[Guidelines for the Management of Community Acquired Pneumonia in Children and Adolescents (Pediatric Community Acquired Pneumonia, pCAP) - Issued under the Responsibility of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Pulmonology (GPP)]. / S2k-Leitlinie Management der ambulant erworbenen Pneumonie bei Kindern und Jugendlichen (pädiatrische ambulant erworbene Pneumonie, pCAP).

The present guideline aims to improve the evidence-based management of children and adolescents with pediatric community-acquired pneumonia (pCAP). Despite a prevalence of approx. 300 cases per 100 000 children per year in Central Europe, mortality is very low. Prevention includes infection control measures and comprehensive immunization. The diagnosis can and should be established clinically by history, physical examination and pulse oximetry, with fever and tachypnea as cardinal features. Additional signs or symptoms such as severely compromised general condition, poor feeding, dehydration, altered consciousness or seizures discriminate subjects with severe pCAP from those with non-severe pCAP. Within an age-dependent spectrum of infectious agents, bacterial etiology cannot be reliably differentiated from viral or mixed infections by currently available biomarkers. Most children and adolescents with non-severe pCAP and oxygen saturation > 92 % can be managed as outpatients without laboratory/microbiology workup or imaging. Anti-infective agents are not generally indicated and can be safely withheld especially in children of young age, with wheeze or other indices suggesting a viral origin. For calculated antibiotic therapy, aminopenicillins are the preferred drug class with comparable efficacy of oral (amoxicillin) and intravenous administration (ampicillin). Follow-up evaluation after 48 - 72 hours is mandatory for the assessment of clinical course, treatment success and potential complications such as parapneumonic pleural effusion or empyema, which may necessitate alternative or add-on therapy.

[Recommendations for the diagnosis and prevention of infectious diseases in pediatric and adolescent refugees in Germany : Statement of the German Society of Pediatric Infectious Diseases, the Society of Tropical Pediatrics and International Child Health, and the Professional Association of Pediatricians]. / Empfehlungen zur infektiologischen Versorgung von Flüchtlingen im Kindes- und Jugendalter in Deutschland : Stellungnahme der Deutschen Gesellschaft für Pädiatrische Infektiologie, der Gesellschaft für Tropenpädiatrie und Internationale Kindergesundheit und des Berufsverbandes der Kinder- und Jugendärzte.

Child and adolescent refugees in Germany represent a particularly vulnerable social group and treating infectious diseases forms a crucial part of providing their medical care. From an infectious diseases perspective, refugees themselves, as a result of their difficult personal circumstances, are the ones at highest risk. Even in crisis situations, medical practitioners are medically and ethically obliged to provide a high standard of care. The guidelines presented here propose recommendations for diagnosing and preventing infectious diseases among refugees under 18 in Germany. The guidelines are intended to assist in optimizing vaccine protection and treatment of diseases while taking into consideration factors such as refugees' challenging living conditions, cultural differences and potential language barriers.Upon refugees' arrival at the first housing sites, it is recommended that a basic clinical screening (and not just a brief visual inspection) be provided in order to identify and initiate treatment for acute medical problems and potentially contagious diseases (including tuberculosis), as well as to close gaps in vaccination coverage. Documentation of the clinical findings is critical, both to avoid redundant investigations and to optimize individual medical care. For this, an effective communication system must be established.Once refugees have been transferred into their destination community, outpatient and inpatient care providers should collaborate to bring refugees up-to-date with all vaccines recommended by STIKO (German Standing Committee on Vaccination). The same high standard of medical care should be delivered to refugees as would be to the general population. Due to the high prevalence of multi-resistant organisms (MRO) in the refugees' countries of origin, MRO screening is recommended for most patients receiving inpatient care.

Schmallenberg virus: experimental infection in goats and bucks.

BACKGROUND: Schmallenberg virus (SBV) is an emerging Orthobunyavirus of ruminant livestock species currently circulating in Europe. SBV causes a subclinical or mild disease in adult animals but vertical transmission to pregnant dams may lead to severe malformations in the offspring. Data on the onset of clinical signs, viremia and seroconversion in experimentally infected adult animals are available for cattle and sheep but are still lacking for goats. For a better understanding of the pathogenesis of SBV infection in adult ruminants, we carried out experimental infections in adult goats. Our specific objectives were: (i) to record clinical signs, viremia and seroconversion; (ii) to monitor viral excretion in the semen of infected bucks; (iii) to determine in which tissues SBV replication took place and virus-induced lesions developed. RESULTS: Four goats and two bucks were inoculated with SBV. Virus inoculation was followed by a short viremic phase lasting 3 to 4 days and a seroconversion occurring between days 7 and 14 pi in all animals. The inoculated goats did not display any clinical signs, gross lesions or histological lesions. Viral genomic RNA was found in one ovary but could not be detected in other organs. SBV RNA was not found in the semen samples collected from two inoculated bucks. CONCLUSIONS: In the four goats and two bucks, the kinetics of viremia and seroconversion appeared similar to those previously described for sheep and cattle. Our limited set of data provides no evidence of viral excretion in buck semen.

Preparing for the future: An examination of healthcare provider and patient communication regarding childhood cancer survivorship.

BACKGROUND: This qualitative, exploratory study examines the content of communication between healthcare providers (HCP) and childhood cancer patients (CCP) during a medical appointment to evaluate the extent to which cancer survivorship issues (medical and psychosocial) are discussed. METHODS: The content of the communication for 16 CCP ages 10-22 and their HCP were examined via audio recorded medical appointments occurring within 6 months of the end of active cancer treatment. The data were analysed using template analysis, a constructivist-interpretivist qualitative approach. RESULTS: HCP addressed more medically focused than psychosocially focused issues related to survivorship. CONCLUSIONS: Most discussions of survivorship are medically focused, potentially leaving patients with little information about future psychosocial functioning. Recommendations for future research on enhancing discussions about psychosocial issues are presented. This research has the potential to inform future interventions to enhance patient-provider communication on survivorship issues.

Automated DNA sequencing and analysis of 106 kilobases from human chromosome 19q13.3.

A total of 116,118 basepairs (bp) derived from three cosmids spanning the ERCC1 locus of human chromosome 19q13.3 have been sequenced with automated fluorescence-based sequencers and analysed by polymerase chain reaction amplification and computer methods. The assembled sequence forms two contigs totalling 105,831 bp, which contain a human fosB proto-oncogene, a gene encoding a protein phosphatase, two genes of unknown function and the previously-characterized ERCC1 DNA repair gene. This light band region has a high average density of 1.4 Alu repeats per kilobase. Human chromosome light bands could therefore contain up to 75,000 genes and 1.5 million Alu repeats.

Expressed genes, Alu repeats and polymorphisms in cosmids sequenced from chromosome 4p16.3.

The sequences of three cosmids (90 kilobases) from the Huntington's disease region in chromosome 4p16.3 have been determined. A 30,837 base overlap of DNA sequenced from two individuals was found to contain 72 DNA sequence polymorphisms, an average of 2.3 polymorphisms per kilobase (kb). The assembled 58 kb contig contains 62 Alu repeats, and eleven predicted exons representing at least three expressed genes that encode previously unidentified proteins. Each of these genes is associated with a CpG island. The structure of one of the new genes, hda1-1, has been determined by characterizing cDNAs from a placental library. This gene is expressed in a variety of tissues and may encode a novel housekeeping gene.

[Care of infectious diseases in underage refugees exemplified by Ukraine]. / Infektiologische Versorgung minderjähriger Flüchtlinge am Beispiel der Ukraine: Vorgehen in Deutschland gemäß der S1-Leitlinine (AWMF-Register Nr. 048-017).

Background: By early June 2022, around 300,000 children and adolescents from Ukraine were registered in the German central registry for foreigners.The updated recommendations for action should provide the foundations for an evidence-based and targeted care for the diagnosis and prevention of infectious diseases in underage refugees and asylum seekers, exemplified by Ukraine. Objective: The recommendations for action are intended to support medical personnel in the care of minor refugees in order to1) ensure early recognition and completion of an incomplete vaccination status,2) diagnose and treat common infectious diseases,3) ensure early recognition and treatment of infectious diseases that are rare in the German healthcare system. Material and methods: The recommendations for action were drafted as level 1 (S1) guidelines coordinated by the Association of the Scientific Medical Societies in Germany (AWMF) and were adapted to the situation of refugees from Ukraine.The recommendations were compiled by a representative expert panel appointed by the participating professional societies in an informal consensus and finally officially adopted by the board of directors of all societies concerned. Results: Recommendations are given for the extent of the medical evaluation of minor refugees, including the medical history and physical examination, adapted to the situation of refugees from Ukraine. A blood count and screening for tuberculosis, hepatitis B and C as well as human immunodeficiency virus (HIV) infections are recommended for all minor refugees.For a rapid completion of the vaccination status, an age-related and indications-related prioritization of individual vaccinations will be undertaken. Conclusion: In view of the continuing high numbers of refugees not only from Ukraine, a further professionalization of medical health care is necessary. For this purpose, the necessary structural and personnel framework conditions need to be accomplished.

HIV-1 Nef associated PAK and PI3-kinases stimulate Akt-independent Bad-phosphorylation to induce anti-apoptotic signals.

A highly conserved signaling property of Nef proteins encoded by human or simian immunodeficiency virus is the binding and activation of a PAK kinase whose function is unclear. Here we show that Nef-mediated p21-activated kinase (PAK) activation involves phosphatidylinositol 3-kinase, which acts upstream of PAK and is bound and activated by Nef similar to the manner of Polyoma virus middle T antigen. The Nef-associated phosphatidylinositol-3-PAK complex phosphorylated the pro-apoptotic Bad protein without involving the protein kinase B-Akt kinase, which is generally believed to inactivate Bad by serine phosphorylation. Consequently, Nef, but not a Nef mutant incapable of activating PAK, blocked apoptosis in T cells induced by serum starvation or HIV replication. Nef anti-apoptotic effects are likely a crucial mechanism for viral replication in the host and thus in AIDS pathogenesis.

Uptake, removal, accumulation, and phytotoxicity of 4-chlorophenol in willow trees.

4-chlorophenol (4-CP) is a well-known hazardous chlorinated compound and a precursor for the synthesis of the herbicide 2,4-dichlorophenoxyacetate. The relation between uptake, accumulation, toxicity, and removal of 4-CP in willow trees (Salix viminalis) was determined. In addition, the feasibility of implementing phytoremediation as a treatment method for 4-CP contamination was investigated. Willows were exposed to 4-CP levels < or =79.9 mg/L in hydroponic solution. The transpiration of the trees was used to determine toxic effects. Almost no inhibition of transpiration was detected at concentrations > or =15 mg/L. For concentrations > or =37.3 mg/L, transpiration decreased to < or =50%, and the trees wilted. Trees exposed to 79.9 mg/L wilted and eventually died. For concentrations of 79.9 mg/L, a significantly higher amount of 4-CP remained at the end of experiments in the test system compared with the amount remaining at all other concentrations. The loss of chemical from the system in experiments with trees was high, < or =99.5%. In treeless experiments, the mass loss of 4-CP was only 6% to 10%. The results indicated that degradation in the root zone is the main reason for the removal of 4-CP from the media. Phytoremediation of 4-CP in willow trees seems to be a remediation option, especially at concentrations <37.3 mg/L, at which point degradation of 4-CP is rapid and efficient, and the toxic effects on trees are not lethal.

Elevated bronchoalveolar lavage fluid histamine levels in allergic asthmatics are associated with methacholine bronchial hyperresponsiveness.

Using a sensitive single isotope enzymatic assay we measured bronchoalveolar lavage (BAL) fluid histamine in asymptomatic normal (nonallergic), allergic rhinitic, and allergic asthmatic subjects. Normal subjects were found to have little or no detectable amounts of histamine in BAL fluid (11 +/- 11 pg/ml), and few BAL fluid mast cells. In comparison, the allergic rhinitics and allergic asthmatics had much higher amounts of BAL fluid histamine (113 +/- 53 and 188 +/- 42 pg/ml, respectively), and a significantly greater number of BAL fluid mast cells. Furthermore, despite having equivalent baseline pulmonary function values, allergic asthmatics with BAL fluid histamine levels greater than 100 pg/ml required only 7 +/- 2 breath units of methacholine to induce a 20% drop in forced expiratory volume in 1 s (FEV1) (PD20FEV1) while asthmatics with BAL fluid histamine levels less than 100 pg/ml required 49 +/- 19 breath units (P less than 0.05). These data suggest that allergic asthmatics have ongoing lung mast cell degranulation that might contribute to the etiology of airway hyperresponsiveness.

Fruit Tree model for uptake of organic compounds from soil and air.

The current European risk assessment for chemicals considers only tap water, while in reality other beverages play an important role. A good part of beverages are made from fruits, for example apple juice and vine. A mathematical model was developed to predict uptake of neutral organic chemicals from soil and air into fruits. The new fruit tree model considers eight compartments, i.e. two soil compartments, fine roots, thick roots, stem, leaves, fruits, and air. Chemical equilibrium, advective transport in xylem and phloem, diffusive exchange to soil and air and growth dilution are the main processes. The parameterization is for a square-meter of an apple orchard. The model predicts that polar, non-volatile compounds will effectively be transported from soil to fruits, while lipophilic compounds will preferably accumulate from air into fruits. Results from various experiments show no disagreement with the model predictions.

Microbial growth yield estimates from thermodynamics and its importance for degradation of pesticides and formation of biogenic non-extractable residues.

In biodegradation studies with isotope-labelled pesticides, fractions of non-extractable residues (NER) remain, but their nature and composition is rarely known, leading to uncertainty about their risk. Microbial growth leads to incorporation of carbon into the microbial mass, resulting in biogenic NER. Formation of microbial mass can be estimated from the microbial growth yield, but experimental data is rare. Instead, we suggest using prediction methods for the theoretical yield based on thermodynamics. Recently, we presented the Microbial Turnover to Biomass (MTB) method that needs a minimum of input data. We have estimated the growth yield of 40 organic chemicals (31 pesticides) using the MTB and two existing methods. The results were compared to experimental values, and the sensitivity of the methods was assessed. The MTB method performed best for pesticides. Having the theoretical yield and using the released CO2 as a measure for microbial activity, we predicted a range for the formation of biogenic NER. For the majority of the pesticides, a considerable fraction of the NER was estimated to be biogenic. This novel approach provides a theoretical foundation applicable to the evaluation and prediction of biogenic NER formation during pesticide degradation experiments, and may also be employed for the interpretation of NER data from regulatory studies.

Symbol Digit Modalities Test: Normative data for Spanish-speaking pediatric population.

OBJECTIVE: To generate normative data for the Symbol Digit Modalities Test (SDMT) in Spanish-speaking pediatric populations. METHOD: The sample consisted of 4,373 healthy children from nine countries in Latin America (Chile, Cuba, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Peru, and Puerto Rico) and Spain. Each participant was administered the SDMT as part of a larger neuropsychological battery. SDMT scores were normed using multiple linear regressions and standard deviations of residual values. Age, age2, sex, and mean level of parental education (MLPE) were included as predictors in the analyses. RESULTS: The final multiple linear regression models showed main effects for age in all countries, such that score increased linearly as a function of age. In addition, age2 had a significant effect in all countries, except in Honduras and Puerto Rico. Models indicated that children whose parent(s) had a MLPE >12 years of education obtained higher score compared to children whose parent(s) had a MLPE ≤12 years for Chile, Guatemala, Mexico, and Spain. Sex affected SDMT score for Paraguay and Spain. CONCLUSIONS: This is the largest Spanish-speaking pediatric normative study in the world, and it will allow neuropsychologists from these countries to have a more accurate interpretation of the SDMT with pediatric populations.

Mechanism of ATP-sensitive K channel inhibition by sulfhydryl modification.

ATP-sensitive potassium (KATP) channels are reversibly inhibited by intracellular ATP. Agents that interact with sulfhydryl moieties produce an irreversible inhibition of KATP channel activity when applied to the intracellular membrane surface. ATP appears to protect against this effect, suggesting that the cysteine residue with which thiol reagents interact may either lie within the ATP-binding site or be inaccessible when the channel is closed. We have examined the interaction of the membrane-impermeant thiol-reactive agent p-chloromercuriphenylsulphonate (pCMPS) with the cloned beta cell KATP channel. This channel comprises the pore-forming Kir6.2 and regulatory SUR1 subunits. We show that the cysteine residue involved in channel inhibition by pCMPS resides on the Kir6.2 subunit and is located at position 42, which lies within the NH2 terminus of the protein. Although ATP protects against the effects of pCMPS, the ATP sensitivity of the KATP channel was unchanged by mutation of C42 to either valine (V) or alanine (A), suggesting that ATP does not interact directly with this residue. These results are consistent with the idea that C42 is inaccessible to the intracellular solution, and thereby protected from interaction with pCMPS when the channel is closed by ATP. We also observed that the C42A mutation does not affect the ability of SUR1 to endow Kir6.2 with diazoxide sensitivity, and reduces, but does not prevent, the effects of MgADP and tolbutamide, which are mediated via SUR1. The Kir6.2-C42A (or V) mutant channel may provide a suitable background for cysteine-scanning mutagenesis studies.

Molecular analysis of ATP-sensitive K channel gating and implications for channel inhibition by ATP.

The beta cell KATP channel is an octameric complex of four pore-forming subunits (Kir6.2) and four regulatory subunits (SUR1). A truncated isoform of Kir6.2 (Kir6.2DeltaC26), which expresses independently of SUR1, shows intrinsic ATP sensitivity, suggesting that this subunit is primarily responsible for mediating ATP inhibition. We show here that mutation of C166, which lies at the cytosolic end of the second transmembrane domain, to serine (C166S) increases the open probability of Kir6.2DeltaC26 approximately sevenfold by reducing the time the channel spends in a long closed state. Rundown of channel activity is also decreased. Kir6.2DeltaC26 containing the C166S mutation shows a markedly reduced ATP sensitivity: the Ki is reduced from 175 microM to 2.8 mM. Substitution of threonine, alanine, methionine, or phenylalanine at position C166 also reduced the channel sensitivity to ATP and simultaneously increased the open probability. Thus, ATP does not act as an open channel blocker. The inhibitory effects of tolbutamide are reduced in channels composed of SUR1 and Kir6.2 carrying the C166S mutation. Our results are consistent with the idea that C166 plays a role in the intrinsic gating of the channel, possibly by influencing a gate located at the intracellular end of the pore. Kinetic analysis suggests that the apparent decrease in ATP sensitivity, and the changes in other properties, observed when C166 is mutated is largely a consequence of the impaired transition from the open to the long closed state.

Genomic organization of plant terpene synthases and molecular evolutionary implications.

Terpenoids are the largest, most diverse class of plant natural products and they play numerous functional roles in primary metabolism and in ecological interactions. The first committed step in the formation of the various terpenoid classes is the transformation of the prenyl diphosphate precursors, geranyl diphosphate, farnesyl diphosphate, and geranylgeranyl diphosphate, to the parent structures of each type catalyzed by the respective monoterpene (C(10)), sesquiterpene (C(15)), and diterpene synthases (C(20)). Over 30 cDNAs encoding plant terpenoid synthases involved in primary and secondary metabolism have been cloned and characterized. Here we describe the isolation and analysis of six genomic clones encoding terpene synthases of conifers, [(-)-pinene (C(10)), (-)-limonene (C(10)), (E)-alpha-bisabolene (C(15)), delta-selinene (C(15)), and abietadiene synthase (C(20)) from Abies grandis and taxadiene synthase (C(20)) from Taxus brevifolia], all of which are involved in natural products biosynthesis. Genome organization (intron number, size, placement and phase, and exon size) of these gymnosperm terpene synthases was compared to eight previously characterized angiosperm terpene synthase genes and to six putative terpene synthase genomic sequences from Arabidopsis thaliana. Three distinct classes of terpene synthase genes were discerned, from which assumed patterns of sequential intron loss and the loss of an unusual internal sequence element suggest that the ancestral terpenoid synthase gene resembled a contemporary conifer diterpene synthase gene in containing at least 12 introns and 13 exons of conserved size. A model presented for the evolutionary history of plant terpene synthases suggests that this superfamily of genes responsible for natural products biosynthesis derived from terpene synthase genes involved in primary metabolism by duplication and divergence in structural and functional specialization. This novel molecular evolutionary approach focused on genes of secondary metabolism may have broad implications for the origins of natural products and for plant phylogenetics in general.

Analysing half-lives for pesticide dissipation in plants.

Overall dissipation of pesticides from plants is frequently measured, but the contribution of individual loss processes is largely unknown. We use a pesticide fate model for the quantification of dissipation by processes other than degradation. The model was parameterised using field studies. Scenarios were established for Copenhagen/Denmark and Shanghai/PR China, and calibrated with measured results. The simulated dissipation rates of 42 pesticides were then compared with measured overall dissipation from field studies using tomato and wheat. The difference between measured overall dissipation and calculated dissipation by non-degradative processes should ideally be contributable to degradation in plants. In 11% of the cases, calculated dissipation was above the measured dissipation. For the remaining cases, the non-explained dissipation ranged from 30% to 83%, depending on crop type, plant part and scenario. Accordingly, degradation is the most relevant dissipation process for these 42 pesticides, followed by growth dilution. Volatilisation was less relevant, which can be explained by the design of plant protection agents. Uptake of active compound from soil into plants leads to a negative dissipation process (i.e. a gain) that is difficult to quantify because it depends largely on interception, precipitation and plant stage. This process is particularly relevant for soluble compounds.

Spinally projecting preproglucagon axons preferentially innervate sympathetic preganglionic neurons.

Glucagon-like peptide-1 (GLP-1) affects central autonomic neurons, including those controlling the cardiovascular system, thermogenesis, and energy balance. Preproglucagon (PPG) neurons, located mainly in the nucleus tractus solitarius (NTS) and medullary reticular formation, produce GLP-1. In transgenic mice expressing glucagon promoter-driven yellow fluorescent protein (YFP), these brainstem PPG neurons project to many central autonomic regions where GLP-1 receptors are expressed. The spinal cord also contains GLP-1 receptor mRNA but the distribution of spinal PPG axons is unknown. Here, we used two-color immunoperoxidase labeling to examine PPG innervation of spinal segments T1-S4 in YFP-PPG mice. Immunoreactivity for YFP identified spinal PPG axons and perikarya. We classified spinal neurons receiving PPG input by immunoreactivity for choline acetyltransferase (ChAT), nitric oxide synthase (NOS) and/or Fluorogold (FG) retrogradely transported from the peritoneal cavity. FG microinjected at T9 defined cell bodies that supplied spinal PPG innervation. The deep dorsal horn of lower lumbar cord contained YFP-immunoreactive neurons. Non-varicose, YFP-immunoreactive axons were prominent in the lateral funiculus, ventral white commissure and around the ventral median fissure. In T1-L2, varicose, YFP-containing axons closely apposed many ChAT-immunoreactive sympathetic preganglionic neurons (SPN) in the intermediolateral cell column (IML) and dorsal lamina X. In the sacral parasympathetic nucleus, about 10% of ChAT-immunoreactive preganglionic neurons received YFP appositions, as did occasional ChAT-positive motor neurons throughout the rostrocaudal extent of the ventral horn. YFP appositions also occurred on NOS-immunoreactive spinal interneurons and on spinal YFP-immunoreactive neurons. Injecting FG at T9 retrogradely labeled many YFP-PPG cell bodies in the medulla but none of the spinal YFP-immunoreactive neurons. These results show that brainstem PPG neurons innervate spinal autonomic and somatic motor neurons. The distributions of spinal PPG axons and spinal GLP-1 receptors correlate well. SPN receive the densest PPG innervation. Brainstem PPG neurons could directly modulate sympathetic outflow through their spinal inputs to SPN or interneurons.

Test of Memory Malingering (TOMM): Normative data for the Latin American Spanish speaking adult population.

BACKGROUND: The Test of Memory Malingering (TOMM) is an instrument used to assess purposeful embellishment or fabrication of memory difficulties for personal gain. Although the TOMM can be use in non-English speaking cultures, it has not been validated in Spanish-speaking Central and South American contexts. OBJECTIVE: To generate normative data on TOMM across 7 countries in Latin America, with country-specific adjustments for gender, age, and education, where appropriate. METHOD: The sample consisted of 2,266 healthy adults who were recruited from Argentina, Bolivia, Chile, Mexico, Paraguay, Peru, and Puerto Rico. Each subject was administered the TOMM as part of a larger neuropsychological battery. A standardized five-step statistical procedure was used to generate the norms. RESULTS: t-tests did not show significant differences in TOMM performance between men and women in any countries of the TOMM Trial 1 or 2. As a result, gender-adjusted norms were not generated. CONCLUSIONS: The results from this study will have a large impact on the practice of neuropsychology in Latin America, as this is the first normative multicenter study to create norms for the TOMM in this global region.