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Suicide is the third leading cause of death for adolescents and young people in the United States. The etiology of suicide in this popula- tion has eluded policy makers, researchers, and communities. Although many suicide pre- vention programs have been developed and implemented, few are evidence-based in their effectiveness in decreasing suicide rates. In one northern California community, adolescent sui- cide has risen above the state’s average. Two nurses led an effort to develop and implement

an innovative grassroots community suicide prevention project targeted at eliminating any further teen suicide. The project consisted of a Teen Resource Card, a community resource brochure targeted at teens, and education for the public and school officials to raise awareness about this issue. This article describes this proj- ect for other communities to use as a model. Risk and protective factors are described, and a comprehensive background of adolescent sui- cide is provided.

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A Community Takes Action Linda M. Pirruccello, MsN, rN

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I t is not uncommon for ado- lescents to think about end- ing their lives (Gould &

Kramer, 2001; Rueter, Holm, McGeorge, & Conger, 2008), although thinking about suicide does not always lead to suicide attempts (Pelkonen & Mart- tunen, 2003). The national 2007 Youth Risk Behavior Sur- vey of a representative sample of students in grades 9 through 12 indicated 14.5% of students seriously considered attempting suicide, 11.3% made a suicide plan, and 6.9% attempted suicide during the 12 months preceding the survey (Eaton et al., 2008). It is for this reason that the nation’s

public health agenda objectives for Healthy People 2010 prioritized adolescent suicide prevention ef- forts (U.S. Department of Health and Human Services, 2000).

Youth often experience tre- mendous stress, confusion, and hopelessness related to situa- tions in their lives, schools, and communities, which too often lead young people to consider suicide as their only solution. Despite alarmingly high youth suicide rates, there has been limited research on how to com- prehensively predict, treat, and prevent suicide among youth (Macgowan, 2004). Indeed, the complexities of youth suicide behavior continue to confound policy makers, professionals, communities, and researchers. Although public attention and awareness of youth suicide has increased during the past 2 de- cades in the United States, sui- cide was still the third leading cause of death in 2006 among youth ages 15 to 24, accounting for 4,189 deaths (Centers for Disease Control and Preven- tion [CDC], 2009a).

One purpose of this article is to raise awareness of the problem of adolescent suicide, which is the first step in the development of suicide preven- tion strategies. Another pur- pose is to encourage and inspire nurses and other health care professionals to become agents of change and leaders within their communities in prevent- ing youth suicide. This article describes one suicide preven- tion project that led to the implementation of a grassroots community-based intervention program targeting youth. This

project provides an example of nurses leading and collaborat- ing within their local commu- nity in an effort to eliminate adolescent suicide.

scoPe of the ProbLeM Suicide is rare in childhood

and early adolescence but in- creases every year as children age (Pelkonen & Marttunen, 2003). Suicide rates in the United States for male adoles- cents between ages 15 and 19 are four times higher than the rates for their female peers (CDC, 2009b). Due to the growing risk of suicide with increasing age, there is a critical need to tar- get suicide prevention efforts in adolescents (Pelkonen & Mart- tunen, 2003) and develop sui- cide prevention programs.

During the past several de- cades, adolescent (ages 15 to 19) suicide rates in the United States have shifted. In 1950, sui- cide rates for both sexes for ages 15 to 19 were 2.7 per 100,000. By 1990, these rates reached a peak rate of 11.1 per 100,000. Subsequently, from 1990 to 2003, the rates significantly de- clined in this age group from 11.1 to 7.3 per 100,000 (Na- tional Center for Health Sta- tistics, 2005). According to a recent CDC report, adolescent suicide rates for 2003-2004 dem- onstrated the largest increase in annual suicide rates during the past 15 years, from 11.61 to 12.65 per 100,000 (CDC, 2007b). The problem may actu- ally be worse than these figures indicate because suicide rates may be underreported and mis- classified (Institute of Medicine [IOM], 2002). These trends

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35Journal of Psychosocial nursing • Vol. 48, no. 5, 2010

demonstrate the urgency to pri- oritize suicide prevention efforts for adolescents.

Explanations for the differing rate trends are not easily under- stood. Some researchers assert the increased youth suicide rates of the 1990s were attributed to greater exposure of this popula- tion, particularly boys, to drugs and alcohol (Gould, Green- berg, Velting, & Shaffer, 2003). The possible reasons for declin- ing adolescent suicide rates be- tween 1990 and 2003 in the United States include the use of antidepressant medication in treating depressed adolescents (Olfson, Shaffer, Marcus, & Greenberg, 2003), the reduction of alcohol use (Birckmayer & Hemenway, 1999), and more re- strictive gun control laws (Web- ster, Vernick, Zeoli, & Mangan- ello, 2004).

risk ANd Protective fActors

During the past two decades, there has been increased under- standing about factors contribut- ing to suicide, although the etiol- ogy of youth suicide has not been determined (Evans et al., 2005). Primary risk factors and protec- tive factors (those that mitigate against youth suicide) have been suggested (IOM, 2002). How- ever, the manner in which pro- tective and risk factors influence

suicide remains unclear (Lubell & Vetter, 2006).

risk factors Risk factors reported to con-

tribute to suicidal behavior in- clude the following:

l Presence of psychiatric illness, with depression being most common (Burns & Patton, 2000).

l Previous history of sui- cide attempts (Hawton, Zahl, & Weatherall, 2003).

l Low family and peer sup- port (Kerr, Preuss, & King, 2005).

l Physical and sexual abuse (Bensley, Van Eenwyk, Spieker, & Schoder, 1999).

l Victimization (Borowsky, Ireland, & Resnick, 2001).

l Same-sex orientation (Rus- sell & Joyner, 2001).

l Serotonin deficiency (Ka- mali, Oquendo, & Mann, 2001).

l Having a family mem- ber who had attempted suicide (Brent & Mann, 2006).

l Access to firearms (Miller, Azrael, Hepburn, Hemenway, & Lippmann, 2006).

The relationship of substance abuse to adolescent suicide is unclear (Rowan, 2001). Certain psychosocial factors or stressors are also suggested to interact and contribute to increased youth sui- cide risk. These stressors include family discord, poor parent-child

relationships, family history of suicide behavior, problems in school, breakup of a close rela- tionship, arguments and fights, a friend attempting or completing suicide, and relocation (Mac- gowan, 2004).

Protective factors Protective factors in general

are consistent with psychologi- cal health, but their influence in providing protection against youth suicide remains uncertain (Evans et al., 2005). Leading protective factors include having the following (World Health Or- ganization, 2000):

l Supportive family and adult relationships.

l Connectedness to school and other organizations.

l Good social and coping skills.

l Self-confidence in one’s own abilities.

l Willingness to seek help with difficulties.

Additional protective factors include access to evaluation and ongoing mental health resources, community support, and con- flict resolution and skill building (CDC, 2007a).

suicide PreveNtioN APProAches

Although multiple risk and protective factors have been identified with suicide behavior in adolescence, further research is needed concerning the impact they have on current interven- tion strategies. Many different approaches have been taken to prevent suicide behavior in youth; however, few programs have been empirically tested for their effectiveness (Evans et al., 2005). Given the range of sug- gested risk and protective factors influencing youth suicide behav- ior, prevention efforts focusing on reducing risk factors and pro- moting protective factors should

tAbLe 1

AdoLesceNt suicide PreveNtioN Project strAtegies

Community-Wide Consciousness Raising

Suicide Prevention Education for Parents, Students, Educators, and Counselors

• Designing and distributing a teen resource card

• Design and distribute the Teen Resource Card for local adolescents

• Developing program resources

• Development and dissemination of a local crisis intervention resource brochure targeted to adolescents

• Measuring outcomes • Goal: to eliminate adolescent suicides

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incorporate and integrate the ex- pertise of both health and non- health related sectors including the school system, community, government, business, religion, human services, and health or- ganizations (Davidson, Ross, & Silverman, 2001).

coMMuNity suicide PreveNtioN Project

One local community in ru- ral northern California that had adolescent suicide rates higher than the state average recognized the seriousness of the problem of youth suicide and decided to take action to address the prob- lem. The project’s suicide pre- vention strategies captured the entire community’s energy and attention, and formalized a col- laborative partnership between individuals and agencies from both health and non-health community sectors.

The program, led by nurses, included senior and junior high school educators, youth leaders, school counselors, civic leaders, mental health professionals, po- lice officers, probation officers, religious leaders, local hospital officials, concerned parents, high school students, and media. The objectives of this project were to develop new suicide prevention strategies and to augment exist- ing programs. The suicide pre- vention project focused primarily on raising community awareness about youth suicide and provid- ing local adolescents with easy access to local community crisis intervention resources. The proj- ect strategies focused on three areas (Table 1).

Project goals The four goals of the adolescent

suicide prevention project were: l Elimination of adolescent

suicide as measured by a zero adolescent suicide rate on the annual coroner’s report.

l Improved community agency collaboration.

l Increased community awareness about identifying at- risk and high-risk youth.

l Enhanced awareness about accessible crisis response and referral sources.

Project Planning The project began when a

small group of concerned citi- zens gathered to discuss the problem. Community stake- holders understood that the problem required a multidisci- plinary collaborative approach and would involve the entire community, including schools, social services, faith-based or- ganizations, law enforcement, town council, health care orga- nizations, youth services, local media, teens, and concerned community members.

Organizers contacted leaders from these groups by telephone inviting them to join in the ef- fort to identify possible interven- tions to eliminate local teen sui- cide. More than 30 community members came together, finding common ground. Initially, the community group met bimonthly during a 6-month period to final- ize and adopt project interven-

tions. The primary considerations in the initial 6 months included identifying innovative solutions to the problem; recruiting local teens to lead and make project decisions; developing a budget and identifying existing funding resources; identifying timelines and the project completion date; identifying all agency and com- munity stakeholders; and identi- fying barriers and solutions to the project implementation.

Project Prevention strategies

The three project prevention strategies included developing a wallet-size card; creating a local resource brochure; and providing suicide prevention education for parents, students, and counselors (Table 1). The teen card and re- source brochure were developed and designed by local teens; both were distributed 6 months after the planning phase.

Teen Resource Card. The main prevention strategy was a plastic credit card style and wallet-size Teen Resource Card (Figure). Teens were invited to develop and design their card to maximize buy-in. They worked together with community stakeholders to formulate goals. The goals the

tAbLe 2

AdoLesceNt suicide PreveNtioN Project budget

Program Element Budget Suicide prevention education for parents, students, educators, and counselors (lecturer fee and meeting room rental)

$1,200

Design and development of resource guide, a tri-fold color brochure printed on quality paper ($1.20 per brochure)

$1,900

Design and distribution of Teen Resource Card ($1.50 per card, plus graphic designer fee and distribution costs)

$3,000

Conduct research to measure effectiveness of Teen Resource Card (statistician consulting fees to assist in survey instrument development and analysis of collected data, paper and printing costs, and student incentives)

$1,100

Total $7,200

37Journal of Psychosocial nursing • Vol. 48, no. 5, 2010

teens chose included immediate access to help, simplicity of use, and 24-hour crisis telephone numbers. The principle of com- munity connectedness, includ- ing a spiritual component and guaranteed confidentiality, in- formed the process, and it was decided the card design would display peer support. Participat- ing businesses requested that for discounts to be displayed on the back of the card, an expiration date for these offers should also be printed.

The card included both the key resource telephone numbers as well as discounts at local eat- eries and businesses frequented by youth. The card had to offer immediate access to crisis re- sources. The final version of the card displayed three main 24- hour crisis telephone numbers. The crisis telephone numbers were services offering support for substance abuse, mental health issues, homelessness and runaways, sexual assault crisis

intervention, and unplanned pregnancy help. The card was designed to be simple to use, small enough to carry in a wal- let, and attractive to encourage teens to carry it.

A total of 2,000 Teen Re- source Cards were distributed within the community dur- ing a 2-year period. The total number of cards produced was determined by the total popula- tion of the local high schools, which was 1,600 students. Ad- ditional cards were ordered for distribution in local restaurants and coffee shops, physician of- fices, movie theaters, hospital emergency department wait- ing areas, and all teen gather- ing places community wide. The original 2,000 cards were ordered at an estimated cost of $1.50 per card (Table 2). The cards were made available at no cost to the youth. Student lead- ers in each age group were pro- vided cards to share with their peers. Three hundred cards were estimated to be needed each academic year for incom- ing 9th-grade students.

Local Resource Brochure. The second resource was a tri-fold brochure that included infor- mation on a wide range of ser- vices. The contact telephone numbers included more than 100 local resources and nation- al 24-hour crisis hot-line tele- phone numbers that provide physical and mental health ser- vices, social services, substance abuse treatment, sexual assault and physical abuse help, home- less shelters, employment and transportation services, and leisure activities. All telephone resources provided were verified by the nurse leaders.

Community-Wide Educa- tion. The third project preven- tion strategy was to provide community-wide education to raise awareness about the risk

and protective factors for sui- cide. The education included information on evidence-based prevention strategies and refer- ral resources in the community to increase the response and re- ferral of suicidal youth.

A mental health profes- sional with expertise in youth suicide behavior was sought to focus on the topics. A large va- riety of community venues that could accommodate a diverse community audience including high school students, interested community members, school counselors, teachers, and other professionals was investigated. Venues could range from do- nated space in schools and churches to rented spaces in a large meeting hall. Speakers were sought and asked to do- nate their services or were pro- vided an honorarium. A larger estimated fee was also proposed to attract a nationally known mental health expert in adoles- cent and youth suicide.

Project budget The budget to implement the

project was $7,200 (Table 2). Among the financial contribu- tors were a local hospital, com- munity service organizations, local businesses, private donors, and churches; grant funding was also provided by the local high school. Eleven hundred dollars of the budget were allot- ted for statistician consultation fees in survey instrument devel- opment, analysis of collected data, and student incentives to participate in the survey.

PiLot survey One year after the initial dis-

tribution of the Teen Resource Card, a pilot survey was con- ducted with local high school students (grades 9 through 12). The survey was developed by the nurse leaders and consisted

Figure. Teen resource card. A third panel (not pictured) featured discount offers from local businesses.

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of 17 items that were scored us- ing a 4-point Likert scale. The survey sought to determine teens’ opinions on the follow- ing three domains of the card: awareness of the card, motiva- tion to use the card, and useful- ness of the card.

Students were asked to rate items such as “I am carrying the teen card every day,” “I find the teen card easy to use,” and “I like to carry the teen card be- cause of the telephone numbers available.” Survey items were positively worded. Two open- ended questions were added at the end of the survey instru- ment to provide teens an op- portunity to comment about the design of the card or sug- gest any changes they thought could be useful. Demographic information collected included gender and grade level. Due to the preliminary nature of this project, survey reliability and validity were not evaluated.

The pilot survey was admin- istered to two groups of high

school students by a univer- sity nursing student supervised by the nurse leaders. The first group consisted of students in grades 9 and 10 (n = 22), and the second group consisted of students in grades 11 and 12 (n = 18). Permission to admin- ister the survey was granted by the teacher of record for the class. The purpose of the pilot survey was described to the stu- dents, and students were assured that taking the survey was vol- untary and that their responses would be anonymous.

Composite variables for each of the three areas of interest were calculated by summing survey items in each of the three do- mains to identify level of aware- ness of the card, motivation, and perceived usefulness of the card. The higher the score, the stron- ger the positive evaluation for the three areas of interest.

Student responses from the two open-ended questions were examined. Forty-one percent of students did not respond to the

two questions. Of those students who commented, results sug- gested older students (ages 15 to 18) were aware of the card and found the card useful and easy to use, although they did not always carry it. In addition, the older students were motivated to use the card because of the resource telephone numbers and not only just because of the design or dis- counts. In contrast, the majority of younger students (ages 13 to 14) were unaware of the card and did not know the kind of infor- mation on the card. However, a smaller percentage of younger students indicated they were mo- tivated to carry and use the card because of the resource numbers.

Older students’ suggestions about the card design included changing the color scheme to black and white. One of the older students suggested the design on the card should be more “artistic” to make people feel more at ease about calling the telephone numbers on the card, whereas another older stu-

tAbLe 3

resuLts of the PiLot study oN the teeN resource cArd

Question Ages Response What, if anything, about the Teen Resource Card especially pleased you?

13 to 14 • “How it helps when we need it.” • “That it can be there for help, if you need it or if you are going through a lot of problems.”

15 to 18 • “I think that it is good to give the kids resources.”

• “I feel that the card would be helpful to kids who are struggling.”

• “The discounts are good.”

• “I like it ’cause it gives you numbers that you can call if you need someone to talk to.”

What, if anything, would you change on the design or information on the Teen Resource Card?

13 to 14 • “Design’s good ’cause the information is easy to find.”

15 to 18 • “Different colors but black and white.”

• “I would make the design more artistic—to make people feel more safe calling.”

39Journal of Psychosocial nursing • Vol. 48, no. 5, 2010

dent suggested leaving the card design alone because it “looked cool.” Only one younger stu- dent commented about the card design, stating the “Design’s good ’cause the information is easy to find.” Examples of stu- dent responses are shown in Table 3.

PreLiMiNAry outcoMes Prior to implementation of

this project, the local commu- nity was rocked four times by unrelated deaths of four male adolescents—two from drug overdose and two from suicide. One year after the card distri- bution, an adolescent suicide rate of zero was recorded on the local coroner’s report. It is im- possible, however, to determine whether this reduction was a direct consequence of the cards. Data related to unsuccessful sui- cide attempts are not available.

This is a pilot study to ex- plore and understand how the cards could provide an effec- tive intervention to eliminate successful suicide attempts in adolescents. Due to the pre- liminary nature of this project, no scientific outcome data are available.

coNcLusioN Teenage suicide is a national

health crisis. Nurses, by virtue

of the nature of their role as health care professionals, are ideally positioned in the com- munity to provide leadership in the development of programs designed to prevent suicide. The suicide adolescent preven- tion project demonstrates how nurses in one community took a leadership role in the design and implementation of a sui- cide prevention project. The model they developed could be duplicated and used by nurses in other communities.

refereNces Bensley, L.S., Van Eenwyk, J.V., Spieker,

S.J., & Schoder, J. (1999). Self- reported abuse history and adoles- cent problem behaviors. I. Antiso- cial and suicidal behaviors. Journal of Adolescent Health, 24, 163-172.

Birckmayer, J., & Hemenway, D. (1999). Minimum-age drinking laws and youth suicide, 1970-1990. American Journal of Public Health, 89, 1365- 1368.

Borowsky, I.W., Ireland, M., & Resnick, M.D. (2001). Adolescent suicide at- tempts: Risks and protectors. Pediat- rics, 107, 485-493.

Brent, D.A., & Mann, J.J. (2006). Fa- milial pathways to suicidal behav- ior—Understanding and preventing suicide among adolescents. New England Journal of Medicine, 355, 2719-2721.

Burns, J.M., & Patton, G.C. (2000). Pre- ventive interventions for youth sui- cide: A risk factor-based approach. Australian and New Zealand Journal of Psychiatry, 34, 388-407.

Centers for Disease Control and Preven- tion. (2007a). Suicide prevention. Sci- entific information: Risk and protective factors. Retrieved from http://www. cdc.gov/ncipc/dvp/Suicide/suicide_ risk_pfactors.htm

Centers for Disease Control and Preven- tion. (2007b). Suicide trends among youths and young adults aged 10-24 years—United States, 1990-2004. Morbidity and Mortality Weekly Re- port, 56, 905-908.

Centers for Disease Control and Preven- tion. (2009a). Ten leading causes of death and injury (charts). Retrieved from http://www.cdc.gov/injury/ wisqars/LeadingCauses.html

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Davidson, L., Ross, V., & Silverman, M.M. (2001). Background papers to the National Suicide Prevention Conference: An overview and per- spective. Suicide and Life-Threatening Behavior, 31(Suppl. 1), 1-5.

Eaton, D.K., Kann, L., Kinchen, S., Shanklin, S., Ross, J., Hawkins, J., et al. (2008). Youth risk behavior surveillance—United States, 2007. Morbidity and Mortality Weekly Report Surveillance Summaries, 57(SS4), 1- 131.

Evans, D.L., Foa, E.B., Gur, R.E., Hen- din, H., O’Brien, C.P., Seligman, M.E.P., et al. (Eds.). (2005). Treat- ing and preventing adolescent men- tal health disorders: What we know and what we don’t know. A research agenda for improving the mental health of our youth. New York: Oxford Uni- versity Press.

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Gould, M.S., & Kramer, R.A. (2001). Youth suicide prevention. Suicide and Life-Threatening Behavior, 31(Suppl. 1), 6-31.

Hawton, K., Zahl, D., & Weatherall, R. (2003). Suicide following deliberate self-harm: Long-term follow-up of patients who presented to a general hospital. The British Journal of Psy- chiatry, 182, 537-542.

Institute of Medicine. (2002). Reducing suicide: A national imperative. Re- trieved from National Academies Press website: http://www.nap.edu/ openbook.php?isbn=0309083214

1. Nurses can provide focused and innovative interventions to address critical concerns of youth suicide in a community.

2. Youth suicide is still the third-leading cause of death in ages 12 to 19 and increases every year as children age, indicating the need for new suicide prevention strategies.

3. Adolescents can be motivated and supported to become agents of change among their peers.

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Kamali, M., Oquendo M.A., & Mann, J.J. (2001). Understanding the neu- robiology of suicidal behavior. De- pression and Anxiety, 14, 164-176.

Kerr, C.R., Preuss, L.J., & King, C.A. (2005). Suicidal adolescents’ so- cial support from family and peers: Gender-specific associations with psychopathology. Journal of Abnor- mal Child Psychology, 34, 103-114.

Lubell, K.M., & Vetter, J.B. (2006). Suicide and youth violence preven- tion: The promise of an integrated approach. Aggression and Violent Be- havior, 11, 167-175.

Macgowan, M.J. (2004). Psychosocial treatment of youth suicide: A system- atic review of the research. Research on Social Work Practice, 14, 147-162.

Miller, M., Azrael, D., Hepburn, L., Hemenway, D., & Lippmann, S.J. (2006). The association between changes in household firearm own- ership and rates of suicide in the United States, 1981-2002. Injury Prevention, 12, 178-182.

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Olfson, M., Shaffer, D., Marcus, S.C., & Greenberg, T. (2003). Relationship between antidepressant medication treatment and suicide in adoles- cents. Archives of General Psychiatry, 60, 978-982.

Pelkonen, M., & Marttunen, M. (2003). Child and adolescent suicide: Epide- miology, risk factors, and approaches to prevention. Paediatric Drugs, 5, 243-265.

Rowan, A.B. (2001). Adolescent sub- stance abuse and suicide. Depression and Anxiety, 14, 186-191.

Rueter, M.A., Holm, K.E., McGeorge, C.R., & Conger, R.D. (2008). Ado- lescent suicidal ideation subgroups and their association with suicidal plans and attempts in young adult- hood. Suicide and Life-Threatening Behavior, 38, 564-575.

Russell, S.T., & Joyner, K. (2001). Ado- lescent sexual orientation and suicide risk: Evidence from a national study. American Journal of Public Health, 91, 1276-1281.

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Webster, D.W., Vernick, J.S., Zeoli, A.M., & Manganello, J.A. (2004). Association between youth-focused firearm laws and youth suicides. Jour- nal of the American Medical Associa- tion, 292, 594-601.

World Health Organization. (2000). Pre- venting suicide: A resource for teachers and other school staff. Retrieved from http://www.who.int/mental_health/ media/en/62.pdf

Ms. Pirruccello is Assistant Professor of Nursing, California State University, Chico, Chico, California.

The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.

Address correspondence to Linda M. Pirruccello, MSN, RN, Assistant Professor, California State University, Chico, 400 West First Street, Chico, CA 95929-0200; e-mail: lincelo04@ yahoo.com.

Submitted: July 17, 2009 Accepted: January 26, 2010 Posted: March 22, 2010

doi:10.3928/02793695-20100303-01

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