Comparison of Four Predictive Scores for Cardiovascular Risk in Mexican People with HIV.

Persons with HIV (PWH) face an increased risk of cardiovascular events due to immune activation, comorbidities, and certain antiretrovirals (ARVs). However, the current cardiovascular risk (CVR) scores are not specifically directed toward PWH. This study aimed to assess the agreement between different predictive CVR scores and explore their relationship with clinical and demographic data in Mexican PWH. A descriptive cross-sectional analysis was conducted in 200 PWH with a mean age of 42 years who were treated at a Mexican urban center from 2017 to 2018. The majority (83%) was on ARV treatment and 79.5% had undetectable viral loads (VLs). Moderate- to high-risk scores were infrequent, with Framingham Risk Score for Hard Coronary Heart Disease scores showing higher values, with very low concordance among all scores. Logistic regression analysis revealed significant associations between the CVR scores and the initial recorded VL, CD4 cell count, and elevated triglyceride levels. However, no associations were found with measures such as body mass index or abdominal circumference. Treatment with integrase strand transfer inhibitors (INSTIs), particularly first-generation inhibitors, showed strong associations with all predictive scores, notably ASCVD (odds ratio = 7.03, 95% confidence interval 1.67-29.64). The poor concordance among the CVR scores in PWH highlights the need for a specific score that considers comorbidities and ARV drugs. Despite the relatively young age of the participants, significant correlations were observed between INSTI use, initial VL, CD4 cell count, and triglyceride levels, which are factors not considered in the existing risk scores. Regardless of the actual value of the scores, screening for CVR in PWH is recommended.

Clinical and neurodevelopmental outcomes in premature infants exposed to intravenous fish- and soybean oil-based lipid emulsions.

BACKGROUND: The optimal composition of lipid emulsions in parenteral nutrition (PN) for premature infants remains controversial. This study examined the effects of a combination of soybean oil-based (SoyLE) and fish oil-based (FishLE) lipid emulsions compared to FishLE as monotherapy on the lipid and fatty acid profiles and clinical outcomes of premature infants requiring prolonged PN. METHODS: 42 premature infants received FishLE+SoyLE or FishLE. Serum concentrations of lipoproteins and 29 fatty acids (FA) were measured at baseline, 4, and 8 weeks of PN and growth and neurodevelopmental outcomes were measured at 3, 6, 12, 18, and 24 months of life. RESULTS: Lipid profiles were similar between groups. Plasma concentrations of ω-6 fatty acids tended to decrease over time in both groups. Concentrations of most ω-3 fatty acids, in particular docosapentaenoic acid, eicosapentaenoic acid, and docosahexaenoic acid, were significantly increased over time in the FishLE+SoyLE group whereas they did not change in the FishLE alone group. However, serum concentrations of almost all fatty acids were similar between groups at the end of the study period. No differences in growth parameters including weight, height, fronto-occipital circumference (FOC), and body mass index (BMI) were observed up to two years of age. Similarly, there were no differences in neurodevelopmental test scores at 6, 12, 18, and 24 months of age. CONCLUSIONS: No substantial differences in lipid profiles and short clinical outcomes were found in infants exposed to FishLE+SoyLE when compared to FishLE.

Anatomical variations in the relationship between the spinal accessory nerve and internal jugular vein: a systematic review and meta-analysis.

The relationship between the spinal accessory nerve and internal jugular vein is important for modified neck dissection surgery. Therefore, the aim of this review was to investigate variations in this relationship. Through a search of the PubMed, Scopus, Web of Science, LILACS, and SciELO databases, the review authors collected anatomical data for inclusion in a meta-analysis, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Four relationship patterns were identified and classified: type 1, the nerve lies superficial to the vein; type 2, the nerve lies deep to the vein; type 3, the nerve crosses the branches of the vein; type 4, the nerve splits and its branches pass around the vein. The last pattern was not included in the meta-analysis. Eighteen studies were included (useful sample of 1491 hemi-necks). Type 1 variation had a prevalence of 79.7% (95% CI 77.6-81.7%), type 2 had a prevalence of 19.6% (95% CI 17.7-21.7%), and the type 3 had a prevalence of 0.7% (95% CI 0.0-1.4%). Significant differences were found among geographical subgroups. Normally, the spinal accessory nerve passes superficial to the internal jugular vein, but anatomical variations are common and there is a geographical influence. These findings are important for the safety of modified radical neck dissections.

Lymphadenectomy improves outcome in dogs with resected Kiupel high-grade cutaneous mast cell tumours and overtly metastatic regional lymph nodes.

INTRODUCTION: Historically, the prognosis for dogs with stage II Kiupel high-grade cutaneous mast cell tumours has been considered poor. OBJECTIVES: The aim of this study was to explore the impact of lymphadenectomy on outcome in dogs with Kiupel high-grade cutaneous mast cell tumours and overt regional lymph node metastasis. MATERIAL AND METHODS: Data from dogs with completely staged Kiupel high-grade cutaneous mast cell tumours with overt and/or certain regional lymph node metastasis undergoing excision of the primary tumours and adjuvant medical treatment were extracted. Dogs with a cytological diagnosis of regional lymph node metastasis that did not undergo lymphadenectomy were compared with dogs that underwent lymphadenectomy and had a histological diagnosis of overt lymph node metastasis. RESULTS: Forty-nine dogs were included, 18 did not undergo lymphadenectomy while 31 underwent lymphadenectomy. Median time to progression was significantly shorter in dogs that did not undergo lymphadenectomy (150 days, 95% confidence interval: 129 to 170) compared to the other dogs (229 days, 95% confidence interval: 191 to 266). Median survival time was also shorter in dogs that did not undergo lymphadenectomy (250 days, 95% confidence interval: 191 to 308) compared to dogs that underwent lymphadenectomy (371 days, 95% confidence interval: 311 to 430). On multivariable analysis, lack of lymphadenectomy was associated with higher risk of overall tumour progression (hazard ratio: 2.05, 95% confidence interval: 1.02 to 4.13), nodal progression (hazard ratio: 3.4, 95% confidence interval: 1.65 to 7.02) and tumour-related death (hazard ratio 3.63, 95% confidence interval: 1.72 to 7.66), whereas tumour size was associated with higher risk of local recurrence (hazard ratio: 3.61, 95% confidence interval: 1.06 to 13). CLINICAL SIGNIFICANCE: Regional lymphadenectomy may improve outcome in dogs with biologically aggressive cutaneous mast cell tumours.

MicroRNAs and their role in the malignant transformation of oral leukoplakia: a scoping review.

BACKGROUND: MiRNAs are small non-coding RNAs that regulate gene expression at the post-transcriptional level and have been associated with malignant transformation of oral epithelial precursor lesions such as oral leukoplakia. The aim was to perform a scoping review of the contemporary literature about the different roles of miRNAs during the malignant transformation of oral leukoplakia. MATERIAL AND METHODS: We conducted a systematic search with the following MeSH terms: 'oral leukoplakia', 'carcinoma in situ', 'microRNAs', 'mouth neoplasms' and 'epithelial-mesenchymal transition' in PubMed/MEDLINE, EMBASE and SpringerLink. RESULTS: Fifteen articles were included for analysis, among which in vivo and in vitro articles were included. A total of 21 different miRNAs were found to be involved in the malignant transformation process of oral leukoplakia. Regarding their possible effects, 6 miRNAs were classified as oncogenic, 5 as tumour suppressors and 10 were related to epithelial-mesenchymal transition, invasion and migration. CONCLUSIONS: Based on the current review, we concluded that miRNAs-21, 345, 181-b and 31* seem to be potential markers of malignant transformation of oral leukoplakia. However, further clinical prospective studies are needed in order to validate their utility as prognostic biomarkers.

Origin and main ramifications of coeliac artery in Cerdocyon thous.

BACKGROUND: Cerdocyon thous is the canid with the greatest geographical coverage in South America. The aim of this study was to describe the origin, skeletopy, length and main branches of the coeliac artery in C. thous. MATERIALS AND METHODS: The dissections were performed on 14 cadavers of adult specimens, 6 males and 8 females, with a rostrosacral length average of 67.00 ± 4.7 cm and 62.09 ± 5.7 cm, respectively. The specimens were collected dead on highways on the banks of the Atlantic Forest (Rio de Janeiro) and the Pampa biome (Rio Grande do Sul) in Brazil. The cadavers were fixed and preserved in a formaldehyde solution until dissection. The coeliac artery was dissected, the length was measured "in situ" and its main branches were recorded. The coeliac artery emerged as a single artery in all dissected animals. RESULTS: The average length of the coeliac artery was 1.43 ± 0.17 cm in males and 1.39 mm ± 0.24 cm in females, with no significant difference in this measurement between sexes. The predominant skeletopy was at the level of the second lumbar vertebra (57.1%), positioned on average 1.43 cm cranially to the cranial mesenteric artery. In most individuals (92.9%), the classic trifurcation was formed: the coeliac artery branched into the hepatic, left gastric, and lienal arteries. Only 1 male animal presented a bifurcation formed between the hepatic artery and a gastrolienal trunk. CONCLUSIONS: These anatomical characteristics are similar to those of other species of the Canidae family, possibly due to their phylogenetic proximity.

Enfermedad neumocócica invasiva por serotipo 38, reporte de caso clínico / Invasive pneumococcal disease by serotype 38, a clinical case report

La enfermedad neumocócica invasiva (ENI) es causa de morbimortalidad prevenible en pediatría. Con la introducción de vacunas antineumocócicas conjugadas disminuyó la prevalencia de ENI en 61,9% en los menores de 2 años, y se produjo un cambio en la distribución de serotipos y un aumento de ENI por serotipos no vaccinales. En este contexto, es relevante la vigilancia epidemiológica de los serotipos emergentes causantes de ENI en la población. Se presentará el caso de una lactante de 11 meses con diagnóstico de meningitis causada por neumococo serotipo 38, su evolución y consecuencias clínicas, y se realiza un análisis de la situación epidemiológica actual.

In pediatrics,invasive pneumococcal disease is a preventable cause ofmorbidity andmortality.The introduction of conjugated pneumococcal vaccines has reduced the prevalence of invasive pneumococcal disease by 61.9% in the under two's and has brought about a change in the distribution of serotypes and a rise in invasive pneumococcal disease caused by non-vaccine serotypes.This being the case,itis very importanttomonitorthe epidemiology ofthe emerging serotypes causing the disease in the population.We presentthe case of an 11 month old infant diagnosed with meningitis caused by serotype 38, describing his clinical course andclinical consequences; andweperforman analysis ofthepresent epidemiologica lsituation

Early replication dynamics of sex-linked mitochondrial DNAs in the doubly uniparental inheritance species Ruditapes philippinarum (Bivalvia Veneridae).

Mitochondrial homoplasmy, which is maintained by strictly maternal inheritance and a series of bottlenecks, is thought to be an adaptive condition for metazoans. Doubly uniparental inheritance (DUI) is a unique mode of mitochondrial transmission found in bivalve species, in which two distinct mitochondrial genome (mtDNA) lines are present, one inherited through eggs (F) and one through sperm (M). During development, the two lines segregate in a sex- and tissue-specific manner: females lose M during embryogenesis, whereas males actively segregate it in the germ line. These two pivotal events are still poorly characterized. Here we investigated mtDNA replication dynamics during embryogenesis and pre-adulthood of the venerid Ruditapes philippinarum using real-time quantitative PCR. We found that both mtDNAs do not detectably replicate during early embryogenesis, and that the M line might be lost from females around 24 h of age. A rise in mtDNA copy number was observed before the first reproductive season in both sexes, with the M mitochondrial genome replicating more than the F in males, and we associate these boosts to the early phase of gonad production. As evidence indicates that DUI relies on the same molecular machine of mitochondrial maternal inheritance that is common in most animals, our data are relevant not only to DUI but also to shed light on how differential segregations of mtDNA variants, in the same nuclear background, may be controlled during development.

Mixed type I and type II collagen scaffold for cartilage repair: ultrastructural study of synovial membrane response and healing potential versus microfractures (a pilot study).

The association between microfracture of the subchondral plate and a coverage scaffold has emerged as a promising strategy to treat cartilage lesions in a one-step procedure. Between different types of scaffolds (e.g. collagen, hyaluronic acid, polyglycolic acid) currently studied, type I collagen scaffold is the most used for this purpose, and is currently adopted for humans. The aim of this study was to test a novel scaffold made of mixed type I and II collagen (I-IICS) in order to define the immunological reaction of the synovial tissue and the repair capabilities induced by the collagen membrane when associated with microfracture. Eight New Zealand White rabbits, aged 180 days, were operated on bilaterally on the medial femoral condyle. A circular cartilage lesion was performed up to the calcified layer of the medial femoral condyle, and the centre of the lesion was microfractured. Randomly, one of the two lesions was covered with the I-IICS (treated), and the other was left uncovered (control). The synovial membrane reaction and the quality of the cartilage tissue repair were investigated at 2, 90, 180 and 270 days macroscopically, histomorphologically and ultrastructurally. Expression of tumor necrosis factor-alpha (TNF-alpha) in synovial tissue by immunocytochemistry analyses was also investigated. In the control group, at 2 days gold particles were localized mainly on synoviocyte type A, less on synoviocytes type B and on collagen bundles; in the treated group the reaction is more intense in cells in the matrix, but at 180 days controls and treated joints were very similar. The synovial membranes of the joints receiving the I-IICS did not reveal significant changes compared to the age-matched controls. Signs of inflammation were present at the 90-day time-point, and became less evident at afterwards. The degradation of the scaffolds was already evident at the 90-day time-point. The quality of the cartilage repair of the rabbits treated with the I-IICS was slightly better in 5 cases out of 6 in comparison to the controls. However, a statistically significant difference was not detected (p=0.06). Scaffolds made of mixed type I and II collagen exhibited good biocompatibility properties in vivo and favoured cartilage restoration when associated with microfracture, as shown in this pilot study.

Monosomic and molecular mapping of adult plant leaf rust resistance genes in the Brazilian wheat cultivar Toropi.

Leaf rust is one of the most destructive diseases affecting wheat worldwide. The most effective way to control it is to use resistant cultivars. Resistance based on slow-rusting adult plant resistance (APR) genes has proven to be the best method for developing cultivars with durable resistance. A source of slow-rusting APR for leaf rust is the Brazilian wheat cultivar Toropi. The Toropi/IAC 13 F2 and F7 recombinant inbred lines (RILs) were developed in previous studies. Phenotypic analysis of the F2 and F7 RILs showed that 2 recessive genes that were temporarily named trp-1 and trp-2 conferred APR in Toropi. In the present study, we used monosomic families and amplified fragment length polymorphism (AFLP), sequence-tagged site, and simple sequence repeat (SSR) markers to map trp-1 and trp-2 on wheat chromosomes. Analysis of the F2 monosomic RIL showed that trp- 1 and trp-2 were located on chromosomes 1A and 4D, respectively. AFLP analysis of the F7 RIL identified 2 independent AFLP markers, XPacgMcac3 and XPacgMcac6, which were associated with Toropi APR. These markers explained 71.5% of the variation in the phenotypic data in a multiple linear regression model. The AFLP markers XPacg/ Mcac3 and XPacg/Mcac6 were anchored by SSR markers previously mapped on the short arms of chromosomes 1A (1AS) and 4D (4DS), respectively. The trp-2 gene is the first leaf rust resistance gene mapped on wheat chromosome 4DS. The mapping of trp-1 and trp-2 provides novel and valuable information that could be used in future studies involving the fine mapping of these genes, as well as in the identification of molecular markers that are closely related to these genes for marker-assisted selection of this important trait in wheat.

HIV-positive patients treated for multidrug-resistant tuberculosis: clinical outcomes in the HAART era.

SETTING: Multidrug-resistant tuberculosis (MDR-TB) and the human immunodeficiency virus (HIV) pose two of the greatest threats to global tuberculosis (TB) control. Given expanding global access to antiretroviral therapy (ART) and second-line TB drugs, more data are needed on experiences treating MDR-TB and HIV co-infection in resource-poor settings. OBJECTIVE: To describe the clinical characteristics, management, outcomes, and factors associated with survival among HIV-positive individuals receiving treatment for MDR-TB. DESIGN: This was a retrospective case series of 52 HIV-positive individuals receiving treatment for MDR-TB in Lima, Peru. We used Cox proportional hazards regression models to identify risk factors for mortality. RESULTS: A total of 31 (57%) of the cohort died on treatment, with the majority of deaths due to MDR-TB. Low baseline weight predicted a three-fold increased rate of death (aHR 3.1, 95%CI 1.5-6.7), while individuals receiving highly active ART experienced a significantly lower rate of death compared to those who were not (aHR 0.4, 95%CI 0.2-0.9). CONCLUSION: Early ART is likely a key component of effective MDR-TB management in co-infected individuals.

Electron microscope study on a transmissible cytotoxic factor isolated from cerebrospinal fluid of neurological patients: analysis of its structure and of its effects on various types of cell cultures.

AIMS: In previous studies, the present group showed that a factor, present in the cerebrospinal fluid of seven neuro-patients, was capable of inducing cell damages on cell cultures of epithelial cells (Vero), glial cells (DG54-MG) and human primary lymphocytes. The cytotoxicity, once induced, could be transmitted to fresh cell cultures using crude preparations obtained from the cytotoxic cell cultures. METHODS AND RESULTS: The present electron microscope study describes in detail the pathological changes occurring in the previously assayed cultured cell types, and for the first time in human fibroblasts, as a consequence of the treatment with crude cytotoxic preparation. It also demonstrates with reasonable certainty the absence of virus-like particles in both the treated cells and the partially purified cytotoxic fraction. Indeed high-resolution electron microscopy analysis shows that this fraction consists almost entirely of protein spheroids with a diameter of 8-12 nm. CONCLUSIONS: The possible significance of nanotubular aggregates, observed in particular in the glial and in the epithelial cells undergoing cytotoxic damage, is also discussed.

Gender differences in ancestral contribution and admixture in Venezuelan populations.

The origin of the contribution of uniparental heritage were analyzed in 615 samples of individuals proceeding from 13 towns classified according to historic differences in their emergence and development as African-derived, European-derived, and admixed/urban. Mitochondrial and Y-chromosome haplogroups were identified by PCR-restriction fragment length polymorphism. The results were compared with previous estimates of admixture made with autosomal markers and with historic aspects. The results show a predominantly indigenous genetic contribution through the female, being more prevalent in urban populations; the African contribution, although dispersed, presents a larger concentration in the African-derived towns, whereas the European contribution is limited to populations with this origin, reflecting isolation and the conservation of the distribution pattern of genes of the Colonial era. With regard to admixture through males, it is almost exclusively of European origin, whereas the African contribution is basically concentrated in the African-derived towns, and the Amerindian lineages are almost nonexistent. The genome of paternal heredity, as opposed to the autosomal and the mitochondrial, shows a homogeneous pattern of admixture that is independent of the origin of the population studied, suggesting that European genes have been introduced into the Venezuelan population through male immigrations, whereas the indigenous contribution has been preserved in the Venezuelan genetic pool through the women. These results provide evidence of the heterogeneity in the genetic origin of the Venezuelan population, which should be taken into account in forensic and epidemiologic genetic studies.

Components of (co)variance of the days open in Siboney dairy cows / Componentes de (co)variância dos dias vazios em vacas leiteiras Siboney

The records of 63,406 calvings of Siboney dairy cows (5/8 Holstein 3/8 Cuban Zebu) were used to estimate the components of covariance of the days open (DO). Five models were used: of repeatability; univariate; bivariate; of random regression with Legendre polynomials and the parity number as predicting variable; and a model of random regression with Legendre polynomials and heterogeneity of the residual variance. The heritability obtained with the univariate model was 0.09 in the first calving and decreased to 0.05 in the fifth. A higher estimate of heritability (0.12) was obtained with the repeatability model. When the model of random regression with heterogeneity of the residual variance was used, the heritability was higher than the values estimated with the previous models. The genetic correlations among the DO in different calvings, estimated with the models of random regression with and without heterogeneity of the residual variance, were close to 1.0. It is concluded that the estimates of heritability increased with the use of the random regression models. The genetic correlations among the DO of different calvings indicated that in the first three, the DO are regulated for the most part by the same genes.

Os registros de 63.406 partos de vacas Siboney (5/8 Holstein 3/8 Cebu de Cuba) foram utilizados para estimar os componentes de (co)variância de dias vazios (DV). Utilizaram-se cinco modelos: de repetitividade; univariado; bivariado; de regressão aleatória com polinômios de Legendre e número de partos como variável preditiva; e de regressão aleatória com polinômios de Legendre e heterogeneidade da variância residual. A herdabilidade obtida com o modelo univariado foi de 0,09 no primeiro e diminuiu a 0,05 no quinto parto. Uma estimativa de herdabilidade mais alta (0,12) foi obtida com o modelo de repetitividade. Quando foi usado o modelo de regressão aleatória com heterogeneidade da variância residual a herdabilidade foi superior aos valores estimados com os modelos anteriores. As correlações genéticas entre os DV em distintos partos, estimadas com os modelos de regressão aleatória com e sem heterogeneidade da variância residual, foram próximos a 1,0. Concluiu-se que as estimativas de herdabilidade foram incrementadas com o uso dos modelos de regressão aleatória. As correlações genéticas entre os DV de diferentes partos indicaram que, nos três primeiros, os DV são regulados na sua maior proporção pelos mesmos genes.

On the principle of spin potential equalization.

In analogy with Sanderson's electronegativity equalization principle, it is possible to postulate a principle of spin potential equalization in the E[N(alpha), N(beta)] representation of the spin polarized density functional theory, where N(alpha) and N(beta) refer to the number of electrons with spins alpha and beta, respectively. The principle provides simple expressions to evaluate the energy changes DeltaE between two interacting molecules, A and B, together with the electron transfer, DeltaN(alpha) and DeltaN(beta). The model is illustrated for a series of addition reactions of electrophilic, nucleophilic, and ambiphilic carbenes to alkenes in their singlet and triplet multiplicities. The results are in a consistent qualitative agreement with the experimental reactivity established for these systems.

Postextubation pulmonary edema: a case series and review.

UNLABELLED: We report a series of patients with postextubation pulmonary edema who had no obvious risk factors for the development of this syndrome. METHODS: Patients identified by the pulmonary consultation service at an academic medical center were reviewed. RESULTS: Fourteen cases were collected and analyzed. The average age was 34.5 years; 12 patients were male. The average BMI was 25.5. None had documented previous lung disease. Most operations were scheduled as outpatient procedures, and the type of surgery ranged from an incision and drainage of a bite wound to an open reduction-internal fixation of the radius. None of the patients had upper airway surgery. The length of surgeries ranged from 27 to 335 min. Laryngospasm was the most commonly identified obstructing event postextubation. Treatment involved airway support when needed, supplemental oxygen, and diuretics. CONCLUSIONS: It would appear that all patients, especially young men, are at risk for the development of this syndrome and that the pathogenesis remains uncertain in many cases.

Expression of fibroblast growth factor receptors during development and regression of the bovine corpus luteum.

There is evidence that fibroblast growth factors (FGFs) are involved in the regulation of growth and regression of the corpus luteum (CL). However, the expression pattern of most FGF receptors (FGFRs) during CL lifespan is still unknown. The objective of the present study was to determine the pattern of expression of 'B' and 'C' splice variants of FGFRs in the bovine CL. Bovine CL were collected from an abattoir and classed as corpora hemorrhagica (Stage I), developing (Stage II), developed (Stage III) or regressed (Stage IV) CL. Expression of FGFR mRNA was measured by semiquantitative reverse transcription-polymerase chain reaction and FGFR protein was localised by immunohistochemistry. Expression of mRNA encoding the 'B' and 'C' spliced forms of FGFR1 and FGFR2 was readily detectable in the bovine CL and was accompanied by protein localisation. FGFR1C and FGFR2C mRNA expression did not vary throughout CL lifespan, whereas FGFR1B was upregulated in the developed (Stage III) CL. FGFR3B, FGFR3C and FGFR4 expression was inconsistent in the bovine CL. The present data indicate that FGFR1 and FGFR2 splice variants are the main receptors for FGF action in the bovine CL.

Psychosocial support groups for patients with multidrug-resistant tuberculosis: five years of experience.

This detailed case history traces the first 5 years of a psychosocial support group intervention aimed to improve adherence to individualized drug regimens for multidrug-resistant tuberculosis (MDR-TB) in Peru. A total of eight groups were established in metropolitan Lima and two provinces of Peru led by teams of psychiatrists and nurses. The intervention consisted of bi-monthly support groups, recreational excursions, symbolic celebrations, and periodic family workshops. Notably, of the 285 patients who participated in this intervention, only 3.5% defaulted from treatment. Details include the description of services, patient data, major psychosocial difficulties faced by this population, key challenges, and implications. Psychosocial support is a crucial component of treatment for MDR-TB in order to ensure completion of complicated treatment regimens and enable psychosocial rehabilitation after treatment.