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org/jchemeduc Communication

Minimize Online Cheating for Online Assessments During COVID-19

Pandemic
Joseph G. Nguyen,* Kristopher J. Keuseman, and Jonathan J. Humston

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ABSTRACT: When campuses across the world needed to transition to

the online format due to the COVID-19 pandemic, there were many
challenges educators faced, and addressing academic integrity issues were
Downloaded via CARLETON UNIV on August 4, 2020 at 14:30:50 (UTC).

some of the most important. Certain strategies, such as online proctoring

or additional software, were not available to most institutions because the
expenses and training were too much to overcome. A more pedagogical
and cost-effective strategy involved modifying the assessment format in a
way that minimized or discouraged cheating. This paper presents
strategies that effectively minimize cheating while addressing learning
outcomes.

KEYWORDS: Introductory Chemistry, First-Year Undergraduate/General, Second-Year Undergraduate, Upper-Division Undergraduate,

Curriculum, Distance Learning/Self Instruction, Internet/Web-Based Learning, Testing/Assessment

C hemistry pedagogy has undergone continuous change as

new technologies emerge. For example, online home-
work systems (e.g., Mastering Chemistry, OWL, WileyPLUS,
WebAssign, ARIS, ALEKS, Sapling Learning, Knewton Alta)
are now well established because they have been shown to help
students with learning.1−3 Learning gains are made with these
homework systems because they provide immediate feedback,
encourage active learning, and increase student time on task.1,2
The current COVID-19 pandemic is forcing a rapid shift to
technological solutions for even basic classroom functions,
such as lectures and office hours. Furthermore, it is likely that
the use of technology and distance-learning techniques will
continue to play a larger role in higher education, even after
current restrictions are lifted. As the availability of various
technological solutions increase, students have turned to the
internet for help.4 Sites such as Chegg, Course Hero, Koofers,
Slader, SparkNotes, and others provide students with solutions
to many textbook problems5−7 and provide students an
opportunity to ask for help from others. One study found that
students do not view finding homework answers through the
internet as “cheating” because they only downloaded or used
someone else’s homework solutions that were posted online.4,8
Some professors believe the students are just cheating
themselves out of the learning process, and their performance
on exams tends to support the notion.5−7 Even though many
students and professors do not focus on the use of internet
sources to complete their homework as an academic integrity
issue, most students and professors view cheating on
© XXXX American Chemical Society and
Division of Chemical Education, Inc.
A J. Chem. Educ. XXXX, XXX, XXX−XXX
examinations as a serious concern.4 For some campuses, the
concern has been serious enough that the faculty adopted
policies requiring answers on multiple-choice exams be
scrambled for paper exams and even have established indices
to be able to determine if cheating has occurred.9−11
As the number of science courses offered online continues to
increase, academic integrity issues have focused primarily on
plagiarism in the laboratory portion of online courses.12−14
However, cheating on exams became a major concern across
campuses during the Spring of 2020 when colleges and
universities across the world started closing their campuses to
help limit the spread of COVID-19. One of the hardest
challenges educators had with this transition was converting
their assessments to an online format that was still valuable in
differentiating the performance of students. Academic integrity,
time constraints, and exam formats were some of the concerns
that made it challenging for educators, especially since most
had not previously taught in the online format. Since it has
been reported that more than 70% of college students admitted
to cheating during exams and quizzes during their online class,
Special Issue: Insights Gained While Teaching Chem-
istry in the Time of COVID-19
Received: June 18, 2020
Revised: July 18, 2020
https://dx.doi.org/10.1021/acs.jchemed.0c00790
Journal of Chemical Education
regardless of directions prohibiting the use of books, notes, and
electronic devices, cheating is among the greatest concerns.14 It
is also believed that online students have the highest tendency
to consult online sources, complete exams jointly, or seek help
from another person or expert.14
Since both students and professors were unexpectedly
thrown into the online format with little or minimal time to
prepare for the transition, any potential solutions would need
to address both the professors’ cheating concerns and the
students’ increased anxiety. Most institutions were also not in a
financial position to invest in effective and expensive
anticheating technologies, such as online proctoring, secure
browsers that prevent students from searching the Internet or
accessing other programs, or predictive analytics.15−17 It was
also difficult to use adaptive tests because it would require
additional costs and structural changes to the course.16
Professors and institutions did not have the time to
incorporate measures that have effectively been able to catch
cheating.9−11 Thus, it was important to find effective measures
that minimized costs, minimized disruption to the course
structure, and were amenable to a variety of courses. This
paper will present the various strategies used for chemistry
courses at Mount Mercy University (Cedar Rapids, Iowa).
■
ASSESSMENT STRATEGIES
Higher-Order Thinking Multiple Choice Questions
Competency and programmatic assessments prominently use a
mixture of multiple-choice and short answer (show your work)
questions.18 Unfortunately, both types of questions have their
challenges. It is generally easier to write high-order short
answer questions but grading them is time-consuming and not
amenable to automation, which is a huge disadvantage for
courses that have large enrollment. Multiple-choice questions
can be efficient, objective, easy to grade automatically, and can
be successfully used to assess a variety of learning out-
comes.19−23 Because multiple-choice questions are advanta-
geous on a number of different levels, they are the most
frequently used assessment to measure learning outcomes.22,23
Writing good multiple-choice questions is difficult and time-
consuming because both the exam stem (the question) and the
answers or distractors have to be taken into consideration.19−21
To save time, test bank questions could be utilized; however, it
has been found that the majority of them are only knowledge-
level questions.21,24 Multiple-choice questions can be written
in such a way as to promote critical thinking.23,26 To achieve
better critical thinking skills through the use of multiple-choice
questions, the questions need to engage students in a higher-
level of cognitive reasoning through application-based
questions requiring students to combine concepts they have
learned.20,23,26 Since test bank questions are available to most
instructors, there is also a higher possibility that they are
available through the previously mentioned sites. Thus, it is
important that novel multiple-choice questions be constructed.
One strategy to writing higher-level critical thinking
questions that are novel is to provide the students with the
chemical content information (“facts”) within the question
(Table 1, question 1). Providing the chemical content helps
students develop reading comprehension and is a fairer
question for all of the students.26 Another strategy is to use
either a student (Table 1, question 2) or instructor (Table 1,
question 3) as part of the question in order to provide the
context of the question. While the question might contain
pubs.acs.org/jchemeduc Communication
Table 1. Example Question Stems
Question
Label Question Stem
1 The critical mass (minimal mass to sustain a nuclear reaction)
of neptunium-236 is smaller than that of plutonium-239,
but a neptunium atomic bomb has never been built because
it is difficult to purify. Since neptunium-236 has more than
83 protons, it is automatically a radioisotope. What is the
new (or daughter) nucleus that is produced when it decays
to become a more stable isotope?
(A) 93237Np (B) 91
232Pa (C) 92
237U (D) 95
236Am (E) 93
236Np
2 Being on a team together, Angie has to deal with Ben way
more than she cares for, and it makes her contemplate
taking Xanax to deal with him. Benzodiazepines, like Xanax,
bind to GABA receptors in the brain, which may be
responsible for the efficacy of it in anxiety disorder. It was
found to have a binding constant (Kf) with GABA of 38.62.
Is the binding of Xanax to the receptor a spontaneous
process at 310 K?
(A) Yes because ΔG° (B) No because ΔG° =
= −9.42 kJ/mol −9.42 kJ/mol
(C) Yes because ΔG° (D) No because ΔG° =
= 9.42 kJ/mol 9.42 kJ/mol
3 During this time of COVID, Dr. Nguyen’s daughters have
been working hard at training their cats to sit and stand
using positive reinforcement. They’ve learned that the same
strategy does not work on their dad, so they have an interest
in using shock therapy. They wanted to experimentally
determine which electrochemical reactions could be used
for shock therapy with Dr. Nguyen as their training test
subject. Which of the following reaction should Dr.
Nguyen’s daughters use to train him (i.e., spontaneous
reaction)? (Table given with question)
(A) Cl2 (g) + 2I− (aq) → 2Cl− (aq) + I2 (g)
(B) Cu2+ (aq) + Zn (s) → Cu (s) + Zn2+ (aq)
(C) I2 (g) + Zn (s) → Zn2+ (aq) + 2I− (aq)
(D) All of the above would work.
4 In The Curious World of Justin Beiber, Beiber discovers a new
halogen. He would no doubt name it beiberine and the
symbol Bn, which of the following acids of beiberine is
named correctly?
(A) HBn, (B) HBnO2, beiberous
hypobeiberous acid acid
(C) HBnO, (D) HBnO4, beiberic
hydrobeiberous acid acid
some irrelevant material,19,20 it makes it difficult for the
students to search for the answer online. Searches of clear and
succinct questions result in questions that will help students
answer the questions quickly because there are a high number
of similar questions available online. However, searches of
questions that contain chemical content result in information
that is not useful for students to answer the question. Searches
for questions that incorporate a student or instructor result in
an empty search, which further supports the idea that this
strategy minimizes the ability to cheat online.
The average item difficulty (fraction of students who
answers the question correctly) on these higher-level critical
thinking questions is 0.54 ± 0.17 (based on 14 questions). In
addition to a good item difficulty average, 12 of the 14
questions showed either good or high discrimination.19 This
analysis does not fully address the concern with using extra
information because doing so could make the question less
reliable (or reproducible) and valid (or accurate) in evaluating
student learning; however, it does show that these higher-order
thinking questions help differentiate between the high-
achieving and low-achieving students. Anecdotally, students
have also mentioned that they appreciate the humor
accompanying the question because it reduces their anxiety.
While the reduction in anxiety has not been formally measured,
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it may represent an additional benefit. Famous people can be Box 1. Examples of Scaffolded Short Answer Organic
utilized in the same context instead for courses with large Chemistry Questions
numbers of students or for instructors that do not feel
comfortable incorporating students into a humorous context
(Table 1, question 4).
Novel, Higher-Order Thinking Short Answer Questions
Although student-faculty rapport may be easier to establish in
smaller classes, caution regarding student academic integrity is
important for maintaining a respectful professional relationship
and course culture of fairness on all classes. Faculty who are
too lenient may give students the wrong impression about the
importance of chemistry or the difficulty of the subject matter.
On the other hand, it is also unfair to have unrealistic
expectations of student behavior, develop elaborate schemes to
prevent cheating, or have extremely rigid instructions for taking
examinations. Instead of trying to “eliminate” cheating, it is
perhaps better to be more accommodating and structure exams
so that students using “unauthorized” resources will not have a
large advantage over those who do not. This approach allows
the educator to focus on maximizing student learning for the
majority instead of focusing on stopping the minority that will
cheat.27
One way to focus on optimizing student learning is to write
questions that are novel, specific, and straightforward. The goal
Box 2. Example of Scaffolded Short Answer General
is to write questions that students may be able to use online
Chemistry Question
resources to help them answer, but the question is specific
enough that it is unlikely to completely solve it for them. When
this happens, the assessment tool itself is also a learning tool.
Students can improve their recall of learning objectives and
synthesize this information with information gleaned from
other sources, and students are mimicking “expert practice”.28
The questions can be incorporated as short answer questions
in a mixed assessment since many educators and learning
experts believe that the use of multiple-choice questions does question combining thermodynamics, electrochemistry, and
not assess students’ responses to real-world situations.29 A equilibrium. In this example, the students need to use the
different strategy is to formulate an assessment as if it was a answers they found in the subsequent parts.
take home exam composed of only these novel and specific Short answer questions, such as the examples provided, are
questions. One study even showed that open book and open “straight-forward” in that students need little instruction to
web exams better engage students, minimize the desire to determine expectations for answering a question. Furthermore,
cheat, and can yield better student learning.27 Take home without question “set up” text, these questions provide
exams also provide students an opportunity to apply their students with fewer terms, compound names, or information
knowledge in meaningful, authentic situations, which helps to search for online. Even though image searching is a
stimulate critical thinking.27,29,30 Students are able to focus on possibility and increasingly effective, students are still required
the question asked, especially since the questions require to interpret the search results, especially if the instructor has
higher-order thinking and synthesis of knowledge. already ensured that the answer solution is not readily
In the examples given in Boxes 1, a question was written to available. These types of questions allow for simple changes
provide students an opportunity to show the mechanism of an to be made each time the question is used on an exam, which
organic reaction. The “scaffolding” of the question provides can help the instructor with writing additional novel questions.
students with clues to solve the problem in a manner For example, the molecule skeleton can be significantly
consistent with the way the mechanism was explained in modified, while preserving the functional groups that are
their textbook and lecture. Although there are often several important for the reaction to proceed. Alternative reagents can
acceptable ways to diagram a reaction mechanism in organic also be used to make “new” questions. In the general chemistry
chemistry, this type of question helps to narrow the student’s example, the reaction can be flipped, or different temperatures
focus to the electron flow and how the molecule changes from or concentrations can be used. In all of these cases, many
one step to the next. The student is given some of the underprepared students might see the modified question as
intermediate structures, to help prevent students from being “completely different”.
completely stumped, but others are empty for students to It can be obvious when students use an internet resource to
complete. While Example 1 (Box 1) provided the same answer the questions. For example, it is possible that students
reaction conditions for each step, multistep syntheses can also use a reagent not described in the lecture or textbook.
be written in a similar manner (Box 1, Example 2), with or However, if the reagent/reactant was plausible, the student has
without the accompanying mechanism steps or electron flow demonstrated “expert practice”25 and has found a suitable
arrows. The example in Box 2 shows another “scaffolding” method for the reaction step. For the other chemistry courses
C https://dx.doi.org/10.1021/acs.jchemed.0c00790
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Journal of Chemical Education
Table 2. Example Questions for Open-Book or Take-Home Exams
Question Label
1 (Introduction When my son Dallas broke his leg last year, I overheard the doctor tell the nurse, “Give him Tylenol 10 milligrams per kilogram.” If my son weighs
to Chemistry) 30.0 pounds, how many milliliters of Tylenol should the nurse have given Dallas? (*Included with the question is a picture of the label for
Children’s Tylenol, which shows the concentration in mg/mL.)
2 (Analytical It is recommended that drinking water contain 1.60 ppm fluoride (F−) for prevention of tooth decay. Cedar Rapids recently completed
Chemistry) construction of the new 1.50 million-gallon Kirkwood Tank. Assuming all the fluoride must be added in, how many grams of F−should be
added to the Kirkwood Tank to give 1.60 ppm? Assume fluoride is only provided by the addition of hexafluorosilicate, H2SiF6. How many grams
of H2SiF6 contain this much F−?
that use math to answer the questions, students could use an
equation or a constant not used or taught in the lecture or
textbook. Since the student displays enough understanding
through the selection of an answer in these examples, the
instructor has awarded some or all the credit assigned.
Although we should reward students’ appropriate use of
resources, the instructor should be critical when answers
contain inappropriate, extraneous material. For example, if the
student answer includes things not asked for in the question,
when the right functional group is included but the overall
structure is incorrect, or the correct equation is used but not
with the numbers from the question. These situations deserve
greater scrutiny because they are more likely to be copied
without proper interpretation from an outside reference.
These short answer questions were part of a mixed
assessment, and the students were required to submit their
work using a drop box in the Learning Management System.
Students were encouraged to use a “scanner app” on their
smartphone if a scanner was not available. Students were
instructed to upload pictures or scans of their answers either
on blank pages (clearly numbered) or written on a printed
copy of the test. The short answer problems could then be
“hand graded” using a tablet device, tablet computer, or tablet
pen to provide feedback electronically.
In the previous examples, students cannot utilize memorized
equations, constants, or mechanisms to answer the questions.
Many educators do not feel that memorizing information is as
important as the ability to recognize what is relevant, what is
needed to solve a problem, and to use it properly, which is why
students are given additional information, such as equations,
physical constants, and a periodic table on the last pages of an
exam by many educators. The same idea is expanded when an
exam is given open-book or open-note. It is expanded still
further by a take-home exam, when the “sheets of useful
information” now include all resources available to students.
Thus, open-book or take-home exams require writing novel
questions that students have not seen before and cannot
directly be found somewhere. An internet search can easily
reveal a conversion factor or a molecular weight, so a question
needs to be more complex where it can involve using these
internet-retrieved values. Student are still required to
determine what conversion factors are needed or how to use
the molecular weight in a calculation. This naturally leads to
questions of higher-order thinking skills and synthesis of
knowledge.
Instead of asking students to convert 30.0 pounds into
kilograms, which is easily found online, they are asked to
combine a couple of different conversion factors in one
question (Table 2, question 1). This question is given to
prenursing students and requires them to set up the problem
for themselves, determine which conversion factors are needed,
and sequence them together correctly using unit analysis. Each
individual step could be found, but to solve the problem
pubs.acs.org/jchemeduc Communication
Question
requires an understanding of the content and the process. This
question also implicitly involves significant figures, which
cannot be given in an online converter. The instructor can
insert him or herself into the question or use events happening
around the community, which occurred in a question given to
analytical students (Table 2, question 2). Whether the
questions are part of a mixed assessment, an open-book
exam, or a take-home exam, novel questions require students
to combine and synthesize information. Any required
information needed to answer these questions should be
given in class and in the textbook, so students do not need to
resort to online resources. However, finding the information
online does not give them any advantage besides perhaps time.
Increasing Assessment Frequency
Traditional face-to-face chemistry courses generally use four to
five multichapter exams because it minimizes the amount of
class time used for assessment. However, in an online or hybrid
delivery format, this is less of a concern, and a different strategy
to increase learning outcomes is to increase assessment
frequency by using quizzes or single-chapter exams. Increasing
the frequency of assessments provides students the oppor-
tunity to retain the material for a longer period of time.31−33
The lower stakes assessment environment also decreases the
students’ desire to cheat online.5−7 Even though the literature
on the use of quizzes still include summative or final exams, the
results showed that the students made greater learning gains
with the higher frequency of use. Additionally, the time
commitment involved per quiz is less, so it makes it easier for
instructors who had to play double duty at home because day
cares and schools were closed.
Frequent, lower-stakes assessments can lead to greater
learning gains and reduced risk for academic dishonesty.34,35
One important factor for the learning gains is that the students
are receiving more frequent feedback, which also allows the
instructor to make corrections as needed to both the
assessment tools or the teaching strategies employed.34−37
There are many reasons students may want to cheat, and since
grades are one of the top reasons, the desire to cheat on
assessments worth fewer points is lower.34 Additionally, if a
student is suspected of academic misconduct, the lower-stakes
assessments will help isolate the influence of the misconduct
on the overall course grade.
To help discourage procrastination, the assessment
frequency increased for a few of the chemistry courses at
Mount Mercy when the institution transitioned to the online
format in Spring 2020. While this increased exam preparation
time, it provided more frequent, lower-stakes assessment for
students and helped prevent students from procrastinating
until the week of an examination to study and complete
homework. Most students who enroll in face-to-face classes as
undergraduates were faced with the difficult challenge of
creating a routine during online delivery in Spring 2020.
Switching to more frequent assessments helped them better
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Table 3. Academic Integrity Pledges

Instructor Academic Integrity Pledge
Nguyen I understand that the value of my grade in this course is intended to reflect the knowledge and skills that I have gained while taking the class. I also
understand that the reputation of my degree from Mount Mercy rests on the perception that students here earn their grades and know the course
content well. Therefore, I pledge
1. That my work on this exam represents my own knowledge and skills
2. That I took the test by myself and without assistance from any other person, and
3. That I only utilized my periodic table, equation sheet, notes, and/or book and did not use any other resources (for example, the internet).
By agreeing to this pledge, Dr. Nguyen is putting a lot of trust in you. Any violation of that trust, whether it is based on marked differences in
performance or other sources, may result in the addition of an oral component to the test with Dr. Nguyen before my final grade is recorded.
Keuseman My signature below signifies that I affirm the following academic integrity values:
1. It is my responsibility to learn the material covered in this course. My instructor is here to assist me in my responsibility and assess my progress
in gaining knowledge consistent with the learning objectives set forth by the instructor of this course, and the faculty of Mount Mercy
University.
2. To ensure fairness for myself, my peers, and those with whom I work in the future, I pledge to abide by the academic integrity policies of
Mount Mercy University, and the instructions given for this examination.
3. Furthermore, I pledge to neither receive nor give prohibited assistance to complete this examination, and to report to the instructor any
dishonest work I may witness.
The instructions for this examination are [for example]
• You may use your textbook, notes, and online resources.
• You may only ask the instructor questions about this examination; it is dishonest to consult other persons and peers.
Humston Science is a collaborative effort. Throughout this semester working together is often appropriate, even encouraged. However, there are times when it
is not. During a quiz, exam, or occasional other times when I will clearly tell you, any collaboration is strictly prohibited. That means do not do it! If
you do, you are doing yourself and your classmates a disservice, and you are cheating.
By signing this pledge, I guarantee that during noncollaborative assignments:
1. in addition to my own brain, I will only consult my textbook, my past assignments, my class notes, and my handouts. I will not use any other
resources.
2. the only person I will discuss the assignment or share information with is Dr. Humston. I will not talk to any other personasking or
answering questions.
3. the work I turn in is a representation of my own work, and I will show my calculations and reasoning whenever possible. I will not cheat,
plagiarize, or partake in academic misconduct.
4. I am familiar with the definitions and procedures related to academic integrity provided by Mount Mercy in The Good Book (link provided)
and I will adhere to these standards and understand the disciplinary procedures I face if I do not.
Mount Mercy values integrity and honesty in all aspects of academics and campus life. Any questions about what is or is not appropriate should be f reely and
openly discussed in advance with Dr. Humston (or another faculty member).

manage their time and break up their study into smaller
segments.
The possibility that a student may be temporarily
unavailable was higher with the unique situation faced during
the COVID-19 pandemic due to their own illness, responsi-
bility of taking care of others, or just the abnormality of life.
These cases would then increase the likelihood that a student
missed a portion of a chapter or may be distressed and
distracted enough to do poorly on a quiz or chapter exam, so
the instructors needed to be more empathetic and aware of
students’ personal difficulties they may face at different times.
Thus, one strategy employed was to drop each student’s lowest
quiz score from the gradebook at the end of the semester,
which was not as feasible if only three or four multichapter
exams were given. With the increased number of quizzes and
the reduced number of points for each quiz, students were
given a lower-stakes and lower stress environment, but the
impact of the dropped score was not as significant.
a pledge only works if the institution has a culture of academic
integrity.17,38
While there are a couple of different ways to motivate
students to sign an academic integrity pledge, it is important
that it is accomplished before they take any online assessments.
The pledge should also be clear on the definition of academic
integrity, how it will be monitored, and the consequences.17,38
Students are more apt to sign a pledge that strikes a positive
versus an accusatory tone because the pledge is more
encouraging and supportive of the belief that they will act
properly. Table 3 shows the examples of pledges used by the
authors.
One student had performed significantly better on the first
online exam (over 20%) compared to the first two in class
exams. The student and instructor met through a video-
conference so the student could discuss the matter and answer
modified questions and show content knowledge. The student
did not appear defensive through email communication or
during the video meeting. The instructor concluded that the

■ ACADEMIC INTEGRITY PLEDGE STRATEGIES

Academic Integrity Pledge
A preventive approach to stop the cheating from happening in
the first place is to have the students sign an academic integrity
pledge. These pledges are supported by Kohlberg’s cognitive
development theory and Chickering and Reese’s developmen-
tal tasks for optimal student growth and success.17 Studies have
also shown that schools with academic integrity pledges have
less cheating during tests than schools that do not.38 However,
E https://dx.doi.org/10.1021/acs.jchemed.0c00790
student had benefitted from being at home during the
pandemic because athletic and other commitments were
canceled, providing fewer distractions and more time to
prepare for the exam.
■ CONCLUSION
As campuses switched to the online format during the COVID
pandemic, educators were concerned with addressing potential
academic integrity issues with online assessments. The
strategies discussed here were focused on ensuring students
achieved learning gains in a learning environment that was new
J. Chem. Educ. XXXX, XXX, XXX−XXX
Journal of Chemical Education
to all involved. While the strategies used might not have been
innovative, they were cost-effective, helped students achieve
learning gains, and could effectively be utilized in face-to-face
settings.
■
AUTHOR INFORMATION
Corresponding Author
Joseph G. Nguyen − Department of Natural and Applied
Sciences, Mount Mercy University, Cedar Rapids, Iowa 52402-
4797, United States; orcid.org/0000-0002-8855-9604;
Email: jnguyen@mtmercy.edu
Authors
Kristopher J. Keuseman − Department of Natural and Applied
Sciences, Mount Mercy University, Cedar Rapids, Iowa 52402-
4797, United States
Jonathan J. Humston − Department of Natural and Applied
Sciences, Mount Mercy University, Cedar Rapids, Iowa 52402-
4797, United States; orcid.org/0000-0002-9910-4963
Complete contact information is available at:
https://pubs.acs.org/10.1021/acs.jchemed.0c00790
Notes
The authors declare no competing financial interest.
■
ACKNOWLEDGMENTS
The authors of the paper thank Dr. Heather Nguyen for
assistance preparing the manuscript.
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