Development of Decreased-Gluten Wheat Enabled by Determination of the Genetic Basis of lys3a Barley.

Celiac disease is the most common food-induced enteropathy in humans, with a prevalence of approximately 1% worldwide. It is induced by digestion-resistant, proline- and glutamine-rich seed storage proteins, collectively referred to as gluten, found in wheat (Triticum aestivum). Related prolamins are present in barley (Hordeum vulgare) and rye (Secale cereale). The incidence of both celiac disease and a related condition called nonceliac gluten sensitivity is increasing. This has prompted efforts to identify methods of lowering gluten in wheat, one of the most important cereal crops. Here, we used bulked segregant RNA sequencing and map-based cloning to identify the genetic lesion underlying a recessive, low-prolamin mutation (lys3a) in diploid barley. We confirmed the mutant identity by complementing the lys3a mutant with a transgenic copy of the wild-type barley gene and then used targeting-induced local lesions in genomes to identify induced single-nucleotide polymorphisms in the three homeologs of the corresponding wheat gene. Combining inactivating mutations in the three subgenomes of hexaploid bread wheat in a single wheat line lowered gliadin and low-molecular-weight glutenin accumulation by 50% to 60% and increased free and protein-bound lysine by 33%.

Development and field performance of nitrogen use efficient rice lines for Africa.

Nitrogen (N) fertilizers are a major input cost in rice production, and its excess application leads to major environmental pollution. Development of rice varieties with improved nitrogen use efficiency (NUE) is essential for sustainable agriculture. Here, we report the results of field evaluations of marker-free transgenic NERICA4 (New Rice for Africa 4) rice lines overexpressing barley alanine amino transferase (HvAlaAT) under the control of a rice stress-inducible promoter (pOsAnt1). Field evaluations over three growing seasons and two rice growing ecologies (lowland and upland) revealed that grain yield of pOsAnt1:HvAlaAT transgenic events was significantly higher than sibling nulls and wild-type controls under different N application rates. Our field results clearly demonstrated that this genetic modification can significantly increase the dry biomass and grain yield compared to controls under limited N supply. Increased yield in transgenic events was correlated with increased tiller and panicle number in the field, and evidence of early establishment of a vigorous root system in hydroponic growth. Our results suggest that expression of the HvAlaAT gene can improve NUE in rice without causing undesirable growth phenotypes. The NUE technology described in this article has the potential to significantly reduce the need for N fertilizer and simultaneously improve food security, augment farm economics and mitigate greenhouse gas emissions from the rice ecosystem.

"Talk with me": perspectives on services for men with problem gambling and housing instability.

BACKGROUND: Problem gambling and homelessness are recognized as important public health concerns that significantly impact individuals, their friends and families, communities and broader society. We aimed to explore the experiences with health and social services of men who had histories of problem gambling and housing instability in Toronto, Ontario. METHODS: We used a community-based participatory approach with a multi-service agency serving low-income individuals. We conducted qualitative interviews with men (n = 30) who had experienced problem gambling and housing instability. Our interviews employed open-ended questions to elicit men's perceptions of services related to housing instability, problem gambling and other comorbid conditions (e.g., mental illness, substance use). We reviewed relevant themes related to experiences with services (e.g., Use of and feedback on: health and social services, housing services, justice/legal aid services, substance use services, gambling services; stigma; goals; triggers; physical health; coping strategies; finances; relationships; barriers to services and recommendations for services). RESULTS: The concept of person-centred engagement was identified as a main overarching theme, and seemed to be lacking in most of the men's experiences of services. Person-centred engagement for these men entailed empowerment and autonomy; empathy, compassion and sincerity; respectful communication; and tailored and holistic life plans. While there was a strong emphasis placed on independence, the men identified the importance of positive therapeutic relationships as being critical aspects of the recovery process. Based on our analyses, several recommendations were identified: 1) Increasing general awareness of services for problem gambling; 2) Delivering integrated services in a one-stop-shop; 3) Addressing mental health with psychotherapy and pharmacotherapy; 4) Providing timely access to prevention and recovery services; and 5) Enhancing life skills with peer support. CONCLUSIONS: Our study highlighted that most of the men we interviewed were not having their health and social needs met. Services need to address the intersection of problem gambling, housing instability, and other comorbidities. Ensuring services are grounded in person-centred engagement appears to be critical for optimal service delivery.

Gamblers Anonymous as a Recovery Pathway: A Scoping Review.

Given the preponderance of Gamblers Anonymous (GA), there has been relatively little effort to explore the existing evidence base on its effectiveness as a recovery approach for problem gambling. To remedy this gap in the literature we conducted a scoping review of the literature on mutual aid for individuals experiencing problem gambling published between 2002 and 2015. We searched 13 databases and reviewed reference lists and websites of relevant organizations. We reviewed records for eligibility and extracted relevant data from eligible articles. Three reviewers independently assessed the methodological quality of the included studies using the Mixed Methods Appraisal Tool. We identified 17 studies in 25 publications that were eligible for inclusion. Most studies were conducted in the United States, were cross-sectional in design, and involved both male and female adult participants. Results indicate that the evidence for the effectiveness of GA either as a control condition or in conjunction with formal treatment or medication is inconsistent. An emphasis on patience, using the Serenity Prayer as a way to gain acceptance of financial matters and reality, and absolute assertion of identity as a "compulsive gambler" were identified as important aspects of GA's recovery culture. There is a need for large-scale randomized controlled trials to determine GA's effectiveness, as well as research exploring the mechanisms through which GA works, barriers to GA as a recovery approach, and the status of women in the fellowship.

Development of high amylose wheat through TILLING.

BACKGROUND: Wheat (Triticum spp.) is an important source of food worldwide and the focus of considerable efforts to identify new combinations of genetic diversity for crop improvement. In particular, wheat starch composition is a major target for changes that could benefit human health. Starches with increased levels of amylose are of interest because of the correlation between higher amylose content and elevated levels of resistant starch, which has been shown to have beneficial effects on health for combating obesity and diabetes. TILLING (Targeting Induced Local Lesions in Genomes) is a means to identify novel genetic variation without the need for direct selection of phenotypes. RESULTS: Using TILLING to identify novel genetic variation in each of the A and B genomes in tetraploid durum wheat and the A, B and D genomes in hexaploid bread wheat, we have identified mutations in the form of single nucleotide polymorphisms (SNPs) in starch branching enzyme IIa genes (SBEIIa). Combining these new alleles of SBEIIa through breeding resulted in the development of high amylose durum and bread wheat varieties containing 47-55% amylose and having elevated resistant starch levels compared to wild-type wheat. High amylose lines also had reduced expression of SBEIIa RNA, changes in starch granule morphology and altered starch granule protein profiles as evaluated by mass spectrometry. CONCLUSIONS: We report the use of TILLING to develop new traits in crops with complex genomes without the use of transgenic modifications. Combined mutations in SBEIIa in durum and bread wheat varieties resulted in lines with significantly increased amylose and resistant starch contents.

Improving Nitrogen Use Efficiency Through Overexpression of Alanine Aminotransferase in Rice, Wheat, and Barley.

Nitrogen is an essential nutrient for plants, but crop plants are inefficient in the acquisition and utilization of applied nitrogen. This often results in producers over applying nitrogen fertilizers, which can negatively impact the environment. The development of crop plants with more efficient nitrogen usage is, therefore, an important research goal in achieving greater agricultural sustainability. We utilized genetically modified rice lines over-expressing a barley alanine aminotransferase (HvAlaAT) to help characterize pathways which lead to more efficient use of nitrogen. Under the control of a stress-inducible promoter OsAnt1, OsAnt1:HvAlaAT lines have increased above-ground biomass with little change to both nitrate and ammonium uptake rates. Based on metabolic profiles, carbon metabolites, particularly those involved in glycolysis and the tricarboxylic acid (TCA) cycle, were significantly altered in roots of OsAnt1:HvAlaAT lines, suggesting higher metabolic turnover. Moreover, transcriptomic data revealed that genes involved in glycolysis and TCA cycle were upregulated. These observations suggest that higher activity of these two processes could result in higher energy production, driving higher nitrogen assimilation, consequently increasing biomass production. Other potential mechanisms contributing to a nitrogen-use efficient phenotype include involvements of phytohormonal responses and an alteration in secondary metabolism. We also conducted basic growth studies to evaluate the effect of the OsAnt1:HvAlaAT transgene in barley and wheat, which the transgenic crop plants increased seed production under controlled environmental conditions. This study provides comprehensive profiling of genetic and metabolic responses to the over-expression of AlaAT and unravels several components and pathways which contribute to its nitrogen-use efficient phenotype.

Changing spousal roles and their effect on recovery in gamblers anonymous: GamAnon, social support, wives and husbands.

This paper examines changing spousal roles and their effects upon recovery in Gamblers Anonymous (GA). It is based upon a qualitative study designed to gage uniformity as well as variations in approaches to recovery in GA. Interviews were conducted with 39 GA members (26 men, 13 women; mean age 56.5 years). Though the study was based in the Toronto area, only 13 interviews involved participants from that region. Phone interviews were conducted with GA members from various regions of both Canada and the US. GamAnon, GA's sister fellowship, has been designed for anyone affected seriously by someone's gambling problem. In practice, GamAnon comprises mostly women--spouses of male GA members--who traditionally have taken a keen interest in the ways in which their husbands achieve and maintain abstinence from gambling. Changing spousal roles have led to fewer women joining GamAnon, as many opt instead to part with troubled spouses. As well, more women are attending GA than in the past, typically with husbands who are disinclined to join GamAnon. All of this has drastically altered how GA members pursue recovery. These changes and their implications are discussed.

Problem gambling and intimate partner violence.

This study examined the prevalence and severity of intimate partner violence (IPV) among 248 problem gamblers (43 women, 205 men) recruited from newspaper advertisements. The main outcome measures used were the Canadian Problem Gambling Index, the Conflicts Tactics Scale-2, the State Trait Anger Expression Inventory-2, the drug and alcohol section of the Addiction Severity Index and the substance use section of the Structured Clinical Interview for the DSM-IV. In this sample, 62.9% of participants reported perpetrating and/or being the victims of IPV in the past year, with 25.4% reporting perpetrating severe IPV. The majority of the sample (64.5%) also had clinically significant anger problems, which was associated with an increased risk of being both the perpetrator and victim of IPV. The presence of a lifetime substance use disorder among participants who had clinically significant anger problems further increased the likelihood of both IPV perpetration and victimization. These findings underscore the importance of routinely screening gambling clients for anger and IPV, and the need to develop public policy, prevention and treatment programs to address IPV among problem gamblers. Future research to examine IPV among problem gamblers is recommended.

Randomized control trial of an integrated therapy for comorbid anger and gambling.

This study evaluated an integrated treatment for comorbid problem gambling, anger, and substance use. Problem gamblers with comorbid anger problems (N=42), half of whom also had substance use disorders, were randomized to either a 14-week integrated treatment targeting anger and addictions (i.e., both gambling and substance use) or a specialized treatment-as-usual (TAU) for gambling and substance use. Participants were assessed at baseline (Tl), 14 weeks (T2), and 12 weeks follow-up (T3). Relative to the TAU, participants in the integrated anger and addictions treatment reported significantly less gambling at T2 and T3 and less trait anger and substance use at T3. Findings suggest that it is important to screen gambling clients for the presence of comorbid anger and substance use problems and that, when present, these problems need to be addressed concurrently in gambling treatment in order to optimize treatment outcomes.

Minimal treatment approaches for concerned significant others of problem gamblers: a randomized controlled trial.

The goal of this study was to examine the efficacy of minimal treatment interventions for concerned significant others (CSOs) of problem gamblers. One hundred and eighty-six participants (82% females, 56% spouses) were randomly assigned to one of three groups: the first minimal intervention group received a self-help workbook [based on behavioral principles, modified from the Community Reinforcement and Family Therapy (CRAFT) model] and the second minimal intervention group received the workbook plus telephone support. The control condition received a treatment resource information package. Overall, all participants reported significant improvement in personal and relationship functioning and gambling behavior and consequences at the 3- and 6-month follow-up. The data demonstrated differences in favor of the interventions in three areas: days gambling, satisfaction with the program, and number who had their needs met. There was no difference in the number who had entered treatment. It may be that CSOs require more guidance and follow-up support to achieve these goals using the CRAFT procedures and strategies.

Using LC-MS Based Methods for Testing the Digestibility of a Nonpurified Transgenic Membrane Protein in Simulated Gastric Fluid.

The digestibility of a nonpurified transgenic membrane protein was determined in pepsin, as part of the food safety evaluation of its resistance to digestion and allergenic potential. Delta-6-desaturase from Saprolegnia diclina, a transmembrane protein expressed in safflower for the production of gamma linolenic acid in the seed, could not be obtained in a pure, native form as normally required for this assay. As a novel approach, the endoplasmic reticulum isolated from immature seeds was digested in simulated gastric fluid (SGF) and the degradation of delta-6-desaturase was selectively followed by SDS-PAGE and targeted LC-MS/MS quantification using stable isotope-labeled peptides as internal standards. The digestion of delta-6-desaturase by SGF was shown to be both rapid and complete. Less than 10% of the initial amount of D6D remained intact after 30 s, and no fragments large enough (>3 kDa) to elicit a type I allergenic response remained after 60 min.

Large-volume injection gas chromatography-mass spectrometry for automated broad-spectrum drug screening in horse urine.

A rapid, sensitive, and rugged method for detecting drugs and drug metabolites in extracts of horse urine is described. The use of large-volume injection (LVI) gas chromatography-mass spectrometry (GC-MS) for analysis of horse urine extracts allowed automation of the derivatization procedure and reduction of the sample volume from 5 mL to 1 mL of urine. An autosampler and temperature-programmable inlet were used to automatically dissolve the sample extract and form trimethylsilyl derivatives of over 200 analytes. The suitability of this procedure for routine GC-MS detection of approximately 80 basic analytes in extracts of racehorse urine was investigated. The formation of derivatives using LVI with in-liner derivatization was compared to a manual procedure involving the dissolution of sample extracts in N,O-bis(trimethylsily)trifluoroacetamide, heating the resulting mixture, and injecting 1 or 2 microL of the mixture through a splitless injector into the GC-MS instrument. In all cases, the in-liner derivatization reactions were found to be as complete as conventional heating block procedures. Ruggedness testing of the method demonstrated that peak resolution, shape, and area were maintained through 40 consecutive injections of sample extracts. No evidence of the accumulation of interfering substances was observed. The limits of detection using LVI GC-MS for routine screening of basic drugs in urine were generally in the range of 5-25 ng/mL. The method is currently being used to detect basic analytes in horse urine extracts with a throughput of approximately 50 urine sample extracts per instrument per day.

Continuing education to go: capacity building in psychotherapies for front-line mental health workers in underserviced communities.

OBJECTIVE: To address the gaps between need and access, and between treatment guidelines and their implementation for mental illness, through capacity building of front-line health workers. METHODS: Following a learning needs assessment, work-based continuing education courses in evidence-supported psychotherapies were developed for front-line workers in underserviced community settings. The 5-hour courses on the fundamentals of cognitive-behavioural therapy, interpersonal psychotherapy, motivational interviewing, and dialectical behaviour therapy each included videotaped captioned simulations, interactive lesson plans, and clinical practice behaviour reminders. Two courses, sequentially offered in 7 underserviced settings, were subjected to a mixed methods evaluation. Ninety-three nonmedical front-line workers enrolled in the program. Repeated measures analysis of variance was used to assess pre- and postintervention changes in knowledge and self-efficacy. Qualitative data from 5 semistructured focus groups with 25 participants were also analyzed. RESULTS: Significant pre- and postintervention changes in knowledge (P < 0.001) were found in course completers. Counselling self-efficacy improved in participants who took the first course offered (P = 0.001). Dropouts were much less frequent in peer-led, small-group learning than in a self-directed format. Qualitative analysis revealed improved confidence, morale, self-reported practice behaviour changes, and increased comfort in working with difficult clients. CONCLUSION: This work-based, multimodal, interactive, interprofessional curriculum for knowledge translation of psychotherapeutic techniques is feasible and helpful. A peer-led group format is preferred over self-directed learning. Its application can build capacity of front-line health workers in helping patients who suffer from common mental disorders.

Objectif : Aborder l'écart entre les besoins et l'accès, et entre les lignes directrices de traitement et leur mise en œuvre pour la maladie mentale, par la création de capacité des travailleurs de première ligne de la santé. Méthodes : À la suite d'une évaluation des besoins d'apprentissage, des cours de formation continue en milieu de travail sur les psychothérapies fondées sur des données probantes ont été mis au point à l'intention des travailleurs de première ligne dans des milieux communautaires sous-desservis. Les cours de 5 heures sur les fondements de la thérapie cognitivo-comportementale, la psychothérapie interpersonnelle, la technique d'entrevue motivationnelle, et la thérapie comportementale dialectique comportaient tous des simulations enregistrées sur vidéo, des plans de leçon interactifs, et des rappels de comportement en pratique clinique. Deux cours, offerts en ordre séquentiel dans 7 milieux sous-desservis, ont été soumis à une évaluation de méthodes mixtes. Quatre-vingt-treize travailleurs de première ligne non médicaux se sont inscrits au programme. Une analyse de variance des mesures répétées a servi à évaluer les changements des connaissances et de l'auto-efficacité avant et après l'intervention. Les données qualitatives de 5 groupes de discussion semi-structurés de 25 participants ont également été analysées. Résultats : Des changements significatifs des connaissances (P < 0,001) avant et après l'intervention ont été observés chez ceux qui ont terminé le cours. L'auto-efficacité en counseling s'est améliorée chez les participants qui ont suivi le premier cours offert (P = 0,001). Les décrocheurs étaient beaucoup moins fréquents dans les petits groupes d'apprentissage menés par les pairs que dans le format autodirigé. L'analyse qualitative a révélé une confiance améliorée, un meilleur moral, des changements du comportement dans la pratique auto-déclaré, et une plus grande assurance de travailler avec des clients difficiles. Conclusion : Ce programme d'études en milieu de travail, multimodal, interactif, interprofessionnel pour la transmission des connaissances en techniques psychothérapeutiques est faisable et utile. Le format du groupe mené par les pairs est préféré à l'apprentissage autodirigé. Son application peut renforcer la capacité des travailleurs de la santé de première ligne d'aider les patients qui souffrent de troubles mentaux communs.

Negotiating the Relationship Between Addiction, Ethics, and Brain Science.

Advances in neuroscience are changing how mental health issues such as addiction are understood and addressed as a brain disease. Although a brain disease model legitimizes addiction as a medical condition, it promotes neuro-essentialist thinking, categorical ideas of responsibility and free choice, and undermines the complexity involved in its emergence. We propose a 'biopsychosocial systems' model where psycho-social factors complement and interact with neurogenetics. A systems approach addresses the complexity of addiction and approaches free choice and moral responsibility within the biological, lived experience and socio-historical context of the individual. We examine heroin-assisted treatment as an applied case example within our framework. We conclude with a discussion of the model and its implications for drug policy, research, addiction health care systems and delivery, and treatment of substance use problems.

Chiral HPLC analysis of formoterol stereoisomers and thermodynamic study of their interconversion in aqueous pharmaceutical formulations.

A chiral HPLC method was validated and successfully applied for the determination of formoterol stereoisomers and their inversion products in an aqueous matrix stored at 5-70 degrees C up to 3 weeks. Analysis was performed on a Chiral-AGP column (100 x 4-mm, 5-microm) using a variable mixture of mobile phase A (50-mM sodium phosphate buffer, pH 7.0) and B (10% v/v IPA) at a flow rate of 1.3 ml min(-1), and UV detection at 242 nm. All four formoterol stereoisomers were adequately resolved with acceptable detection and quantitation limits varying from 0.01-0.04 microg/ml and 0.04-0.1 microg/ml, respectively. The method showed acceptable accuracy (> or = 88%), precision (RSD < or = 8.5%) and good linearity (r(2) > or = 0.9999) over the concentration range investigated. While interconversion at 5+/-3 degrees C and 25+/-2 degrees C/60% RH +/-5% RH was too low to be determined accurately within the study period, chiral inversion of formoterol stereoisomers measured at high temperatures followed the first order rate kinetics and occurred at a single chiral center, resulting in the reversible formation of diastereoisomers, (R,R)<-->(S,R) and (S,S)<-->(R,S). No enantiomerization or diastereomerization occurred. There was no significant difference in inversion of the active components in racemic (R,R/S,S)-formoterol fumarate and the single isomer (R,R)-arformoterol tartrate drug formulations, and both drugs are expected to maintain their stereochemical integrity throughout the proposed shelf-life at the recommended storage condition (5+/-3 degrees C).

Chromatographic and Spectral Analysis of Two Main Extractable Compounds Present in Aqueous Extracts of Laminated Aluminum Foil Used for Protecting LDPE-Filled Drug Vials.

Laminated aluminum foils are increasingly being used to protect drug products packaged in semipermeable containers (e.g., low-density polyethylene (LDPE)) from degradation and/or evaporation. The direct contact of such materials with primary packaging containers may potentially lead to adulteration of the drug product by extractable or leachable compounds present in the closure system. In this paper, we described a simple and reliable HPLC method for analysis of an aqueous extract of laminated aluminum foil overwrap used for packaging LDPE vials filled with aqueous pharmaceutical formulations. By means of combined HPLC-UV, GC/MS, LC/MS/MS, and NMR spectroscopy, the two major compounds detected in the aqueous extracts of the representative commercial overwraps were identified as cyclic oligomers with molecular weights of 452 and 472 and are possibly formed from poly-condensation of the adhesive components, namely, isophthalic acid, adipic acid, and diethylene glycol. Lower molecular weight compounds that might be associated with the "building blocks" of these compounds were not detected in the aqueous extracts.

"Attitude is a little thing that makes a big difference": reflection techniques for addiction psychiatry training.

OBJECTIVE: The authors aim to incorporate educational reflection techniques in an addiction psychiatry postgraduate core rotation in order to increase critical self-awareness of attitudes, values, and beliefs related to working with people with substance use and other addictive disorders. METHODS: Reflection discussion times, reflection journaling, and mandatory end-of-rotation reflection papers were embedded into a core addiction psychiatry postgraduate training block. Qualitative analysis of 28 reflection papers was performed to determine key factors and constructs that impacted on the development of attitudes and professionalism. RESULTS: A number of constructs emerged that demonstrated the attitudes, beliefs, stereotypes, and stigmas students have regarding addictive disorders. Some constructs also highlighted that students felt much more comfortable dealing with addictive disorders after the training and would treat individuals with these conditions in a more effective manner. CONCLUSION: Reflection techniques were endorsed as extremely valuable by students, especially in the development of professional attitudes that will help clinicians effectively engage and provide appropriate care for individuals suffering from addictive disorders. The authors suggest that reflective practices be used more extensively in psychiatric training in order to build and establish reflexive self-awareness as a core professional competence essential to work effectively in clinical practice, especially in the most demanding contexts.

Patterns of substance use in treatment-seeking problem gamblers: impact on treatment outcomes.

Accumulating evidence suggests that treatment-seeking problem gamblers have high rates of substance abuse. However, relatively little is known about the relation between gambling problems and specific psychoactive substances apart from alcohol and methadone-treated opiate addicts. In this study of 169 individuals seeking outpatient treatment for problem gambling, lifetime drug use and medication use were very high. Approximately half of the sample were using a psychiatric medication at the time they sought gambling treatment while very few individuals were using other drugs. Gambling treatment outcomes were unrelated to history of drug or medication use. No evidence was found for substitution of psychoactive substance use for gambling during the follow-up year. These findings indicate that gamblers are more likely to be involved with drug and medication use compared to the general population, but that such histories are not associated with gambling treatment outcomes.

The Centre for Addiction and Mental Health Concurrent Disorders Screener.

OBJECTIVES: To review the characteristics of psychiatric screening tools currently available in addiction treatment services for rapid assessment of comorbid pathology and to introduce the Centre for Addictions and Mental Health Concurrent Disorders Screener (CAMH-CDS), a computer-administered questionnaire that screens for the occurrence of 11 Axis I disorders plus all substance use disorders, as well as for a history of conduct disorder. METHODS: We describe the structure, contents, and application of the CAMH-CDS. We undertook a sensitivity and specificity trial involving 171 subjects, a test-retest reliability study with 301 participants, and an open-label concordance study with 656 respondents. All subjects were regular clients of a major addiction treatment facility. RESULTS: The CAMH-CDS was easily and effectively used by addiction counsellors with limited or no mental health training. It has a low rate of false-negative responses, and it yields excellent test-retest reliability figures. It is highly sensitive to identifying persons with psychiatric disturbances; however, its ability to discriminate among specific disorders appears to be more limited. CONCLUSIONS: The CAMH-CDS can be reliably used to rule out the presence of psychiatric comorbidity in addiction service populations. As with other psychiatric screening instruments, its sensitivity values are stronger than its specificity values. The use of nonstructured clinical evaluations as the gold standard for diagnosis and a likely variance in the patients' symptom reports between the 2 examinations may have contributed to the latter finding.