyte function. Vasculature (a) the marrow vasculature consists of a nutrient artery that penetrates the bone and branches into smaller and smaller divisions (arterioles) ulti mately forming open vascular channels, a sinusoidal network, in the medul lary cavity. Hematopoietic c ells (a) Hematopoietic cells lie in groups or cords in the inter-trabecular spaces and enter the circulation by migrating through the sinusoidal endothelium. On histologic sections these zones are not always evident: (i) Erythroid progenitors localize in small collections around marrow macrophages. In reality, marrow cellularity decreases to roughly 50% by age 30 and declines slowly thereafter until late adulthood. In general a bone marrow examination should be done for an unexplained cytopenia, evaluation for a lymphoproliferative process or suspected hematopoietic dis order. A thorough examination of a suspected marrow process consists of a review of the blood cell counts and indices and microscopic review of the peripheral blood smear. Medical history is important and the reason for the marrow biopsy needs to be transmitted to the pathologist to help focus the evaluation. Therefore the timing of the marrow biopsy in relation to therapy needs to be known. A bone marrow performed 14 days after initiating chemotherapy has a signi cantly different appearance than a marrow exam ined 35 days later. Overview the diagnostic bone marrow aspiration and biopsy procedure is an essential tool in the evaluation of patients who have a suspected hematologic disorder. A variety of disorders can be diagnosed includ ing bone marrow failure states, hematologic malignancies, metastatic cancers, enzymatic and congenital storage diseases and other conditions. With proper training this technique can be undertaken successfully in most patients by medical practitioners such as internists, house of cers in-training and depending on the state in which a person practices, mid-level care providers (licensed nurse practitioners and phy sician assistants) as well. Procedures in very young children, however, should be restricted to individuals highly experienced in this patient sub population.

It is therefore important to mention at this point that although five of the thirty-six participants preferred whistling medications resembling percocet 512 cheap 5mg prochlorperazine fast delivery, ten participants said that they could not whistle medications diabetic neuropathy order prochlorperazine pills in toronto. Self-evidently symptoms 0f yeast infectiion in women order line prochlorperazine, whistling is not an ideal primary input for any application 85 medications that interact with grapefruit purchase prochlorperazine on line amex, unless the objective is to teach users to whistle symptoms right after conception order prochlorperazine line. It is also important to note that the preferences of the hearing-impaired may possibly differ from those with normal hearing illness and treatment purchase prochlorperazine 5 mg. Sounds are arranged on the abscissa from the most preferred (left) to the least preferred (right). The reason could be that the nature of whistling and blowing mainly involves exhaling but hardly allows any inhaling, thus causing the player to quickly run out of breath. This, however, calls for further research on the relationship between the different structures of the vocal tract (lips, jaw, palate, tongue, teeth etc. It is hoped that these observations will help future developers anticipate vocal preferences and patterns in this new form of interaction. Roles for Paralinguistic Voice Input While working on the projects described in the previous chapter, many other issues of potential importance arose, including the possible roles and applications of paralinguistic voice input. This chapter summarizes some of the ideas that arose and which seem worthy of further investigation, by myself or by others, and gives an account of one additional evaluation that I undertook. For some players, who played Sing Pong, sssSnake, and Expressmas Tree vocal control was an opportunity to express themselves more openly and to use their voices in ways that would normally feel forbidden in a public context. Sing Pong and sssSnake, in this context, also provide an outlet for emotions and encourage social and vocal disinhibition through expression and discharge of embarrassment. The fact that they both incorporate a two-player experience encourages players to make voices in public more than it would if they were for one player. This is because the experience is shared and explored by both players while their voices overlap; masking and at the same time augmenting each other. In such games, disinhibition is not initially experienced by the player during the game but is also experienced beforehand when the player-to-be is a spectator. As a result, Sing Pong, sssSnake, and Expressmas Tree involve a hidden form of social interaction and of social learning through which people learn by watching others who are rewarded. Moreover, the laughter and joy that playing such voice-controlled games brings to the players and audiences may also be cathartic to both. Some people scream when angry or stressed in order to release their negative emotions. Screambody silences the vocalizations of the user when the user is in a public area, and records them for later release in a private area (Figure 79). Some researchers believe that singing is also cathartic and that it is an artistic and biological means of emotional expression and release [Beeman, 1998]. Since the paralinguistic dimension of singing is what distinguishes it from normal everyday speech, the cathartic effect of singing may arguably be at least partly attributed to this dimension. The next section investigates the role of the paralinguistic dimension of singing in expressive communication. Similar evidence about the role of singing in enhancing memory and communication skills were found by Loewy [2004]. Singing was found to be of therapeutic benefit to neurologically impaired patients and of significance in enhancing the mental and physical health of the aged [Unwin et al. However, such research on the effect of singing on the singer rather than the listener is still comparatively thin on the ground [Unwin et al. According to Austin, this technique was useful to people who suffered from eating disorders and those who were sexually abused [Austin 2003 quoted in Loewy, 2004]. Jindrak and Jindrak [Jindrak, 1986] claim that vocalizations cause the vocal folds, the walls of the mouth, and the pharynx to vibrate. These vibrations are then transmitted by the interstitial fluid to the skull and lead to its vibration. The vibration of the skull causes the sphenoid bone to vibrate which in turn causes the parietal bone to vibrate. I do not have adequate knowledge to be sure of the validity of any of these claims. C since Hippocrates wrote about the significance of the laryngeal system in voice production [Harman 1991 quoted in Arizona Health Sciences Library, 2006]. The writings of Leonardo Da Vinci during the Renaissance also contributed to earlier speculations on voice production. Rhazes in Baghdad, on the other hand, made the earliest attempts to explore voice disorders and to advocate voice training [Harman 1991 quoted in Arizona Health Sciences Library, 2006]. Other ways included the use of systems that consisted of a special indicative lamp or a deflective meter needle [Oster, 1996]. Oscilloscopes have also been used to explore further acoustic dimensions of speech but their usefulness was found to be limited because the visual feedback was difficult to understand, delayed, and unappealing to children [Oster, 1996]. Since then, a number of effective voice-visual training tools have been developed to assist dyslexic, hearing-impaired, speech-impaired, and asthmatic patients. Computer-based speech and voice therapy is nowadays gaining increasing rehabilitative credibility and clinical popularity [Walker, 2006]. Computers, however, are not yet cognitively skilled enough to connotatively interpret and detect errors in continuous speech without human involvement [Walker, 2006]. One of the few interactive therapeutic speech training systems that exist today is Video Voice. This system consists of a number of entertaining therapy games that improve voice production and articulation by encouraging various speech activities. Some of the games may help improve pitch and volume control as well as breath control [Arizona Health Sciences Library, 2006]. The speech patterns of which the system generates a variety of visual representations allow the patient and the therapist to judge voice production instantly. Colors are used to differentiate between voiced sounds which are displayed in red and voiceless sounds which are displayed in green [Oster, 1996]. It allows the eye to complement the ear in quickly assessing and correcting the otherwise invisible vocal impairments. Using voice-visualization in therapeutic sessions may also involve one major advantage over traditional therapeutic sessions that only involve a therapist. This advantage is that a voice-to-vision application may possibly be more engaging and appealing to the patient than a face-to-face session with a therapist. The next section highlights the need for gathering a rich set of requirements and preferences for creating voice-controlled applications that are accessible and engaging to the deaf. Furthermore, many existing strategies for conveying these characteristics and teaching the deaf how to perceive them do not seem efficient, especially when dealing with the concept of pitch. Paradoxically, this does not only apply to the deaf, but some of the hearing cannot make a clear distinction between the concepts of pitch and loudness [Ma, 2001]; when asked to generate a higher-pitched sound, many generate a louder sound, which may of course be a linguistic rather than a cognitive confusion. These were some of the many reasons that led to my exploration of additional approaches to the visual representation of voice. I employed SpitSplat and Expressmas Tree in analyzing the interaction patterns of seven deaf children. I slightly modified the screen version of Expressmas Tree to test it on deaf users. The aim was to explore the potential role of paralinguistic vocal control of interactive media in enabling the deaf to have a greater understanding of voice and to offer their instructors more efficient and engaging strategies for explaining voice characteristics. There are many reasons why non-speech voice-controlled games could be useful to the deaf as well as to the hearing. As a result, several loudness charts have been designed to aid the deaf in learning the variations between loud and soft voices. These usually contain a small figure representing a soft sound, a medium figure representing a medium sound, and a larger figure representing a loud sound. However, there are hardly any well-designed charts that establish an understanding of pitch or duration. Moreover, charts are unlikely to be as engaging, appealing and memorable as an interactive experience. Figure 81: An illustration of a star was employed as a visual feedback signal in the virtual version of Expressmas Tree. The evaluation involved observing, writing field-notes, and video-recording seven children with varying degrees of hearing loss that ranged from mild (hearing threshold => 25 dB) to profound (hearing threshold => 95 dB). I started with Zahra, a seven-year-old female (mild hearing loss) who had a cochlear implant. The instructor, Afrah Al Fardan, was present during the study to help in instructing the children. She produced an air stream by blowing on her hand and instructed Zahra to avoid doing so. She immediately realized that she was expected to produce a voiced sound rather than a voiceless air-stream. Zahra, however, seemed too shy to generate a loud voice and was therefore not very willing to vocalize in the presence of an invigilator.

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