A systematic review of the determinants of seafood consumption.

Although seafood is considered to be an important part of a balanced diet, many national food consumption surveys suggest that seafood is not consumed in sufficient amounts. As consumers are moving to diversify their diet from animal-based protein, it is important to understand the factors influencing consumption of marine foods. This review aims to assess the characteristics of seafood consumers as well as the influences on seafood consumption in Europe, USA, Canada, Australia and New Zealand. Systematic search strategies were used to identify relevant journal articles from three electronic databases (PubMed, Web of Science and Embase). Three searches were carried out and identified 4405 unique publications from which 121 met the criteria for the review process. The reviewed studies revealed that seafood consumers were more likely to be older, more affluent and more physically active and were less likely to smoke compared with non-seafood consumers. Sex and BMI did not appear to have a directional association with seafood consumption. The most commonly reported barriers to seafood consumption were cost, followed by sensory or physical barriers, health and nutritional beliefs, habits, availability and cooking skills. The most commonly reported influences were beliefs about the contribution of seafood to health, environmental influences and personal preferences. Based on the findings of this review, future intervention strategies to increase seafood consumption may need to consider affordability and education in terms of health, nutrition and cooking skills. More research is needed to explore the effectiveness of specific interventions at increasing the consumption of seafood.

Cronobacter species (formerly known as Enterobacter sakazakii) in powdered infant formula: a review of our current understanding of the biology of this bacterium.

Cronobacter species (formerly known as Enterobacter sakazakii) are opportunistic pathogens that can cause necrotizing enterocolitis, bacteraemia and meningitis, predominantly in neonates. Infection in these vulnerable infants has been linked to the consumption of contaminated powdered infant formula (PIF). Considerable research has been undertaken on this organism in the past number of years which has enhanced our understanding of this neonatal pathogen leading to improvements in its control within the PIF production environment. The taxonomy of the organism resulted in the recognition of a new genus, Cronobacter, which consists of seven species. This paper presents an up-to-date review of our current knowledge of Cronobacter species. Taxonomy, genome sequencing, current detection protocols and epidemiology are all discussed. In addition, consideration is given to the control of this organism in the manufacturing environment, as a first step towards reducing the occurrence of this pathogen in PIF.

Central retinal artery occlusion treated with oxygen: a literature review and treatment algorithm.

Central retinal artery occlusion (CRAO) is an uncommon eye disorder, but one that typically produces severe and irreversible vision loss in the affected eye. The retina has a dual blood supply, with the retinal circulation supplying the inner layers and the choroidal circulation supplying the outer layers. In CRAO, vision loss results from cell death in the inner retinal layers despite relative sparing of the outer layers. If supplemental oxygen is provided, however, oxygen from the choroidal circulation may diffuse in adequate quantity to the inner layers of the retina to maintain retinal function and restore vision. In some patients this can be achieved with normobaric hyperoxia; in others, hyperbaric oxygen (HBO2) may be required. The challenge is to provide the supplemental oxygen early enough after the onset of vision loss to prevent irreversible damage to the retina. In experimental models of complete CRAO, the ischemic time window before permanent retinal damage occurs is just over 90 minutes; in the clinical setting where occlusion may be incomplete, return of vision may be achieved even after delays of eight to 24 hours. In patients with a clinical picture of CRAO who present within 24 hours of vision loss, supplemental oxygen should be started immediately at the highest possible fraction of inspired oxygen (FiO2). If vision is not quickly restored, emergent HBO2 should be undertaken if feasible. If the patient responds to HBO2, follow-up treatment with supplemental oxygen should be customized to maintain retinal viability until the obstructed retinal artery recanalizes, which typically occurs within the first 72 hours. This paper reviews the pertinent literature on CRAO and HBO2 and provides a treatment algorithm.

Quality and sensory acceptability of a chilled functional apple ready-dessert.

An apple and dairy based ready-dessert with an added prebiotic was stored and chill temperatures and number of quality attributes were monitored during chill (4 °C) storage for 30 days. All ready-desserts were thermally processed by sous vide (P (90) > 10 min). The stability of the dairy component in ready-desserts was monitored by measuring volatile free fatty acids. Changes in these components were more evident in prebiotic-enriched samples compared to controls. However, no significant differences were observed over storage in control and prebiotic-enriched ready-desserts. This was supported by sensory analysis that showed no significant changes over storage in control or prebiotic-enriched samples. Of the other quality parameters, the addition of prebiotic inclusions resulted in lower L and b values and dry matter (p < 0.05), while increasing (p < 0.05) soluble solids content compared to control samples. Fluctuations in some of the quality parameters were also observed over storage. Rheological characteristics, i.e. flow behaviour (n), consistency index (K), storage (G'), loss (G″) and complex (G*) moduli were unaffected by prebiotic inclusion. However, storage affected the rheological characteristics of ready-desserts. A decrease (p < 0.05) in flow behaviour (n) led to concomitant increases in consistency index (K) and complex modulus (G*) values in control samples.

Quality and antioxidant properties of fresh-cut apple wedges from 10 cultivars during modified atmosphere packaging storage.

Antioxidant activity and quality parameters of skin-on apple wedges from 10 cultivars were examined during chill storage and over two growing seasons. Storage of fresh-cut apple wedges had a significant impact on quality parameter indices such as browning index (p < 0.001) and texture firmness (p < 0.001). Headspace gas analysis indicated that the degree of browning negatively correlated to oxygen (-0.69) and positively (0.70) correlated to carbon dioxide levels. Antioxidant capacity as assessed by three in vitro methods (DPPH, FRAP and ORAC) decreased significantly for 9 of the 10 cultivars after 5 days of storage at 3 ± 1 °C (p < 0.001). These indices increased in case of Shampion apples over the same storage period for all three assays. With regard to antioxidant capacity and quality parameters, the cultivars Gloster, Alwa, Idared and Jonica were the best performing overall and could therefore be recommended as a core ingredient in fresh-cut fruit products.

Comparison of growth limits of Listeria monocytogenes in milk, broth and cheese.

AIM: To determine growth initiation differences of Listeria monocytogenes between a cheesemaking context, milk and tryptic soy broth (TSB). METHODS AND RESULTS: A laboratory-scale cheese was made with a mix of two strains of L. monocytogenes at four initial pH values, five water activity (a(w)) values and two contamination levels at 30°C. Counts of L. monocytogenes were determined at time 0 and after 8h of cheese manufacture. Milk and TSB at the same pH and a(w) conditions were inoculated with the L. monocytogenes mix in multi-well plates. Growth was determined by plating each well onto Agosti & Ottaviani Listeria Agar after 8h of incubation at 30°C. Each condition was repeated six times, and growth initiation probability was modelled with logistic regression models. Growth initiation boundaries were obtained for each matrix type. The results showed that the growth limits were matrix dependent. In the three matrix types, a(w) was the most important factor affecting the probability of growth initiation. Contamination level affected growth TSB and cheesemaking conditions. CONCLUSIONS: The interface wideness and position in cheese, milk and TSB were dissimilar, indicating that the use of models evaluated in TSB or milk could not be used to predict the behaviour of L. monocytogenes under cheesemaking conditions. SIGNIFICANCE AND IMPACT OF THE STUDY: Predictive models generated in liquid media are not necessarily adaptable to solid food, and the generation of real food models is necessary.

Recommended medical and non-medical factors to assess military preventable deaths: subject matter experts provide valuable insights.

INTRODUCTION: Historically, there has been variability in the methods for determining preventable death within the US Department of Defense. Differences in methodologies partially explain variable preventable death rates ranging from 3% to 51%. The lack of standard review process likely misses opportunities for improvement in combat casualty care. This project identified recommended medical and non-medical factors necessary to (1) establish a comprehensive preventable death review process and (2) identify opportunities for improvement throughout the entire continuum of care. METHODS: This qualitative study used a modified rapid assessment process that includes the following steps: (1) identification and recruitment of US government subject matter experts (SMEs); (2) multiple cycles of data collection via key informant interviews and focus groups; (3) consolidation of information collected in these interviews; and (4) iterative analysis of data collected from interviews into common themes. Common themes identified from SME feedback were grouped into the following subject areas: (1) prehospital, (2) in-hospital and (3) forensic pathology. RESULTS: Medical recommendations for military preventable death reviews included the development, training, documentation, collection, analysis and reporting of the implementation of the Tactical Combat Casualty Care Guidelines, Joint Trauma System Clinical Practice Guidelines and National Association of Medical Examiners autopsy standards. Non-medical recommendations included training, improved documentation, data collection and analysis of non-medical factors needed to understand how these factors impact optimal medical care. CONCLUSIONS: In the operational environment, medical care must be considered in the context of non-medical factors. For a comprehensive preventable death review process to be sustainable in the military health system, the process must be based on an appropriate conceptual framework implemented consistently across all military services.

Prevalence and numbers of Salmonella spp. and Enterobacteriaceae on pork cuts in abattoirs in the Republic of Ireland.

AIMS: This study aimed to determine the numbers and types of Salmonella spp. and Enterobacteriaceae on pork cuts in the meat cutting room environment of four commercial pork abattoirs in the Republic of Ireland. METHODS AND RESULTS: Pork oysters (M. gluteus medius; n = 720) and swabs (n = 56) from equipment and surfaces were screened for Salmonella spp. using a DNA-based PCR method and confirmed by culture. Salmonella numbers were assessed using a three-tube most probable number (MPN) technique. Salmonella spp. was detected on 24/720 (3.3%) pork cuts (range of <0.03-0.36 MPN g(-1)) and in 7/56 (12.5%) environmental swabs (range of <0.03-1.10 MPN cm(-2)). There was significant variation in the prevalence of Salmonella on pork between different abattoirs and days of sampling (range of 0-31.7%). The predominant serotype was Salmonella serotype Typhimurium followed by Salmonella serotype Derby. CONCLUSIONS: Overall prevalence data conceal the key finding that there was considerable variation in the incidence of Salmonella on different days. A direct association between Salmonella contamination of pork cuts and equipment/surfaces was observed. SIGNIFICANCE AND IMPACT OF THE STUDY: Prevalence and numbers of Salmonella were low; however, results clearly demonstrate the potential for cross-contamination from equipment and meat contact surfaces in the cutting room environment.

A meta-analysis study of the effect of chilling on prevalence of Salmonella on pig carcasses.

In the field of food safety, meta-analysis can be used to combine results of prevalence studies of pathogens at critical stages within the food processing chain so that policy makers can access reliable and concise information on the effectiveness of interventions for controlling and preventing foodborne illnesses in humans. The objective of this work was to demonstrate the applicability of a parametric approach of meta-analysis to the specific case of determining the overall effect of chilling on Salmonella prevalence on pig carcasses. A meta-analysis was performed on each of two parameters measuring effect size for binary outcomes (relative risk and risk difference). Both meta-analyses confirmed that the chilling operation has a significant beneficial effect (P < 0.001) on the reduction of Salmonella prevalence on pig carcasses. Because risk difference is a parameter sensitive to the differences across studies in carcass swab areas and Salmonella detection methods, its meta-analysis highly reflected this heterogeneity (P < 0.001). However, parameterization of relative risk, not being biased by the above sources of variability, did not give rise to heterogeneity among studies and produced a fixed-effects meta-analysis solution, which is deemed more suitable for compilations based on a small number of individual studies (n = 9). Because of the systematic approach of meta-analysis (i.e., individual studies are weighed according to precision) and its reliance for actual data, the output distribution of the relative risk effect size (approximately eN(-0.868,0.166)) merits consideration for inclusion in the chilling stage of quantitative risk assessments modeling the prevalence of this pathogen along the pork production chain.

Development and validation of a probabilistic second-order exposure assessment model for Escherichia coli O157:H7 contamination of beef trimmings from Irish meat plants.

A second-order quantitative Monte Carlo simulation model was developed for Escherichia coli O157:H7 contamination of beef trimmings in Irish abattoirs. The assessment considers initial contamination levels, cross-contamination and decontamination events during the cattle slaughter process. The mean simulated prevalence of E. coli O157:H7 on trimmings was 2.36% and the mean simulated counts of E. coli O157:H7 on contaminated trimmings was -2.69log(10)CFU/g. A parallel validation survey provided some confidence in the model predictions. An uncertainty analysis indicated that microbial test sensitivity is a significant factor contributing to model uncertainty and requires further investigation while also indicating that risk reduction measures should be directed towards reducing the hide to carcass transfer (correlation coefficient 0.25) during dehiding and reducing the initial prevalence and counts on bovine hides (correlation coefficients 0.19 and 0.16, respectively). A characterisation of uncertainty and variability indicating that further research is required to reduce parameter uncertainty and to achieve better understanding of microbial transfer in meat plants. The model developed in this study highlights the need for further development of quantitative risk assessments in the food industry.

Hyperbaric oxygen therapy and the eye.

Hyperbaric oxygen therapy (HBOT) is a primary or adjunctive therapy for a variety of medical disorders including some involving the eye. This paper is the first comprehensive review of HBOT for ocular indications. The authors recommend the following as ocular indications for HBOT: decompression sickness or arterial gas embolism with visual signs or symptoms, central retinal artery occlusion, ocular and periocular gas gangrene, cerebro-rhino-orbital mucormycosis, periocular necrotizing fasciitis, carbon monoxide poisoning with visual sequelae, radiation optic neuropathy, radiation or mitomycin C-induced scleral necrosis, and periorbital reconstructive surgery. Other ocular disorders that may benefit from HBOT include selected cases of ischemic optic neuropathy, ischemic central retinal vein occlusion, branch retinal artery occlusion with central vision loss, ischemic branch retinal vein occlusion, cystoid macular edema associated with retinal venous occlusion, post-surgical inflammation, or intrinsic inflammatory disorders, periocular brown recluse spider envenomation, ocular quinine toxicity, Purtscher's retinopathy, radiation retinopathy, anterior segment ischemia, retinal detachment in sickle cell disease, refractory actinomycotiC lacrimal canaliculitis, pyoderma gangrenosum of the orbit and refractory pseudomonas keratitis. Visual function should be monitored as clinically indicated before, during, and after therapy when HBOT is undertaken to treat vision loss. Visual acuity alone is not an adequate measure of visual function to monitor the efficacy of HBOT in this setting. Ocular examinations should also include automated perimetry to evaluate the central 30 degrees of visual field at appropriate intervals. Interpretation of the literature on the efficacy of HBOT in treating ocular disorders is complicated by several factors: frequent failure to include visual field examination as an outcome measure, failure to adequately address the interval from symptom onset to initiation of HBOT, and lack of evidence for optimal treatment regimens for essentially all ocular indications. Because some ocular disorders require rapid administration of HBOT to restore vision, patients with acute vision loss should be considered emergent when they present. Visual acuity should be checked immediately, including vision with pinhole correction. If the patient meets the criteria for emergent HBOT outlined in the paper, normobaric oxygen should be started at the highest inspired oxygen fraction possible until arrangements can be made for HBOT.

Use of next-generation sequencing in microbial risk assessment.

Despite the ever increase in rigorous control and monitoring measures to assure safe food along the entire farm-to-fork chain, the past decade has also witnessed an increase in microbial food alerts. Hence, research on food safety and quality remain of utmost importance. Complementary, and at least as important, is the necessity to be able to assess the potential microbial risks along the food chain. Risk assessment relies on sound scientific data. Unfortunately, often, quality data are limited if not lacking. High-throughput tools such as next-generation sequencing (NGS) could fill this gap. NGS approaches can be used to generate ample qualitative and quantitative data to be used in the risk assessment process. NGS applications are not new in food microbiology with applications ranging from pathogen detection along the food chain, food epidemiology studies, whole genome analysis of food-associated microorganisms up to describing complete food microbiomes. Yet, its application in the area of microbial risk assessment is still at an early stage and faces important challenges. The possibilities of NGS for risk assessment are ample, but so are the questions on the subject. One of the major strengths of NGS lies in its capacity to generate a lot of data, but to what extend can this wealth be of use in hazard identification, hazard characterisation and exposure assessment to perform a sound risk characterisation, which in turn will make it possible to take substantiated risk management decisions.

A Genetic Method To Evaluate the Prevalence of Unique DNA Profiles between Sequential Ground Beef Batches.

The delineation of ground beef batches has implications for the management of product disposition policies in the event of Shiga toxin-producing Escherichia coli contamination. Analysis of individual contributor animal-specific DNA profiles can provide valuable empirical data for understanding the dynamics of ground meat production processes and can act as a surrogate for cross-contamination. A genetic method was developed for characterizing the source raw material flow and carryover between discrete batches of ground beef in a large-scale commercial beef grinding operation. The application developed involves the introduction of a genetically distinct source raw material batch into the grinding system and comprehensive sampling of that index batch and subsequent batches followed by single nucleotide polymorphism genotyping of random subsamples. Capture-mark-recapture statistical techniques were used to estimate (i) the number of carcass contributors and (ii) the associated level of carryover between batches. Carryover, expressed as a percentage of the total weight of the batch material (in pounds), was observed between the genetically distinct index batch and the next sequential batch at approximately 1%. The nondetection of additional carryover to subsequent batches, with a detection level of approximately 0.2%, supports a serial dilution model of same source raw material carryover, consistent with the recorded weight of beef trimmings used in each batch. For ground beef manufacturers, this method is a simple approach for validating the independence of finished batches of beef in their grind systems in support of product disposition policies.

Magnesium ion effects on microtubule nucleation in vitro.

Much interest has currently been attached to the length distribution of microtubules polymerized in vitro and the related question of their possible 'dynamic instability'. Fundamental to this question is the mechanism of microtubule nucleation, which controls the rates of assembly and disassembly of microtubule protein in vitro. These kinetics are affected by a number of factors, including both the guanine nucleotides, GTP and GDP, and magnesium ion. Mg2+ exerts complex effects, as indicated by the existence of an optimal Mg2+ concentration for the maximum assembly rate of microtubule protein, and we investigate these effects in this report. At [Mg2+] greater than 0.5 mM, the characteristic lag-phase is substantially increased and the rate of assembly is greatly reduced without affecting the critical concentration significantly. We show that increasing [Mg2+] has two effects on the assembly process: nucleation is less efficient and the intrinsic rate constant for the elongation reaction is reduced. Lowering [Mg2+] (less than 0.5 mM) also inhibits nucleation. These effects of varying [Mg2+] can be explained predominantly in terms of enhanced stability of the microtubule-associated protein-containing oligomeric species present in the microtubule protein preparation. [Mg2+] is thus found to be a further important factor in microtubule nucleation, and hence, in determining length distributions in assembling microtubules.

Relating physicochemical and microbiological safety indicators during processing of linguiça, a Portuguese traditional dry-fermented sausage.

Linguiça is a Portuguese traditional fermented sausage whose microbiological quality and safety can be highly variable. In order to elucidate risk factors and the particularities of the manufacturing technology that explain the between-batch variability in total viable counts (TVC), Enterobacteriaceae, Staphylococcus aureus and Listeria monocytogenes in the product; microbiological and physicochemical characterisation of linguiça at five stages of production (i.e., raw pork meat, mixed with ingredients, macerated, smoked and ripened) was carried out. A total of six production batches were surveyed from two factories; one utilised curing salts and polyphosphate in their formulation (Factory II). The delayed fermentation in the nitrite-formulated sausages was partly responsible for the increase (p<0.01) in Enterobacteriaceae, S. aureus and L. monocytogenes from raw meat (3.21logCFU/g, 1.30logCFU/g and 22.2CFU/g, respectively) to the end of maceration (4.14logCFU/g, 2.10logCFU/g and 140CFU/g, respectively) while the better acidification process in the nitrite-free sausages (Factory I) led to lower counts of S. aureus (2.64logCFU/g) and L. monocytogenes (10CFU/g) in the finished products. In Factory II, although L. monocytogenes entered the chain at the point of mixing, it became steadily inactivated during smoking and ripening (<50CFU/g), despite the initially-delayed fermentation. Nitrite had a strong effect on reducing Enterobacteriaceae throughout smoking (r=-0.73) and ripening (r=-0.59), while it failed to control the growth of S. aureus. The main hurdle preventing the development of S. aureus in linguiça is the pH, and other factors contributing to its control are: longer ripening days (p=0.019), low S. aureus in raw meat (p=0.098), properly-washed casings (p=0.094), and less contamination during mixing (p=0.199). In the case of L. monocytogenes, at least three hurdles hinder its development in linguiça: low aw (p=0.004), low pH (p=0.040) and nitrite (p=0.060), and other factors contributing to its control are: longer ripening (p=0.072) and maceration (p=0.106) periods, lower aw at the end of smoking (p=0.076) and properly-washed casings (p=0.099). Results have shown that there is a need to standardise the productive process of linguiça, to optimise the initial acidification process, and to reinforce proper programmes of quality control of ingredients and good hygiene practices, so as to minimise the introduction of Enterobacteriaceae and pathogens from external sources.

Disposition of a murine monoclonal antibody vinca conjugate (KS1/4-DAVLB) in patients with adenocarcinomas.

The pharmacokinetics of a murine monoclonal antibody vinca conjugate (KS1/4-DAVLB) was investigated in 13 patients with adenocarcinomas who received single intravenous doses ranging from 40 to 250 mg/m2 and in three patients who were administered 1.5 mg/kg every 48 to 72 hours for up to 15 doses. Five patients in the single-dose study also received 100 microCi of [3H]-KS1/4-DAVLB. Overall mean values for the pharmacokinetic variables were as follows: elimination half-life, 31.5 hours; distribution volume, 4.43 L; and clearance, 0.09 L/hr. KS1/4-DAVLB demonstrated linear elimination kinetics in both the single- and multiple-dose studies. Significant concentrations of KS1/4-DAVLB were noted in a pleural effusion. Ten percent of the radioactive dose was recovered in the urine and 20% in the feces over a 5-day period. Small molecular weight vinca species were detected in the feces but not in the serum.

The application of positron emission tomography to the study of panic disorder.

Positron emission tomography was used to study eight patients with panic disorder who were vulnerable to lactate-induced panic, eight patients with panic disorder who were not vulnerable to lactate-induced panic, and 25 normal control subjects. Patients who were vulnerable to lactate-induced panic had several abnormalities in the resting, nonpanic state: an abnormal hemispheric asymmetry of parahippocampal blood flow, blood volume, and oxygen metabolism; abnormally high whole brain metabolism; and abnormal susceptibility to episodic hyperventilation. A hypothetical model for the neurobiology of panic disorder, involving the abnormal parahippocampal region and its afferent and efferent connections, is proposed.

Control of nucleation in microtubule self-assembly.

The inhibition of the rate and amplitude of assembly of microtubule protein at low GTP concentration is shown by measurement of microtubule length distributions to be due to the suppression of microtubule nucleation. This inhibitory effect is enhanced by GDP added before assembly, but can be overcome by a number of molecules such as pyrophosphate or ADP. The selective inhibition of nucleation by GDP in vitro, which occurs in addition to inhibition of elongation, could provide a mechanism for the control of spontaneous microtubule nucleation in vivo.

Spontaneous expression of fra(10)(q25) in bone marrow from a patient with agranulocytosis.

We report on the spontaneous expression of fra(10)(q25) in bone marrow from a patient with agranulocytosis. Expression of this fragile site in both bone marrow and leukocytes was enhanced by bromodeoxyuridine (BrdU), while folic-acid-deficient medium enhanced the expression of fra(10)(q25) only in leukocytes. Variability in the expression of fra(10)(q25) in bone marrow and leukocyte cultures over an 18-month period was also found.

Treadmill walking in old age may not reproduce the real life situation.

OBJECTIVE: In a preliminary study in our laboratory, healthy elderly people had a higher heart rate during treadmill walking than during corridor walking at the same speed. The objective of this study was to determine whether this initial observation, (1) persisted after repeated testing, (2) was present in younger adults, (3) was due to wearing a mouthpiece during treadmill walking, or (4) was due to a change in gait. DESIGN: A study of elderly and young volunteers undergoing repeated testing, with comparison of treadmill walking with corridor walking. SETTING: The Royal Free Hospital School of Medicine. PARTICIPANTS: Twelve healthy elderly (71-80 years) and 12 healthy young (21-37 years) volunteers. MAIN OUTCOME MEASURES: Heart rate (beats/min) and step rate (steps/min) during comfortable self-paced corridor walking and during treadmill walking at the same speed. MAIN RESULTS: The elderly subjects had higher heart rates during treadmill walking than during corridor walking at the same speed (mean difference = 6 beats/min, 95% Confidence Interval (CI) = 1 to 10). This difference increased (to a mean of 11 beats/min, 95% CI = 5 to 16) when a mouthpiece was worn on the treadmill. These differences persisted after repeated testing. The young subjects did not have higher heart rates on the treadmill, (with or without the mouthpiece). In both groups, step rate was lower (95% CI = -9 to -2, elderly; -5 to -2, young) during treadmill walking, corresponding to a 3% increase in stride length. CONCLUSION: The heart rate response to treadmill walking in healthy elderly people may be less representative of the "real life" situation than in younger adults.