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Genetic factors play a significant role in the risk for development of alcohol use disorder (AUD). Using 3-bottle choice intermittent access ethanol (IEA), we have employed the Diversity Outbred (DO) mouse panel as a model of alcohol use disorder in a genetically diverse population. Through use of gene expression network analysis techniques, in combination with expression quantitative trait loci (eQTL) mapping, we have completed an extensive analysis of the influence of genetic background on gene expression changes in the prefrontal cortex (PFC). This approach revealed that, in DO mice, genes whose expression was significantly disrupted by intermittent ethanol in the PFC also tended to be those whose expression correlated to intake. This finding is in contrast to previous studies of both mice and nonhuman primates. Importantly, these analyses identified genes involved in myelination in the PFC as significantly disrupted by IEA, correlated to ethanol intake, and having significant eQTLs. Genes that code for canonical components of the myelin sheath, such as Mbp, also emerged as key drivers of the gene expression response to intermittent ethanol drinking. Several regulators of myelination were also key drivers of gene expression, and had significant QTLs, indicating that genetic background may play an important role in regulation of brain myelination. These findings underscore the importance of disruption of normal myelination in the PFC in response to prolonged ethanol exposure, that genetic variation plays an important role in this response, and that this interaction between genetics and myelin disruption in the presence of ethanol may underlie previously observed behavioral changes under intermittent access ethanol drinking such as escalation of consumption.
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To fulfil the technical requirements for accreditation to ISO/IEC 17025, the end-to-end validation of all processes associated with standardising 60Co, including gravimetric source dispensing, primary standardisation by the 4π(LS)ß-γ coincidence and live-timed anti-coincidence extrapolation techniques, and impurity determination were performed and documented. Pure-beta-emitting impurities in a 60Co stock solution were identified. The impact of such impurities on measurement by liquid scintillation counting and comparison in the ESIR are discussed. A fresh 60Co source was produced, standardised, and compared using the SIR.
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A well-type NaI(Tl) detector was modelled and characterised by means of a Monte Carlo simulation, as part of a project to develop a 4πß (Plastic Scintillator)-4πγ instrument to be used for the primary standardisation of radionuclides at ANSTO. The simulation based on GEANT4 was used to characterise the 4πγ detector in terms of potential dead layer/inactive materials, full energy peak efficiency, coincidence-summing correction, and energy resolution. An excellent agreement was obtained between the simulation results and the experimental measurements.
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OBJECTIVES: This study aims to identify older adult malnutrition in Texas, examine county-level characteristics associated with crude malnutrition death rates, and describe assets and opportunities available to address and improve malnutrition among the older population. DESIGN: Secondary data analysis using the Centers for Disease Control and Prevention's WONDER online database, the U.S. Census 2014-2018 American Community Survey, and the U.S. Department of Agriculture's Food Access Research Atlas data. SETTING: All 254 counties in the state of Texas. PARTICIPANTS: Individuals aged 65 years and older. MEASUREMENT: The dependent variable was the proportion of county-level malnutrition crude death rates. Independent variables included Health Provider Shortage Area designations, rurality, poverty status, food access, age, race, ethnicity, and education. RESULTS: The overall malnutrition crude death rate in Texas was 65.6 deaths per 100,000 older Texans, ranging from 0 to 414.46 deaths per 100,000 depending on the county. Higher malnutrition crude death rates were associated with non-metropolitan counties (P=0.018), lower education (P=0.047), greater household poverty (P=0.010), and low food access (P<0.001). CONCLUSION: Socioeconomic disadvantages at the county-level appear to be one of the root causes of malnutrition crude death rates in Texas.
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Desnutrição , Idoso , Idoso de 80 Anos ou mais , Etnicidade/estatística & dados numéricos , Insegurança Alimentar , Humanos , Desnutrição/epidemiologia , Desnutrição/mortalidade , Pobreza/etnologia , Pobreza/estatística & dados numéricos , População Rural/estatística & dados numéricos , Fatores Socioeconômicos , Texas/epidemiologia , Estados Unidos , População Urbana/estatística & dados numéricos , Populações Vulneráveis/etnologia , Populações Vulneráveis/estatística & dados numéricosRESUMO
AIMS: Application of exogenous nucleotides can modulate wound healing via the activation of purinergic receptors. However, evidence for the release of endogenous nucleotides and the subsequent activation of purinergic receptors in this process has not been well defined. Therefore, the current study aimed to investigate wound-mediated nucleotide release and autocrine purinergic signalling during HaCaT keratinocyte wound closure following scratch injury. MAIN METHODS: An in vitro scratch wound apparatus was employed to study wound healing over 24-h in the presence of modulators of ATP release, P2 receptors and pathways downstream of P2 receptor activation. KEY FINDINGS: Adenosine 5'-triphosphate (ATP) was released from scratched cells. The ectonucleotidase apyrase and pharmacological inhibition of the nucleotide release hemichannel, pannexin-1, decreased wound closure over time. The non-selective P2Y receptor antagonist suramin and the selective P2Y2 receptor antagonist AR-C118925XX, but not other P2 antagonists, decreased wound closure. AR-C118925XX decreased wound closure in a concentration-dependent fashion. However, exogenous P2Y2 receptor agonists, ATP or uridine 5'-triphosphate, did not enhance wound closure. PCR and immunoblotting confirmed P2Y2 receptor expression in HaCaT cells. U73122, a phospholipase C antagonist, and 2-aminoethoxydiphenylborate, an inositol 1,4,5-trisphosphate receptor-sensitive Ca2+-release channel antagonist, decreased wound closure consistent with P2Y2 receptor activation. Absence of extracellular or intracellular Ca2+ or inhibition of intracellular Ca2+-release also impaired wound closure. SIGNIFICANCE: These data describe a novel autocrine signalling mechanism in which wound-mediated release of endogenous ATP in response to mechanical scratching of HaCaT cells activates P2Y2 receptors to facilitate wound closure.
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Trifosfato de Adenosina/metabolismo , Comunicação Autócrina , Receptores Purinérgicos P2Y2/metabolismo , Cicatrização , Células HEK293 , Humanos , Antagonistas do Receptor Purinérgico P2Y/farmacologia , Suramina/farmacologiaRESUMO
We determined if a microbial inoculant could improve the fermentation and aerobic stability of corn silage subjected to various challenges during storage that included an air stress challenge and low packing density. In Experiment 1, whole-plant corn was untreated (CTR) or treated (INO, Lactobacillus buchneri 40788 and Pediococcus pentosaceus 12455. Five individually replicated 7.5-L silos, at a density of 240 kg of dry matter (DM)/m3, for each treatment were kept sealed (NAS) for 19 wk, air stressed early (ES, 3 h/wk for wk 1-9), or air stressed late during storage (LS, 3 h/wk for wk 10-19). Inoculation increased the number of agar-culturable lactic acid bacteria regardless of air stress status, but it did not affect the relative abundance of Lactobacillus. Early, but not late air stress, resulted in silages with a higher relative abundance of Acetobacter when compared with NAS. Silages treated with INO had greater concentrations of acetic acid than CTR. Numbers of yeasts were lowest for INO regardless of air stress and CTR-LS had the most yeasts among all treatments. Silages that were not air stressed had a higher relative abundance of Candida tropicalis than air stressed silages. Monascus purpureus was detected in ES and LS but not in NAS, and its relative abundance was numerically higher in CTR-ES than in INO-ES and statistically higher in CTR-LS compared with INO-LS. Early air stress numerically reduced aerobic stability compared with NAS, and there was a statistical tendency for lower stability in LS compared with NAS. Inoculation improved aerobic stability regardless of when the air stress occurred. In Experiment 2, corn silage was prepared with the same primary treatments of CTR and INO but was packed at a low (LD; 180 kg of DM/m3) or a normal (ND; 240 kg of DM/m3) density and sealed (NAS) or air stressed (AS; 24 h on d 28, 42, and 89) for 92 d of storage. The concentration of acetic acid was greater in INO compared with CTR and in AS compared with NAS. Numbers of yeasts were lower in NAS compared with AS regardless of inoculation and they were lower in INO-AS compared with CTR-AS. Treatment with INO improved aerobic stability but the improvement was better in NAS versus AS and better in ND versus LD. Overall, our experiments corroborate past findings showing that INO markedly improves the aerobic stability of corn silage but they are the first to show that improvement can be sustained even when the silage was exposed to regular air stresses and when packed at a low density.
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Silagem , Zea mays , Aerobiose , Animais , Fermentação , Lactobacillus , Silagem/análiseRESUMO
AIMS: To evaluate the capacity of Lactobacillus hilgardii and Lactobacillus buchneri on modifying the bacterial community and improving fermentation and aerobic stability of high-moisture corn (HMC). METHODS AND RESULTS: High-moisture corn was untreated (CTR), treated with L. hilgardii (LH) or L. buchneri (LB) at 600 000 CFU per gram fresh weight, or with L. hilgardii and L. buchneri at 300 000 CFU per gram fresh weight each (LHLB), and stored for 10, 30 or 92 days. Compared to CTR, inoculated silages had higher Lactobacillaceae relative abundance, lower yeasts numbers and higher aerobic stability. Treatment with LHLB resulted in a higher acetic acid concentration than LH and higher 1,2 propanediol concentration than LB, such differences were numerically greater at 10 and 30 days but statistically greater at 92 days. At 10 days, all inoculated silages were more stable than CTR, but LHLB was even more stable than LB or LH. CONCLUSIONS: The combination of L. hilgardii and L. buchneri had a synergistic effect on yeast inhibition, leading to greater improvements in aerobic stability as early as 10 days after ensiling. SIGNIFICANCE AND IMPACT OF THE STUDY: Lactobacillus hilgardii, especially in combination with L. buchneri, can improve the aerobic stability of HMC after a very short period of ensiling.
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Lactobacillus/fisiologia , Microbiota , Silagem , Zea mays , Ácido Acético/análise , Aerobiose , Bactérias/crescimento & desenvolvimento , Fermentação , Propilenoglicol/análise , Silagem/análise , Silagem/microbiologia , Leveduras/crescimento & desenvolvimento , Zea mays/microbiologiaRESUMO
Technetium-99m was standardised by the 4π(LS)ce-γ coincidence extrapolation method. Sensitivity of the 4π(LS) channel to two types of radiation, namely conversion electrons and γ-rays, resulted in incorrect activity values being obtained when this was not adequately accounted for. Measurements were more robust when the LS detection efficiency was optimised, and when a γ-window setting was used that monitored the combined LS efficiency for conversion electrons and γ-rays. The primary standard was internationally compared through participation in the BIPM.RI(II)-K4.Tc99m key comparison.
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This paper describes 10 core features of a neuropsychological assessment with the aim of helping neurologists understand the unique contribution the evaluation can make within the wider context of diagnostic methods in epilepsy. The possibilities, limitations and cautions associated with the investigation are discussed under the following headings. (1) A neuropsychological assessment is a collaborative investigation. (2) Assessment prior to treatment allows for the accurate assessment of treatment effects. (3) The nature of an underlying lesion and its neurodevelopmental context play an important role in shaping the associated neuropsychological deficit. (4) Cognitive and behavioural impairments result from the essential comorbidities of epilepsy which can be considered as much a disorder of cognition and behaviour as of seizures. (5) Patients' subjective complaints can help us understand objective cognitive impairments and their underlying neuroanatomy, resulting in improved patient care. At other times, patient complaints reflect other factors and require careful interpretation. (6) The results from a neuropsychological assessment can be used to maximize the educational and occupational potentials of people with epilepsy. (7) Not all patients are able to engage with a neuropsychological assessment. (8) There are limitations in assessments conducted in a second language with tests that have been standardized on different populations from that of the patient. (9) Adequate intervals between assessments maximize sensitivity to meaningful change. (10) Patients should be fully informed about the purpose of the assessment and have realistic expectations of the outcome prior to referral.
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Epilepsia/psicologia , Epilepsia/terapia , Neurologistas , Testes Neuropsicológicos , HumanosRESUMO
BACKGROUND AND PURPOSE: Although functional connectivity has been linked to cognitive function in epilepsy, its relationship with physical, psychological, or social dysfunction is unknown. This study aimed to assess the relationship between network architecture from resting-state fMRI and health-related quality of life in children with medically intractable focal epilepsy. MATERIALS AND METHODS: Forty-seven children with nonlesional focal epilepsy were included; 22 had frontal lobe epilepsy and 15 had temporal lobe epilepsy. We computed graph metrics of functional connectivity, including network segregation (clustering coefficient and modularity) and integration (characteristic path length and participation coefficient). Health-related quality of life was measured using the Quality of Life in Childhood Epilepsy questionnaire. We examined the associations between graph metrics and the Quality of Life in Childhood Epilepsy total and domains scores, with age, sex, age at seizure onset, fMRI motion, and network density as covariates. RESULTS: There was a negative relationship between the clustering coefficient and total Quality of Life in Childhood Epilepsy score [t(40) = -2.0; P = .04] and social function [t(40) = -2.9; P = .005]. There was a positive association between the mean participation coefficient and total Quality of Life in Childhood Epilepsy score [t(40) = 2.2; P = .03] and cognition [t(40) = 3.8; P = .0004]. In temporal lobe epilepsy, there was a negative relationship between the clustering coefficient and total Quality of Life in Childhood Epilepsy score [t(8) = -2.8; P = .02] and social function [t(8) = -3.6; P = .0075] and between modularity and total Quality of Life in Childhood Epilepsy score [t(8) = -2.5; P = .04] and social function [t(8) = -4.4; P = .0021]. In frontal lobe epilepsy, there was no association between network segregation and integration and Quality of Life in Childhood Epilepsy total or domain scores. CONCLUSIONS: Our findings indicate that there are other higher order brain functions beyond cognition, which may be linked with functional connectivity of the brain.
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Encéfalo/fisiopatologia , Epilepsias Parciais/fisiopatologia , Rede Nervosa/fisiopatologia , Qualidade de Vida , Mapeamento Encefálico/métodos , Criança , Epilepsia do Lobo Frontal/fisiopatologia , Epilepsia do Lobo Temporal/fisiopatologia , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , MasculinoRESUMO
Here we propose a low-cost automated system for the unobtrusive and continuous welfare monitoring of dairy cattle on the farm. We argue that effective and regular monitoring of multiple condition traits is not currently practicable and go on to propose 3D imaging technology able to acquire differing forms of related animal condition data (body condition, lameness and weight), concurrently using a single device. Results obtained under farm conditions in continuous operation are shown to be comparable or better than manual scoring of the herd. We also consider inherent limitations of using scoring and argue that sensitivity to relative change over successive observations offers greater benefit than the use of what may be considered abstract and arbitrary scoring systems.
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BACKGROUND AND PURPOSE: Largely accepted in the literature is the role the interconnections between the thalamus and cortex play in generalized epilepsy. However, thalamocortical involvement is less understood in focal epilepsy in terms of the effect of seizures on thalamocortical circuitry in the developing brain and subsequent cognitive outcome. We investigated thalamocortical pathway microstructure in pediatric frontal lobe epilepsy and temporal lobe epilepsy and examined the associations between pathway microstructure and measures of executive function. MATERIALS AND METHODS: We examined thalamocortical connections in 24 children with frontal lobe epilepsy, 17 patients with temporal lobe epilepsy, and 25 healthy children using DTI. We investigated several executive function measures in patients and controls, which were distilled into latent executive function components to compare among groups, and the associations between measures of thalamocortical microstructure and executive function. RESULTS: We found no differences in thalamocortical pathway microstructure between the groups, but aspects of executive function (mental flexibility/inhibition/shifting) were impaired in the frontal lobe epilepsy group compared with controls. In patients with frontal lobe epilepsy, younger age at seizure onset and a greater number of antiepileptic drugs were associated with DTI indices indicative of damaged/less developed thalamocortical pathways. In patients with temporal lobe epilepsy, poorer performance on all measures of executive function was associated with DTI indices reflective of damaged/less developed pathways. CONCLUSIONS: Our results give insight into vulnerable neural networks in pediatric focal epilepsy and suggest thalamocortical pathway damage as a potential mechanism of executive function impairment in temporal lobe epilepsy but not frontal lobe epilepsy. Identifying structure-function relations can help inform how we measure functional and cognitive/behavioral outcomes in these populations.
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Epilepsia do Lobo Frontal/fisiopatologia , Epilepsia do Lobo Temporal/fisiopatologia , Função Executiva/fisiologia , Vias Neurais/fisiopatologia , Adolescente , Córtex Cerebral/fisiopatologia , Criança , Feminino , Humanos , Masculino , Tálamo/fisiopatologiaRESUMO
In response to the increasing application of 68Ge/68Ga and 68Ga in nuclear medicine, an international comparison of activity measurement of 68Ge in equilibrium with 68Ga was organised. ANSTO standardised the comparison solution by the 4π(LS)ß+-γ coincidence extrapolation and TDCR efficiency calculation methods, with excellent agreement between the two results. The primary standard was transferred to the ANSTO Secondary Standard Ionisation Chamber. Internationally traceable Australian Certified Reference Materials (ACRMs) of 68Ge/68Ga can now be prepared in various measurement geometries applied in nuclear medicine.
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Carcinoma de Células Escamosas/metabolismo , Carcinoma de Células Escamosas/secundário , Inositol Polifosfato 5-Fosfatases/metabolismo , Linfonodos/metabolismo , Neoplasias Orofaríngeas/metabolismo , Neoplasias Orofaríngeas/patologia , Humanos , Imuno-Histoquímica , Linfonodos/patologia , Metástase Linfática , Mucosa Respiratória/metabolismoRESUMO
Graft-versus-host disease (GVHD) remains a major problem after allogeneic haematopoietic stem cell transplantation, a curative therapy for haematological malignancies. Previous studies have demonstrated a role for the adenosine triphosphate (ATP)-gated P2X7 receptor channel in allogeneic mouse models of GVHD. In this study, injection of human peripheral blood mononuclear cells (PBMCs) into immunodeficient non-obese diabetic-severe combined immunodeficiency-interleukin (NOD-SCID-IL)-2Rγnull (NSG) mice established a humanized mouse model of GVHD. This model was used to study the effect of P2X7 blockade in this disease. From five weeks post-PBMC injection, humanized mice exhibited clinical signs and histopathology characteristic of GVHD. The P2X7 antagonist, Brilliant Blue G (BBG), blocked ATP-induced cation uptake into both murine and human cells in vitro. Injection of BBG (50 mg/kg) into NSG mice did not affect engraftment of human leucocytes (predominantly T cells), or the clinical score and survival of mice. In contrast, BBG injection reduced circulating human interferon (IFN)-γ significantly, which was produced by human CD4+ and CD8+ T cells. BBG also reduced human T cell infiltration and apoptosis in target organs of GVHD. In conclusion, the P2X7 antagonist BBG reduced circulating IFN-γ in a humanized mouse model of GVHD supporting a potential role for P2X7 to alter the pathology of this disease in humans.
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Linfócitos T CD4-Positivos/efeitos dos fármacos , Linfócitos T CD8-Positivos/efeitos dos fármacos , Doença Enxerto-Hospedeiro/tratamento farmacológico , Transplante de Células-Tronco Hematopoéticas , Interferon gama/sangue , Antagonistas do Receptor Purinérgico P2X/uso terapêutico , Corantes de Rosanilina/uso terapêutico , Animais , Apoptose/efeitos dos fármacos , Linfócitos T CD4-Positivos/imunologia , Linfócitos T CD8-Positivos/imunologia , Movimento Celular/efeitos dos fármacos , Células Cultivadas , Modelos Animais de Doenças , Doença Enxerto-Hospedeiro/imunologia , Humanos , Subunidade gama Comum de Receptores de Interleucina/genética , Camundongos , Camundongos Endogâmicos NOD , Camundongos Knockout , Camundongos SCID , Receptores Purinérgicos P2X7/metabolismo , Transplante HomólogoRESUMO
BACKGROUND: The growing prevalence of chronic conditions in the ageing workforce has been shown to have a negative impact in terms of optimal work performance and quality of life. It is therefore important to understand the factors associated with sickness absence due to health problems. AIMS: To examine the socio-demographics, health status indicators, barriers to self-care and social support associated with working adults missing work because of chronic conditions. METHODS: We analysed data from working adults in the USA with one or more chronic conditions who completed the National Council on Aging (NCOA) Chronic Care Survey. Analyses were performed using SPSS version 22; independent sample t-tests and chi-squared tests were used to compare sample characteristics and logistic regression was used to assess factors associated with missed work as a dichotomous outcome variable. RESULTS: Among the 250 study subjects, employees who reported poorer general health status [odd ratio (OR) = 1.62, P < 0.05], more physician visits (OR = 1.45, P < 0.01), not having enough money for their health (OR = 3.69, P < 0.01) and a higher reliance on their co-workers (OR = 1.71, P < 0.05) were significantly more likely to report sickness absence due to their chronic conditions. CONCLUSIONS: To reduce absences among employees with chronic conditions, employers need to understand the importance of factors such as employee income, resources and knowledge of disease self-care. US employers should explore opportunities for employees to offset health care costs, apply appropriate time-flexible work policies and encourage employees' participation in health knowledge enhancing interventions.
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Doença Crônica/epidemiologia , Licença Médica/estatística & dados numéricos , Adulto , Idoso , Feminino , Nível de Saúde , Indicadores Básicos de Saúde , Humanos , Renda/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Autocuidado , Apoio Social , Estados Unidos/epidemiologiaRESUMO
Midbrain neurons of the centrally projecting Edinger-Westphal nucleus (EWcp) are activated by alcohol, and enriched with stress-responsive neuropeptide modulators (including the paralog of corticotropin-releasing factor, urocortin-1). Evidence suggests that EWcp neurons promote behavioral processes for alcohol-seeking and consumption, but a definitive role for these cells remains elusive. Here we combined targeted viral manipulations and gene array profiling of EWcp neurons with mass behavioral phenotyping in C57BL/6 J mice to directly define the links between EWcp-specific urocortin-1 expression and voluntary binge alcohol intake, demonstrating a specific importance for EWcp urocortin-1 activity in escalation of alcohol intake.
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Comportamento Animal , Consumo Excessivo de Bebidas Alcoólicas/genética , Depressores do Sistema Nervoso Central/administração & dosagem , Comportamento de Procura de Droga , Núcleo de Edinger-Westphal/metabolismo , Etanol/administração & dosagem , Neurônios/metabolismo , Urocortinas/genética , Animais , Núcleo de Edinger-Westphal/citologia , Feminino , Técnicas de Silenciamento de Genes , Masculino , Camundongos Knockout , AutoadministraçãoRESUMO
BACKGROUND: The presence of a structural cardiac defect in the setting of dextrocardia is extremely rare. Graspable models allow enhanced appreciation of aberrant structures and vascular relations, particularly in rare and complex cases. This is the first case report of the use of a replica of a patients' anatomy to plan the surgical strategy in the setting of dextrocardia. AIMS: We intend to demonstrate the benefit of three-dimensional printing to enhance preoperative planning in complex congenital heart disease undergoing heart transplantation. The anomalous structures encountered include situs inversus dextrocardia, transposition of the great vessels, a single atrium and a dilated double-outlet single right ventricle. METHODS: Computed Tomography acquisition was performed with the use of ECG multiphase gating technology and contrast enhancement. The structures of interest were segmented and the generated 3D mesh was exported as a stereolithographic (STL) file. The model was printed on a Z-Corp 250 binder jetting printer. Post processing techniques were used to enhance model strength. RESULTS: Pre-operative 3D visualisation of the patients' anatomy allowed for a more comprehensive surgical strategy to be planned, thus reducing the intra-operative duration and cross-clamp time which are recognised to correlate with reduced patient morbidity. CONCLUSION: The ongoing advances in medical image procurement and 3D processing software and printing technology will continue to enhance preoperative planning and thereby improve patient care. We demonstrate the pivotal role played by such technologies in advancing spatial comprehension of complex aberrant anatomy.
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Cardiopatias Congênitas/cirurgia , Transplante de Coração/métodos , Impressão Tridimensional/estatística & dados numéricos , Tomografia Computadorizada por Raios X/métodos , Humanos , MasculinoRESUMO
BACKGROUND: Remote consultations that are realistic enough to be useful medically offer considerable clinical, logistical and cost benefits. Despite advances in virtual reality and vision hardware and software, these benefits are currently often unrealised. METHOD: The proposed approach combines high spatial and temporal resolution 3D and 2D machine vision with virtual reality techniques, in order to develop new environments and instruments that will enable realistic remote consultations and the generation of new types of useful clinical data. RESULTS: New types of clinical data have been generated for skin analysis and respiration measurement; and the combination of 3D with 2D data was found to offer potential for the generation of realistic virtual consultations. CONCLUSION: An innovative combination of high resolution machine vision data and virtual reality online methods, promises to provide advanced functionality and significant medical benefits, particularly in regions where populations are dispersed or access to clinicians is limited. Copyright © 2016 John Wiley & Sons, Ltd.