Diagnostic findings in sinonasal aspergillosis in dogs in the United Kingdom: 475 cases (2011-2021).

OBJECTIVES: To describe the diagnostic tests used and their comparative performance in dogs diagnosed with sinonasal aspergillosis in the United Kingdom. A secondary objective was to describe the signalment, clinical findings and common clinicopathologic abnormalities in sinonasal aspergillosis. MATERIALS AND METHODS: A multi-centre retrospective survey was performed involving 23 referral centres in the United Kingdom to identify dogs diagnosed with sinonasal aspergillosis from January 2011 to December 2021. Dogs were included if fungal plaques were seen during rhinoscopy or if ancillary testing (via histopathology, culture, cytology, serology or PCR) was positive and other differential diagnoses were excluded. RESULTS: A total of 662 cases were entered into the database across the 23 referral centres. Four hundred and seventy-five cases met the study inclusion criteria. Of these, 419 dogs had fungal plaques and compatible clinical signs. Fungal plaques were not seen in 56 dogs with turbinate destruction that had compatible clinical signs and a positive ancillary test result. Ancillary diagnostics were performed in 312 of 419 (74%) dogs with observed fungal plaques permitting calculation of sensitivity of cytology as 67%, fungal culture 59%, histopathology 47% and PCR 71%. CLINICAL SIGNIFICANCE: The sensitivities of ancillary diagnostics in this study were lower than previously reported challenging the clinical utility of such tests in sinonasal aspergillosis. Treatment and management decisions should be based on a combination of diagnostics including imaging findings, visual inspection, and ancillary testing, rather than ancillary tests alone.

Ethanol inhibits dopamine uptake via organic cation transporter 3: Implications for ethanol and cocaine co-abuse.

Concurrent cocaine and alcohol use is among the most frequent drug combination, and among the most dangerous in terms of deleterious outcomes. Cocaine increases extracellular monoamines by blocking dopamine (DA), norepinephrine (NE) and serotonin (5-HT) transporters (DAT, NET and SERT, respectively). Likewise, ethanol also increases extracellular monoamines, however evidence suggests that ethanol does so independently of DAT, NET and SERT. Organic cation transporter 3 (OCT3) is an emergent key player in the regulation of monoamine signaling. Using a battery of in vitro, in vivo electrochemical, and behavioral approaches, as well as wild-type and constitutive OCT3 knockout mice, we show that ethanol's actions to inhibit monoamine uptake are dependent on OCT3. These findings provide a novel mechanistic basis whereby ethanol enhances the neurochemical and behavioral effects of cocaine and encourage further research into OCT3 as a target for therapeutic intervention in the treatment of ethanol and ethanol/cocaine use disorders.

Primary school mobile dental program in New South Wales, Australia: protocol for the evaluation of a state government oral health initiative.

BACKGROUND: Socioeconomically disadvantaged children are disproportionately affected by oral disease. Mobile dental services help underserved communities overcome barriers to accessing health care, including time, geography, and trust. The NSW Health Primary School Mobile Dental Program (PSMDP) is designed to provide diagnostic and preventive dental services to children at their schools. The PSMDP is mainly targeted toward high-risk children and priority populations. This study aims to evaluate the program's performance across five local health districts (LHDs) where the program is being implemented. METHODS: The evaluation will use routinely collected administrative data, along with other program-specific data sources, from the district public oral health services to conduct a statistical analysis that determines the reach and uptake of the program, its effectiveness, and the associated costs and cost-consequences. The PSMDP evaluation program utilises data from Electronic Dental Records (EDRs) and other data sources, including patient demographics, service mix, general health, oral health clinical data and risk factor information. The overall design includes cross-sectional and longitudinal components. The design combines comprehensive output monitoring across the five participating LHDs and investigates the associations between socio-demographic factors, service patterns and health outcomes. Time series analysis using difference-in-difference estimation will be conducted across the four years of the program, involving services, risk factors, and health outcomes. Comparison groups will be identified via propensity matching across the five participating LHDs. An economic analysis will estimate the costs and cost-consequences for children who participate in the program versus the comparison group. DISCUSSION: The use of EDRs for oral health services evaluation research is a relatively new approach, and the evaluation works within the limitations and strengths of utilising administrative datasets. The study will also provide avenues to improve the quality of data collected and system-level improvements to better enable future services to be aligned with disease prevalence and population needs.

Presenting signs and clinical outcome in dogs with metaphyseal osteopathy: 39 cases (2009-2018).

OBJECTIVE: To describe the presenting signs, concurrent conditions, treatment and outcome of dogs with metaphyseal osteopathy. MATERIALS AND METHODS: Multi-centre retrospective review of medical records from January 2009 to September 2018 at four referral centres to identify dogs with a radiographic diagnosis of metaphyseal osteopathy. RESULTS: Thirty-nine dogs were identified. The median age at onset was 14 weeks old (range, 8 to 32 weeks old). There was a higher proportion of male dogs (29 of 39 male entire, nine of 39 female entire, one of 39 female neutered and no male neutered dogs). Where information was available, median time from the most recent vaccination was 20 days (range, 2 to 144 days). The most commonly recorded clinical signs were pyrexia (34 of 39), lethargy (32 of 39), pain (30 of 39), and being non-ambulatory (17 of 39). Thirty-five dogs required hospitalisation for analgesia and supportive care, 19 of 39 were discharged on prednisolone (median dose 2.0 mg/kg/day; range, 0.9 to 2.6 mg/kg/day), 18 of 39 were discharged on non-steroidal anti-inflammatories, two of 39 did not receive NSAIDs or prednisolone at any time point. The median duration of hospitalisation for those admitted was 5 days (range, 1 to 21 days). Where follow-up was available, relapse occurred in eight of 25 cases before reaching skeletal maturity. At the time of metaphyseal osteopathy diagnosis, five of 39 cases had concurrent conditions. Where follow-up was available, four of 25 developed future immune-mediated conditions. CLINICAL SIGNIFICANCE: Metaphyseal osteopathy should be considered in non-ambulatory painful young dogs. Some dogs developed future immune-mediated conditions, which may support the hypothesis that metaphyseal osteopathy is an autoinflammatory bone disorder. Further studies with a larger cohort are required to determine the clinical significance of this.

A seafood risk tool for assessing and mitigating chemical and pathogen hazards in the aquaculture supply chain.

Intricate links between aquatic animals and their environment expose them to chemical and pathogenic hazards, which can disrupt seafood supply. Here we outline a risk schema for assessing potential impacts of chemical and microbial hazards on discrete subsectors of aquaculture-and control measures that may protect supply. As national governments develop strategies to achieve volumetric expansion in seafood production from aquaculture to meet increasing demand, we propose an urgent need for simultaneous focus on controlling those hazards that limit its production, harvesting, processing, trade and safe consumption. Policies aligning national and international water quality control measures for minimizing interaction with, and impact of, hazards on seafood supply will be critical as consumers increasingly rely on the aquaculture sector to supply safe, nutritious and healthy diets.

Vitamin D metabolism and disorders in dogs and cats.

Vitamin D plays an important role in regulating calcium metabolism and in the development and maintenance of skeletal health of companion animals. There is also a growing interest in understanding the role vitamin D plays in non-skeletal health in both human and veterinary patients. This review provides an update of our current understanding of vitamin D biology in dogs and cats and gives an overview of how vitamin D metabolism can be assessed in companion animals. Congenital and acquired vitamin D disorders are then summarised before the review concludes with a summary of recent studies which have explored the role of vitamin D in the development and outcomes of non-skeletal diseases of dogs and cats.

Diabetic mitochondria are resistant to palmitoyl CoA inhibition of respiration, which is detrimental during ischemia.

The bioactive lipid intermediate palmitoyl CoA (PCoA) can inhibit mitochondrial ADP/ATP transport, though the physiological relevance of this regulation remains unclear. We questioned whether myocardial ischemia provides a pathological setting in which PCoA regulation of ADP/ATP transport would be beneficial, and secondly, whether the chronically elevated lipid content within the diabetic heart could make mitochondria less sensitive to the effects of PCoA. PCoA acutely decreased ADP-stimulated state 3 respiration and increased the apparent Km for ADP twofold. The half maximal inhibitory concentration (IC50 ) of PCoA in control mitochondria was 22 µM. This inhibitory effect of PCoA on respiration was blunted in diabetic mitochondria, with no significant difference in the Km for ADP in the presence of PCoA, and an increase in the IC50 to 32 µM PCoA. The competitive inhibition by PCoA was localised to the phosphorylation apparatus, particularly the ADP/ATP carrier (AAC). During ischemia, the AAC imports ATP into the mitochondria, where it is hydrolysed by reversal of the ATP synthase, regenerating the membrane potential. Addition of PCoA dose-dependently prevented this wasteful ATP hydrolysis for membrane repolarisation during ischemia, however, this beneficial effect was blunted in diabetic mitochondria. Finally, using 31 P-magnetic resonance spectroscopy we demonstrated that diabetic hearts lose ATP more rapidly during ischemia, with a threefold higher ATP decay rate compared with control hearts. In conclusion, PCoA plays a role in protecting mitochondrial energetics during ischemia, by preventing wasteful ATP hydrolysis. However, this beneficial effect is blunted in diabetes, contributing to the impaired energy metabolism seen during myocardial ischemia in the diabetic heart.

Differential drivers of intraspecific and interspecific competition during malaria-helminth co-infection.

Various host and parasite factors interact to determine the outcome of infection. We investigated the effects of two factors on the within-host dynamics of malaria in mice: initial infectious dose and co-infection with a helminth that limits the availability of red blood cells (RBCs). Using a statistical, time-series approach to model the within-host 'epidemiology' of malaria, we found that increasing initial dose reduced the time to peak cell-to-cell parasite propagation, but also reduced its magnitude, while helminth co-infection delayed peak cell-to-cell propagation, except at the highest malaria doses. Using a mechanistic model of within-host infection dynamics, we identified dose-dependence in parameters describing host responses to malaria infection and uncovered a plausible explanation of the observed differences in single vs co-infections. Specifically, in co-infections, our model predicted a higher background death rate of RBCs. However, at the highest dose, when intraspecific competition between malaria parasites would be highest, these effects of co-infection were not observed. Such interactions between initial dose and co-infection, although difficult to predict a priori, are key to understanding variation in the severity of disease experienced by hosts and could inform studies of malaria transmission dynamics in nature, where co-infection and low doses are the norm.

Side-grooved Charpy impact testing: Assessment of splitting and fracture properties of high-toughness plate steels.

The fracture properties and susceptibility to crack-divider delamination (or splitting) of three commercially produced high-toughness X70 pipeline steels are evaluated with Charpy impact test samples modified to incorporate side grooves. Temperature-dependent impact data are compared with standard Charpy V-notch (CVN) and drop weight tear test data (DWTT). It is shown that the modified geometry prevents the accumulation of plastic deformation at upper shelf energy temperatures and improves the accuracy of impact properties measurements. It also promotes splitting, mirroring the splitting behavior assessed with DWTT samples. To demonstrate the effects of splitting on fracture characteristics and impact energies, steels with similar tensile properties but different splitting susceptibilities are considered. Splitting severity is maximum close to the ductile-brittle transition temperature. However, the effect of splitting on impact energy is minimum at such temperature, as this type of delamination increases energy absorption at lower temperatures and decreases it by a similar extent at higher temperatures. This finding is discussed by examination of force-displacement curves from the instrumented impact tests.

Publisher Correction: Rapid Thermal Processing to Enhance Steel Toughness.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Analysis of spontaneous, user-generated data about gestational diabetes on online forums: implications for diabetes prevention.

AIMS: To explore the experiences and perceptions of gestational diabetes mellitus reported by women within online parental-support forums and, specifically, to analyse what women say about a diagnosis of gestational diabetes, their future risk of type 2 diabetes, and lifestyle behaviour for management of gestational diabetes and prevention of type 2 diabetes. METHODS: The discussion boards of two parenting websites (Mumsnet and Netmums) were searched using the search term 'gestational diabetes or GD' in February 2019. Relevant posts made by users with gestational diabetes on or after 1 January 2017 were retained for analysis. Framework analysis using pre-existing framework from a previous study was used to organize and analyse the data. RESULTS: A total of 646 posts generated by 282 unique users were included in the analysis. Analysis of the online content identified three important implicit messages that may be being conveyed to readers. The first is that gestational diabetes is not a serious diagnosis that warrants undue concern. Secondly, few users recognized the importance of their own behaviours or lifestyle, with others minimizing personal responsibility or attributing gestational diabetes to non-modifiable factors. Finally, there was a lack of acknowledgment of heightened risk of type 2 diabetes. These three messages will all directly mitigate against the efforts of clinicians (and others) to encourage women with gestational diabetes to improve their lifestyle behaviours in the longer term. CONCLUSIONS: These findings highlight messages that are being widely disseminated and that are unlikely to support prevention of type 2 diabetes.

Opioid Analgesics Do Not Improve Abdominal Pain or Quality of Life in Crohn's Disease.

BACKGROUND: Abdominal pain and opioid analgesic use are common in Crohn's disease (CD). AIMS: We sought to identify factors associated with abdominal pain in CD and evaluate the impact of opioid analgesics on pain and quality-of-life scores in this setting. METHODS: We performed a longitudinal cohort study using a prospective, consented IBD natural history registry from a single academic center between 2009 and 2013. Consecutive CD patients were followed for at least 1 year after an index visit. Data were abstracted regarding pain experience (from validated surveys), inflammatory activity (using endoscopic/histologic findings), laboratory studies, coexistent psychiatric disorders, medical therapy, opioid analgesic, and tobacco use. RESULTS: Of 542 CD patients (56.6% women), 232 (42.8%) described abdominal pain. Individuals with pain were more likely to undergo surgery and were more frequently prescribed analgesics and/or antidepressants/anxiolytics. Elevated ESR (OR 1.79; 95%CI 1.11-2.87), coexistent anxiety/depression (OR 1.87; 95%CI 1.13-3.09), smoking (OR 2.08; 95%CI 1.27-3.40), and opioid use (OR 2.46; 95%CI 1.33-4.57) were independently associated with abdominal pain. Eighty patients (14.8%) were prescribed opioids, while 31 began taking them at or after the index visit. Patients started on opioids demonstrated no improvement in abdominal pain or quality-of-life scores on follow-up compared to patients not taking opioids. CONCLUSIONS: Abdominal pain is common in CD and is associated with significant opioid analgesic utilization and increased incidence of anxiety/depression, smoking, and elevated inflammatory markers. Importantly, opioid use in CD was not associated with improvement in pain or quality-of-life scores. These findings reinforce the limitations of currently available analgesics in IBD and support exploration of alternative therapies.

Transfusion requirement and length of stay of anaemic surgical patients associated with a patient blood management service: a single-Centre retrospective study.

OBJECTIVE: To assess the value of patient blood management (PBM) in the detection and management of preoperative anaemia before elective surgery. BACKGROUND: PBM is recognised as the standard of care, with diagnosis and management of preoperative anaemia being the key components of PBM. No formal assessment of the value of PBM anaemia screening and correction before scheduled surgery had been made at our hospital. METHODS: We conducted a retrospective study in a tertiary-care, academic hospital of consecutive records of elective surgery (n = 25 641). We excluded minor surgeries. We identified anaemic patients who had been assessed by PBM or not (non-PBM). We calculated transfusion incidence and hospital length of stay (LOS) across all surgical specialities. RESULTS: During the 1-year study period, 15 245 patients were eligible for inclusion; 311 patients (2·0%) were transfused, and 83·3% of transfusions were in anaemic patients. Transfusion incidence was 9·2% in anaemic PBM-assessed patients and 17·4% in non-PBM patients. For haemoglobin (Hb) <100 g L-1 , the transfusion incidence was 22·1% [95% confidence interval (CI) 15·5-30·6%] in PBM and 40·0% (95% CI 35·1-45·0%) in non-PBM patients, and for Hb 100-119 g L-1 , it was 4·7% (95% CI 2·8-7·5%) and 7·9% (95% CI 6·3-9·8%), respectively. Overall mean LOS was 2·1 days [standard deviation (SD) 6·0]. Mean LOS with Hb <100 g L-1 was 6·7 days (SD 14·8) in PBM-assessed patients and 12·4 days (SD 19·5) in non-PBM patients and was 3·1 (SD 5·2) and 6·2 (SD 9·5) days, respectively, for Hb 100-119 g L-1 . CONCLUSION: Anaemic elective surgery patients assessed by patient blood management (PBM) had a markedly lower transfusion risk and shorter LOS than anaemic patients not assessed by PBM.

Axial length measurement using optical versus immersion ultrasound: Impact on predicted refractive outcome following cataract surgery

Objective: To evaluate optical vs immersion ultrasound biometry to measure ocular axial length (the distance between the anterior surface of the cornea and the fovea). Design and Methodology: The axial length of the eye is usually measured by A-scan ultrasonography or optical coherence biometry. Optical biometry is the gold standard, but cannot be used for patients with dense cataracts, when immersion ultrasound biometry is utilized. Both optical and immersion ultrasound biometry were performed on patients scheduled to undergo cataract surgery between November 2017 and November 2018. Statistical difference was determined using a two tailed t-test. Results: There was no statistical difference between mean axial length measured using optical biometry (23.83 mm ± 1.34) vs immersion ultrasound biometry (23.80 mm ± 1.30); t(46)= -0.05, p=0.96. Conclusion: Accurate axial length measurement is essential for reliable intraocular lens power calculation, minimizing refractive error following cataract surgery. The cost of optical coherence biometry equipment is prohibitive and this technology is not readily available in the public hospital eye clinics. There was no statistical difference in axial length measured using optical biometry and immersion ultrasound. This suggests that in low resource settings, immersion biometry can be utilized without compromising surgical outcome.

Risk factors for relapse and recurrence of depression in adults and how they operate: A four-phase systematic review and meta-synthesis.

PURPOSE: To review and synthesise prognostic indices that predict subsequent risk, prescriptive indices that moderate treatment response, and mechanisms that underlie each with respect to relapse and recurrence of depression in adults. RESULTS AND CONCLUSIONS: Childhood maltreatment, post-treatment residual symptoms, and a history of recurrence emerged as strong prognostic indicators of risk and each could be used prescriptively to indicate who benefits most from continued or prophylactic treatment. Targeting prognostic indices or their "down-stream" consequences will be particularly beneficial because each is either a cause or a consequence of the causal mechanisms underlying risk of recurrence. The cognitive and neural mechanisms that underlie the prognostic indices are likely addressed by the effects of treatments that are moderated by the prescriptive factors. For example, psychosocial interventions that target the consequences of childhood maltreatment, extending pharmacotherapy or adapting psychological therapies to deal with residual symptoms, or using cognitive or mindfulness-based therapies for those with prior histories of recurrence. Future research that focuses on understanding causal pathways that link childhood maltreatment, or cognitive diatheses, to dysfunction in the neocortical and limbic pathways that process affective information and facilitate cognitive control, might result in more enduring effects of treatments for depression.

Emergent synergistic lysosomal toxicity of chemical mixtures in molluscan blood cells (hemocytes).

The problem of effective assessment of risk posed by complex mixtures of toxic chemicals in the environment is a major challenge for government regulators and industry. The biological effect of the individual contaminants, where these are known, can be measured; but the problem lies in relating toxicity to the multiple constituents of contaminant cocktails. The objective of this study was to test the hypothesis that diverse contaminant mixtures may cause a greater toxicity than the sum of their individual parts, due to synergistic interactions between contaminants with different intracellular targets. Lysosomal membrane stability in hemocytes from marine mussels was used for in vitro toxicity tests; and was coupled with analysis using the isobole method and a linear additive statistical model. The findings from both methods have shown significant emergent synergistic interactions between environmentally relevant chemicals (i.e., polycyclic aromatic hydrocarbons, pesticides, biocides and a surfactant) when exposed to isolated hemocytes as a mixture of 3 & 7 constituents. The results support the complexity-based hypothesis that emergent toxicity occurs with increasing contaminant diversity, and raises questions about the validity of estimating toxicity of contaminant mixtures based on the additive toxicity of single components. Further experimentation is required to investigate the potential for interactive effects in mixtures with more constituents (e.g., 50-100) at more environmentally realistic concentrations in order to test other regions of the model, namely, very low concentrations and high diversity. Estimated toxicant diversity coupled with tests for lysosomal damage may provide a potential tool for determining the toxicity of estuarine sediments, dredge spoil or contaminated soil.

Rapid Thermal Processing to Enhance Steel Toughness.

Quenching and Tempering (Q&T) has been utilized for decades to alter steel mechanical properties, particularly strength and toughness. While tempering typically increases toughness, a well-established phenomenon called tempered martensite embrittlement (TME) is known to occur during conventional Q&T. Here we show that short-time, rapid tempering can overcome TME to produce unprecedented property combinations that cannot be attained by conventional Q&T. Toughness is enhanced over 43% at a strength level of 1.7 GPa and strength is improved over 0.5 GPa at an impact toughness of 30 J. We also show that hardness and the tempering parameter (TP), developed by Holloman and Jaffe in 1945 and ubiquitous within the field, is insufficient for characterizing measured strengths, toughnesses, and microstructural conditions after rapid processing. Rapid tempering by energy-saving manufacturing processes like induction heating creates the opportunity for new Q&T steels for energy, defense, and transportation applications.

Prevention of needle stick injury in the clinical setting among new registered nurses

Background: Needle stick injury is one of the greatest work-related health hazard, that registered nurses encounter on an everyday basis for example the risk of being exposed to dangerous and deadly blood borne pathogens through contaminated needle sticks such as human immunodeficiency virus (HIV) and hepatitis viruses. New registered nurses' lacking knowledge and skills regarding standard precautions are exposed to needle stick injuries from unsafe practices such as recapping of needles, manipulating used needles such as bending, breaking or cutting hypodermic needles and passing needles from one nurse to another (American Nurses Association 2002). Methods: This was a quantitative descriptive study. The dependent variable was the needle stick injury and the independent variables consisted of factors which influenced the occurrence of needle stick injuries among new registered nurses. The factors are practice, knowledge, resources and attitudes. The population was new registered nurses with less than three years' experience at the San Fernando General Hospital. A total of 120 new registered nurses were employed during the period under review and the entire population was used as the sample. A 26 item instrument was used to collect data which were analyzed using SPSS version 20. Findings: Most of the respondents 59 (49.2%) were between the ages 20-<30 years and 88 (73.4%) were female. The most common years' experience was 53 (44.2%). Almost half 54 (45%) respondents had experienced a needle stick injury with the most common exposure being while in use (17.5%) and recapping needles (215%). A total of 49 (40.8%) respondents had at least one to less than 3 needle sticks since employment and this was most common among staff on the medical wards. There was a moderate correlation between respondents knowledge about institution's policies and need for training (r0.409, p0.01) and strong correlation between their perception of the need to be more vigilant and the quality of the sharps that they are provided with (r0.913, p0.01). Conclusion: Avoidable practices such as non-adherence to standard precautions while using hypodermic needles are contributing factors to needle stick injuries. Prevention of NSI's should be an integral part of occupational health programs in the work place. Therefore, mandatory training and evaluation of health care worker's, knowledge and attitude regarding safety practices and proper use of available resources should be enforced when carrying out their duties in the clinical area.

Interdecadal changes in the community, population and individual levels of the fish fauna of an extensively modified estuary.

This study examined inter-period changes over two to three decades in the fish fauna of an urbanized estuary experiencing rapid population growth and a drying climate (Swan-Canning Estuary, Western Australia). Responses were compared at the fish community level (species composition; 1978-2009 in the shallows and 1993-2009 in deeper waters) and at the population and individual levels of an estuarine indicator species, black bream Acanthopagrus butcheri (biomass-abundance and per capita mass at age, respectively; 1993-2009). All three levels showed distinct shifts from earlier to later periods, but their patterns, sensitivity and breadth differed. Community composition changed markedly in the shallows of the lower-middle estuary between the late 1970s and all later periods and moderately between more disparate periods from 1995 to 2009. Several species trends could be linked to the increasing salinity of the estuary or declining dissolved oxygen levels in its middle-upper reaches. Community changes were, however, small or insignificant in the shallow and deeper waters of the upper estuary and deeper waters of the middle estuary, where environmental perturbations are often most pronounced. This may reflect the resilience of the limited suite of species that typify those reaches and thus their lack of sensitivity in reflecting longer-term change at the coarser level of mean abundance. One such species, the selected indicator, A. butcheri, did, however, show marked temporal changes at both the population and individual levels. Biomass decreased markedly in deeper waters while increasing in the shallows from earlier to later periods, presumably reflecting an onshore movement of fish, and per capita body mass in the 2+, 3+ and 4+ year classes fell steadily over time. Such changes probably indicate deteriorating habitat quality in the deeper waters. The study outcomes provide support for a multifaceted approach to the biomonitoring of estuaries using fishes and highlight the need for complementary monitoring of relevant stressors to better disentangle cause-effect pathways.