Gut microbiota and its relationship with early vascular ageing in a Spanish population (MIVAS study).

BACKGROUND: Gut microbiota and its by-products are increasingly recognized as having a decisive role in cardiovascular diseases. The aim is to study the relationship between gut microbiota and early vascular ageing (EVA). METHODS: A cross-sectional study was developed in Salamanca (Spain) in which 180 subjects aged 45-74 years were recruited. EVA was defined by the presence of at least one of the following: carotid-femoral pulse wave velocity (cf-PWV), cardio-ankle vascular index (CAVI) or brachial-ankle pulse wave velocity (ba-PWV) above the 90th percentile of the reference population. All other cases were considered normal vascular ageing (NVA). MEASUREMENTS: cf-PWV was measured by SphygmoCor® System; CAVI and ba-PWV were determined by Vasera 2000® device. Gut microbiome composition in faecal samples was determined by 16S rRNA Illumina sequencing. RESULTS: Mean age was 64.4 ± 6.9 in EVA group and 60.4 ± 7.6 years in NVA (p < .01). Women in EVA group were 41% and 53% in NVA. There were no differences in the overall composition of gut microbiota between the two groups when evaluating Firmicutes/Bacteriodetes ratio, alfa diversity (Shannon Index) and beta diversity (Bray-Curtis). Bilophila, Faecalibacterium sp.UBA1819 and Phocea, are increased in EVA group. While Cedecea, Lactococcus, Pseudomonas, Succiniclasticum and Dielma exist in lower abundance. In logistic regression analysis, Bilophila (OR: 1.71, 95% CI: 1.12-2.6, p = .013) remained significant. CONCLUSIONS: In the studied Spanish population, early vascular ageing is positively associated with gut microbiota abundance of the genus Bilophila. No relationship was found between phyla abundance and measures of diversity.

Antiretroviral Therapy-Induced Dysregulation of Gene Expression and Lipid Metabolism in HIV+ Patients: Beneficial Role of Antioxidant Phytochemicals.

Human immunodeficiency virus (HIV) infection has continued to be the subject of study since its discovery nearly 40 years ago. Significant advances in research and intake of antiretroviral therapy (ART) have slowed the progression and appearance of the disease symptoms and the incidence of concomitant diseases, which are the leading cause of death in HIV+ persons. However, the prolongation of ART is closely related to chronic degenerative diseases and pathologies caused by oxidative stress (OS) and alterations in lipid metabolism (increased cholesterol levels), both of which are conditions of ART. Therefore, recent research focuses on using natural therapies to diminish the effects of ART and HIV infection: regulating lipid metabolism and reducing OS status. The present review summarizes current information on OS and cholesterol metabolism in HIV+ persons and how the consumption of certain phytochemicals can modulate these. For this purpose, MEDLINE and SCOPUS databases were consulted to identify publications investigating HIV disease and natural therapies and their associated effects.

Consumption Patterns of Energy Drinks in Adolescents and Their Effects on Behavior and Mental Health: A Systematic Review.

The aim of the current review was to analyze primary studies about energy drink consumption patterns in adolescents and their relationship with mental health. PubMed, PLOS ONE, PsycINFO, and ScienceDirect databases were searched to identify articles related to adverse effects of energy drinks in adolescents and young adults aged 11 to 18 years. Psychological and behavioral measures were based on validated screening tools used in various contexts, and bias was detected in energy drink consumption patterns. In regard to sex, boys consumed more energy drinks than girls, and a strong, positive association was reported between consumption and probability of risky behaviors; tendency for anxiety, depression, and impulsivity; poor academic performance; and sleep disturbances. A progressive increase in consumption was also noted of 25% to 75% within 5 years. Findings suggest that standardized consumption pattern assessment be included in evaluations of mental health to determine potential causal relationships. [Journal of Psychosocial Nursing and Mental Health Services, 60(2), 41-47.].

Differentiation of Epoxide Enantiomers in the Confined Spaces of an Homochiral Cu(II) Metal-Organic Framework by Kinetic Resolution.

TAMOF-1, a homochiral metal-organic framework (MOF) constructed from an amino acid derivative and Cu(II), was investigated as a heterogeneous catalyst in kinetic resolutions involving the ring opening of styrene oxide with a set of anilines. The branched products generated from the ring opening of styrene oxide with anilines and the unreacted epoxide were obtained with moderately high enantiomeric excesses. The linear product arising from the attack on the non-benzylic position of styrene oxide underwent a second kinetic resolution by reacting with the epoxide, resulting in an amplification of its final enantiomeric excess and a concomitant formation of an array of isomeric aminodiols. Computational studies confirmed the experimental results, providing a deep understanding of the whole process involving the two successive kinetic resolutions. Furthermore, TAMOF-1 activity was conserved after several catalytic cycles. The ring opening of a meso-epoxide with aniline catalyzed by TAMOF-1 was also studied and moderate enantioselectivities were obtained.

Influence of weight status on bone mineral content measured by DXA in children.

INTRODUCTION: Childhood obesity is a public health problem with repercussions in later life. As tissue formation peaks in childhood we determined how weight status influences bone mineral content. MATERIAL AND METHODS: We studied 553 children aged 4-18 years over 10 years (46.8% girls). We measured age, weight, height and through bone densitometry (DXA), bone mineral content (BMC), bone mineral density (BMD), and waist, arm and hip circumferences. The patients were divided into groups using the body mass index z-score: underweight, normal weight, overweight, obese and very obese. RESULTS: BMC and BMD values were highest in the normal-weight and overweight groups. Logistic regression showed bone mineralization was inversely associated with waist circumference, the association being positive for weight and age. No differences were found according to sex. DISCUSSION: Studies of the relationship between weight and bone mineralization report contradictory results, often because of different study designs. Moreover, studies in children are either few or with small samples. Our findings in a large sample show the importance of weight status in bone mineralization given the risk of bone fractures or osteoporosis. CONCLUSIONS: Weight status influenced bone mineralization. BMC and BMD decreased in children with a higher degree of obesity. Waist circumference correlated negatively with bone mineralization.

Effects of protein size, thermodynamic stability, and net charge on cotranslational folding on the ribosome.

During the last five decades, studies of protein folding in dilute buffer solutions have produced a rich picture of this complex process. In the cell, however, proteins can start to fold while still attached to the ribosome (cotranslational folding) and it is not yet clear how the ribosome affects the folding of protein domains of different sizes, thermodynamic stabilities, and net charges. Here, by using arrest peptides as force sensors and on-ribosome pulse proteolysis, we provide a comprehensive picture of how the distance from the peptidyl transferase center in the ribosome at which proteins fold correlates with protein size. Moreover, an analysis of a large collection of mutants of the Escherichia coli ribosomal protein S6 shows that the force exerted on the nascent chain by protein folding varies linearly with the thermodynamic stability of the folded state, and that the ribosome environment disfavors folding of domains of high net-negative charge.

Enhanced Performance of Zirconium-Doped Ceria Catalysts for the Methoxycarbonylation of Anilines.

The methoxycarbonylation of anilines stands as an attractive method for the phosgene-free production of carbamates. Despite the high yields obtained for ceria catalysts, the reduction of the amount of side products and the prevention of catalyst deactivation still represent major hurdles in this chemistry. One advantage of ceria is the possibility of tuning its reactivity by doping its lattice with other metals. In the present work, a series of doped ceria-based materials, prepared by substitution with metals, are evaluated in the methoxycarbonylation of 2,4-diaminotoluene with dimethyl carbonate. Among all catalysts, containing Eu, Hf, La, Pr, Sm, Tb, Y or Zr, ceria promoted with 2 mol % Zr exhibited 96 % selectivity towards the desired carbamates, improving the pure CeO2 catalyst. Density functional theory demonstrates that two descriptors are needed: 1) a geometric factor that governs the reduction of energy barriers for carbamate formation through ureas; 2) catalyst basicity as N-H bonds need to be activated. Assessment in subsequent reaction cycles revealed that the CeO2 -ZrO2 catalyst is more stable than bulk CeO2 , along with the reduction of fouling processes.

Homochiral Metal-Organic Frameworks for Enantioselective Separations in Liquid Chromatography.

Selective separation of enantiomers is a substantial challenge for the pharmaceutical industry. Chromatography on chiral stationary phases is the standard method, but at a very high cost for industrial-scale purification due to the high cost of the chiral stationary phases. Typically, these materials are poorly robust, expensive to manufacture, and often too specific for a single desired substrate, lacking desirable versatility across different chiral analytes. Here, we disclose a porous, robust homochiral metal-organic framework (MOF), TAMOF-1, built from copper(II) and an affordable linker prepared from natural l-histidine. TAMOF-1 has shown to be able to separate a variety of model racemic mixtures, including drugs, in a wide range of solvents of different polarity, outperforming several commercial chiral columns for HPLC separations. Although not exploited in the present article, it is worthy to mention that the preparation of this new material is scalable to the multikilogram scale, opening unprecedented possibilities for low-energy chiral separation at the industrial scale.

Evolutionary relationship of two ancient protein superfolds.

Proteins are the molecular machines of the cell that fold into specific three-dimensional structures to fulfill their functions. To improve our understanding of how the structure and function of proteins arises, it is crucial to understand how evolution has generated the structural diversity we observe today. Classically, proteins that adopt different folds are considered to be nonhomologous. However, using state-of-the-art tools for homology detection, we found evidence of homology between proteins of two ancient and highly populated protein folds, the (ßα)8-barrel and the flavodoxin-like fold. We detected a family of sequences that show intermediate features between both folds and determined what is to our knowledge the first representative crystal structure of one of its members, giving new insights into the evolutionary link of two of the earliest folds. Our findings contribute to an emergent vision where protein superfolds share common ancestry and encourage further approaches to complete the mapping of structure space onto sequence space.

Atmospheric Dispersal of Bioactive Streptomyces albidoflavus Strains Among Terrestrial and Marine Environments.

Members of the Streptomyces albidoflavus clade, identified by 16S rRNA sequencing and phylogenetic analyses, are widespread among predominant terrestrial lichens (Flavoparmelia caperata and Xanthoria parietina) and diverse intertidal and subtidal marine macroalgae, brown red and green (Phylum Heterokontophyta, Rhodophyta, and Chlorophyta) from the Cantabrian Cornice. In addition to these terrestrial and coastal temperate habitats, similar strains were also found to colonize deep-sea ecosystems and were isolated mainly from gorgonian and solitary corals and other invertebrates (Phylum Cnidaria, Annelida, Echinodermata, Arthropoda, and Porifera) living up to 4700-m depth and at a temperature of 2-4 °C in the submarine Avilés Canyon. Similar strains have been also repeatedly isolated from atmospheric precipitations (rain drops, snow, and hailstone) collected in the same area throughout a year observation time. These ubiquitous strains were found to be halotolerant, psychrotolerant, and barotolerant. Bioactive compounds with diverse antibiotic and cytotoxic activities produced by these strains were identified by high-performance liquid chromatography (HPLC) and database comparison. These include antibacterials (paulomycins A and B), antifungals (maltophilins), antifungals displaying also cytotoxic activities (antimycins and 6-epialteramides), and the antitumor compound fredericamycin. A hypothetical dispersion model is here proposed to explain the biogeographical distribution of S. albidoflavus strains in terrestrial, marine, and atmospheric environments.

Buttock Lifting with Polypropylene Strips.

BACKGROUND: The purpose of this study was to evaluate the results of gluteal suspension with polypropylene strips. PATIENTS AND METHODS: Ninety healthy female patients between the ages of 20 and 50 years (mean, 26 years), who wished to remodel their buttocks from December 2004 to February 2013 were studied retrospectively. All 90 patients were treated with 2 strips of polypropylene on each buttock using the following procedures: 27 (30 %) patients were suspended with polypropylene strips; 63 (70 %) patients were treated with tumescent liposuction in the sacral "V", lower back, supragluteal regions, and flanks to improve buttocks contour (aspirated volume of fat from 350 to 800 cc); 16 (18 %) patients underwent fat grafting in the subcutaneous and intramuscular layers (up to 300 cc in each buttock to increase volume); 5 (6 %) patients received implants to increase volume; and 4 (4.4 %) patients underwent removal and relocation of intramuscular gluteal implants to improve esthetics. RESULTS: Over an 8-year period, 90 female patients underwent gluteal suspension surgeries. Good esthetic results without complications were obtained in 75 of 90 (84 %) cases. Complications occurred in 15 of 90 (16.6 %) patients, including strip removal due to postoperative pain in 1 (1.1 %) patient, and seroma in both subgluteal sulci in 3 (3.3 %) patients. CONCLUSION: The results of this study performed in 90 patients over 8 years showed that the suspension with polypropylene strips performed as a single procedure or in combination with other cosmetic methods helps to enhance and lift ptosed gluteal and paragluteal areas. LEVEL OF EVIDENCE IV: This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

[Considerations on family dynamics and the malnutrition syndrome in Mexican children]. / Consideraciones sobre la dinámica familiar y el síndrome de la mala nutrición en niños mexicanos.

Since the early 1990s we noted that family dysfunction was more common in children with severe primary malnutrition than in children admitted to the hospital without malnutrition. Defects on feeding habits during the first year of life, especially early weaning and inadequate complementary feeding were more common in dysfunctional families. We also observed that chronic malnutrition in preschool children, and overweight and obesity in schoolchildren were more common in children from dysfunctional families. Once the association between dysfunctional family dynamics and obesity in schoolchildren was demonstrated, it was observed that low education of fathers and mothers increased twofold the possibility of family dysfunction: OR: 2.06; 95% CI: 1.37-3.10 and OR: 2.47; 95% CI: 1.57-3.89, respectively. In addition, the low-income and the lower purchasing power of foods were associated to family dysfunction (p<0.05). A remaining task is to explore how to assess family dysfunction in composite, extended, single-parent families where there exist other persons vulnerable to the different entities of malnutrition syndrome and indeed depend on adults for their care, food and nutrition.

Change in protein-ligand specificity through binding pocket grafting.

Recognition and discrimination of small molecules are crucial for biological processes in living systems. Understanding the mechanisms that underlie binding specificity is of particular interest to synthetic biology, e.g. the engineering of biosensors with de novo ligand affinities. Promising scaffolds for such biosensors are the periplasmic binding proteins (PBPs) due to their ligand-mediated structural change that can be translated into a physically measurable signal. In this study we focused on the two homologous polyamine binding proteins PotF and PotD. Despite their structural similarity, PotF and PotD have different binding specificities for the polyamines putrescine and spermidine. To elucidate how specificity is determined, we grafted the binding site of PotD onto PotF. The introduction of 7 mutations in the first shell of the binding pocket leads to a swap in the binding profile as confirmed by isothermal titration calorimetry. Furthermore, the 1.7Å crystal structure of the new variant complexed with spermidine reveals the interactions of the specificity determining residues including a defined water network. Altogether our study shows that specificity is encoded in the first shell residues of the PotF binding pocket and that transplantation of these residues allows the swap of the binding specificity.

Reproductive outcome in uterine malformations with or without an associated unilateral renal agenesis.

OBJECTIVE: To analyze reproductive performance in women with genital malformations and to determine whether pregnancy outcomes are influenced by the asrenal agenesis (URA). STUDY DESIGN: This was a retrospective study of 174 patients with genitourinary malformations, with available images for reevaluation and classification and a history ofpregnancies. The main outcome measure was the reproductive performance depending on the type of uterine malformation and urinary tract anomalies. RESULTS: The lowest percentage of women who had only live births occurred in women with bicornuate unicollis uterus (28%). Considering only uterine anomalies that might be associated with URA, those cases had significantly better perinatal outcomes (72% had only living children) than those with no renal agenesis (40%). Of the total number of pregnancies (n=355), patients with URA were associated with term deliveries and living children, whereas women with uterine malformation without URA were more associated with abortions, premature births, and breech presentation. CONCLUSION: Uterine malformations are associated with a high rate of abortions, preterm births, breech presentation, and reproductive losses, but reproductive performance is significantly better for a given type of uterine malformation if it is associated with URA; that is, if the Müllerian anomaly is the consequence of mesonephric or Wolffian anomaly. Different embryological origin for the uterine malformations (mesonephric versus isolated Müllerian anomalies), the absence of 1 renal artery, and previous extrauterine surgery could be related.

The pulmonary rehabilitation effect on long covid-19 syndrome: A systematic review and meta-analysis.

OBJECTIVES: This systematic review and meta-analysis aims to evaluate the efficacy of pulmonary rehabilitation (PR) in improving dyspnea, fatigue, physical activity, quality of life, anxiety and depression in patients with Long COVID-19 (LC). The impact of PR on LC and a comparison of face-to-face and telerehabilitation approaches was explored. METHODS: This systematic review and meta-analysis followed PRISMA guidelines and was registered in PROSPERO. A literature search included PubMed, Web of Science, and Cochrane Library until January 2023. No language filters were applied. Randomized controlled trials, non-randomized controlled trials, and observational studies were included. The risk of bias was assessed using appropriate tools. Descriptive analysis and meta-analysis were performed. Forest plots presented results. Statistical analyses were conducted using the Metafor Package in R v.3.4.2. RESULTS/FINDINGS: This systematic review and meta-analysis included 16 studies on PR in LC patients. A total of 1027 adults were included. The studies varied in design, with seven observational studies, three quasi-experimental studies, and six randomized controlled trials. Dyspnea, physical function, quality of life, psychological state, and fatigue were assessed as outcomes. The review found that pulmonary rehabilitation had a significant positive effect on dyspnea, physical function, quality of life (both global and physical domain), anxiety, and depression. However, the effect on fatigue was not significant. Heterogeneity was observed in some analyses, and publication bias was found in certain outcomes. Age and study design were identified as potential moderators. Both face-to-face and telerehabilitation interventions improved the studied outcomes, with only differences in the physical domain of quality of life favoring the face-to-face group. IMPLICATIONS ON PHYSIOTHERAPY PRACTICE: PR improved dyspnea, physical function, quality of life, and psychological state in LC patients, but not fatigue. Face-to-face and telerehabilitation have similar effects, except for physical quality of life.

Molecular handcraft of a well-folded protein chimera.

Modular assembly is a compelling pathway to create new proteins, a concept supported by protein engineering and millennia of evolution. Natural evolution provided a repository of building blocks, known as domains, which trace back to even shorter segments that underwent numerous 'copy-paste' processes culminating in the scaffolds we see today. Utilizing the subdomain-database Fuzzle, we constructed a fold-chimera by integrating a flavodoxin-like fragment into a periplasmic binding protein. This chimera is well-folded and a crystal structure reveals stable interfaces between the fragments. These findings demonstrate the adaptability of α/ß-proteins and offer a stepping stone for optimization. By emphasizing the practicality of fragment databases, our work pioneers new pathways in protein engineering. Ultimately, the results substantiate the conjecture that periplasmic binding proteins originated from a flavodoxin-like ancestor.

Clinical outcomes in the biomarkers of ketamine (Bio-K) study of open-label IV ketamine for refractory depression.

OBJECTIVE: We conducted an open-label clinical trial ("Bio-K") using IV ketamine for treatment-resistant depression to identify biomarkers linked to remission. Here, we report the clinical efficacy and side effect outcomes of Bio-K. METHODS: Across 4 US sites, 75 patients ages 18-65 with treatment-refractory unipolar or bipolar depression received 3 IV ketamine infusions over an 11-day period. Key exclusion criteria were psychotic symptoms, significant substance abuse, unstable medical conditions, and any use of cannabis. Pre-existing antidepressant medication was maintained. Primary outcome was remission as measured by Montgomery-Asberg Depression Rating Scale (MADRS), with secondary outcome of 50 % reduction in Beck Suicide Scale score. Safety monitoring and varying durations of infusions were also key parameters. RESULTS: Using remission as MADRS score <10, after 3 infusions 52 % achieved remission, with 67 % achieving response. Of those achieving response after a single infusion, 66 % (22 of 33) reached remission after 3 infusions, while 40 % (16 of 40) non-responders after the first infusion went on to achieve remission after 3 infusions. Only 20 % of non-responders after 2 infusions achieved remission. Most (81 %) participants had significant suicidal ideation at baseline; of these, two-thirds (67 %) experienced at least a 50 % reduction in suicidality. Side effects were minimal. Uniquely, we had three different types of infusion categories, with individuals receiving: (1) slow (100-min) infusions only or (2) regular (40-min) infusions only or (3) a mix of infusion durations. These three infusion groups showed comparable safety and efficacy. Exploration of clinical factors revealed no link between BMI, age, or gender to remission. CONCLUSIONS: The consistency of outcomes across 4 clinical sites and across multiple instruments, suggests high acute efficacy and safety of IV ketamine for serious depressive episodes. Duration of infusion did not alter outcomes. Meaningfully, 40 % of non-responders after a single infusion did reach remission subsequently, while only 20 % of non-responders after 2 infusions achieved remission, suggesting early response is suggestive for eventual remission. Our data on varying ketamine infusion duration adds novel insights into the clinical administration of this new treatment for refractory and severe patients. Our limitations included a lack of a control group, necessitating caution about conclusions of efficacy, balanced by the utility of reporting "real-world" outcomes across multiple clinical sites. We could also not separately analyze results for bipolar disorder due to small numbers. Together, the Bio-K clinical results are promising and provide significant sample sizes for forthcoming biological markers analyses.

[Comment on articule "Bibliometric analysis of scientific publications on COVID-19 elaborated by staff of the Instituto Mexicano del Seguro Social"]. / Comentario al artículo "Análisis bibliométrico de las publicaciones científicas sobre COVID-19 realizadas por personal IMSS".

In this letter to the editor, some doubts are expressed about the methodology used in the article Bibliometric analysis of scientific publications on COVID-19 elaborated by staff of the Instituto Mexicano del Seguro Social with the purpose of clarifying them and strengthening the scientific rigor with which it was carried out the investigation. The replicability of the studies is essential for other researchers to be able to assess the quality of the study and the validity of its results, in addition to ensuring the transparency of the science.

En esta carta al editor se plasman algunas dudas sobre la metodología empleada en el artículo "Análisis bibliométrico de las publicaciones científicas sobre COVID-19 realizadas por personal IMSS" con la finalidad de que sean aclaradas y se fortalezca la riguridad científica con la que se realizó la investigación. La replicabilidad de los estudios es fundamental para que otros investigadores estén en posibilidad de evaluar la calidad de éste y la validez de sus resultados, además de que asegura la transparencia de la ciencia.

TAMOF-1 as a Versatile and Predictable Chiral Stationary Phase for the Resolution of Racemic Mixtures.

Metal-organic frameworks (MOFs) have become promising materials for multiple applications due to their controlled dimensionality and tunable properties. The incorporation of chirality into their frameworks opens new strategies for chiral separation, a key technology in the pharmaceutical industry as each enantiomer of a racemic drug must be isolated. Here, we describe the use of a combination of computational modeling and experiments to demonstrate that high-performance liquid chromatography (HPLC) columns packed with TAMOF-1 as the chiral stationary phase are efficient, versatile, robust, and reusable with a wide array of mobile phases (polar and non-polar). As proof of concept, in this article, we report the resolution with TAMOF-1 HPLC columns of nine racemic mixtures with different molecular sizes, geometries, and functional groups. Initial in silico studies allowed us to predict plausible separations in chiral compounds from different families, including terpenes, calcium channel blockers, or P-stereogenic compounds. The experimental data confirmed the validity of the models and the robust performance of TAMOF-1 columns. The added value of in silico screening is an unprecedented achievement in chiral chromatography.

The influence of the environment on the patient-centered therapeutic relationship in physical therapy: a qualitative study.

BACKGROUND: Currently, in the scientific literature there is a great interest on the study of strategies to implement patient-centered care. One of the main tools for this is the therapeutic relationship. Some studies suggest that the perception of the environment in which the treatment takes place can influence the perception of its quality, but this is not explored in physical therapy. For all these reasons, the aim of this study was to understand the influence of the environment in which physical therapy treatment takes place on the patients' perception of the quality of the patient-centered therapeutic relationship in public health centers in Spain. METHODS: A qualitative study analysed thematically using a modified grounded theory approach. Data collection used semistructured interviewing during focus groups. RESULTS: We conducted four focus groups. The size of the focus groups ranged from six to nine participants. In total, 31 patients participated in these focus groups. Participants described a series of specific experiences and perceptions relating to the environment, which they felt were influential in the establishment of therapeutic patient-centered relationships, including six physical factors (Architectural barriers, Furniture, Use of the computer, Physical space, Ambiet conditions, and Privacy) and six organizational factors (Patient-physical therapist ratio, Treatment interruptions, Social factors, Continuity with the professional, Lack of professional autonomy, and Coordination or communication among team members). CONCLUSION: The results of this study highlight environmental factors that affect the quality of the therapeutic patient-centered relationship in physical therapy from the patient's point of view, and emphasize the need for physical therapists and administrators to underline the need to review these factors and take them into account in their service delivery.