Integrative Taxonomy of Dermacentor variabilis (Ixodida: Ixodidae) with Description of a New Species, Dermacentor similis n. sp.

Dermacentor variabilis is the most widely distributed three-host tick in North America, and transmits a variety of pathogens. Within the United States, this species has a discontinuous distribution, widespread east of the Rocky Mountains and with a few populations west of the Rockies. Phylogenetic evidence based on individual markers or relatively small data sets has suggested that populations at both sides of this geographic barrier may correspond to two different species. In this study, we further explore this hypothesis using an integrative taxonomy framework. Both molecular (mitochondrial and nuclear markers) and morphological analyses of specimens collected from central-eastern and western states were performed to explore species delimitation in this taxon. Results from these analyses were consistent, and provide strong evidence that D. variabilis actually corresponds to two species. Herein, the western populations are described as a new species, Dermacentor similis n. sp. The usefulness of integrative taxonomy in the context of species delimitation is also discussed.

Non-ICGA treatment criteria for Suboptimal Anti-VEGF Response for Polypoidal Choroidal Vasculopathy: APOIS PCV Workgroup Report 2.

PURPOSE: To develop and validate OCT and color fundus photography (CFP) criteria in differentiating polypoidal choroidal vasculopathy (PCV) from typical neovascular age-related macular degeneration (nAMD) in eyes with suboptimal response to anti-vascular endothelial growth factor (VEGF) monotherapy and to determine whether OCT alone can be used to guide photodynamic therapy (PDT) treatment. DESIGN: Clinical study evaluating diagnostic accuracy. PARTICIPANTS: Patients with nAMD who received 3-month anti-VEGF monotherapy but had persistent activity defined as subretinal fluid or intraretinal fluid at month 3 assessments. METHODS: In phase 1, international retina experts evaluated OCT and CFP of eyes with nAMD to identify the presence or absence of features due to PCV. The performance of individual and combinations of these features were compared with ICGA. In phase 2, these criteria were applied to an independent image set to assess generalizability. In a separate exercise, retinal experts drew proposed PDT treatment spots using only OCT and near-infrared (NIR) images in eyes with PCV and persistent activity. The location and size of proposed spot were compared with ICGA to determine the extent of coverage of polypoidal lesions (PLs) and branching neovascular network (BNN). MAIN OUTCOME MEASURES: Sensitivity and specificity of CFP and OCT criteria to differentiate PCV from nAMD and accuracy of coverage of OCT-guided PDT compared with ICGA. RESULTS: In eyes with persistent activity, the combination of 3 non-ICGA-based criteria (sharp-peaked pigment epithelial detachment [PED], subretinal pigment epithelium [RPE] ring-like lesion, and orange nodule) to detect PCV showed good agreement compared with ICGA, with an area under the receiver operating characteristic curve of 0.85. Validation using both an independent image set and assessors achieved an accuracy of 0.77. Compared with ICGA, the OCT-guided PDT treatment spot covered 100% of PL and 90% of the BNN. CONCLUSIONS: In nAMD eyes with persistent activity, OCT and CFP can differentiate PCV from typical nAMD, which may allow the option of adjunct PDT treatment. Furthermore, OCT alone can be used to plan adjunct PDT treatment without the need for ICGA, with consistent and complete coverage of PL.

Impact of the COVID-19 pandemic on cytology practice: An international survey in the Asia-Pacific region.

BACKGROUND: The purpose of the current study was to examine the impact of coronavirus disease 2019 (COVID-19) on various aspects of cytology practice in the Asia-Pacific region. METHODS: An online questionnaire was distributed to cytopathology laboratories in 24 Asia-Pacific countries to explore the impact of restrictive measures on access to health care, use of general and personal protective equipment (PPE), and changes in cytology workflow and workload from February to April 2020. RESULTS: A total of 167 cytopathology laboratories from 24 countries responded to the survey; the majority reported that restrictive measures that limited the accessibility of health care services had been implemented in their cities and/or countries (80.8%) and their hospitals (83.8%). The respondents noted that COVID-19 had an impact on the cytologic workflow as well as the workload. Approximately one-half of the participants reported the implementation of new biosafety protocols (54.5%) as well as improvements in laboratory facilities (47.3%). Rearrangement or redeployment of the workforce was reported in 53.3% and 34.1% of laboratories, respectively. The majority of the respondents reported a significant reduction (>10%) in caseload associated with both gynecological (82.0%) and nongynecological specimens (78.4%). Most laboratories reported no significant change in the malignancy rates of both gynecological (67.7%) and nongynecological specimens (58.7%) compared with the same period in 2019. CONCLUSIONS: The results of the survey demonstrated that the COVID-19 pandemic resulted in a significant reduction in the number of cytology specimens examined along with the need to implement new biosafety protocols. These findings underscore the need for the worldwide standardization of biosafety protocols and cytology practice.

Global, regional, and country seroprevalence of Toxoplasma gondii in pregnant women: a systematic review, modelling and meta-analysis.

Efficient health-care for pregnant women require accurate data on the prevalence of toxoplasmosis in pregnancy at global, regional, and country levels. In this systematic review with meta- and modelling-analysis, we searched PubMed, EMBASE, Web of Knowledge, Global Index Medicus, and Africa Journal Online to identify studies that reported enough data to compute the immunoglobulins (Ig) M or G seroprevalence estimates of Toxoplasma gondii in pregnant women up to December 31st, 2018, without any language restriction. The global and regional estimates were done using a random-effects meta-analysis. We included 250 studies with 723,655 pregnant women. The global IgM seroprevalence was 1.9% (95%CI: 1.7-2.3). At the regional level, Eastern Mediterranean had the highest IgM seroprevalence (4.1%, 95%CI: 2.8-5.5) and The Americas, the lowest (1.1%, 0.8-1.4), with a statistically significant difference between WHO regions (p < 0.0001). The global IgG seroprevalence was 32.9% (95%CI: 29.4-36.4). Among WHO regions, The Americas had the highest prevalence (45.2%, 95%CI: 33.4-53.4) and Western Pacific the lowest (11.2%, 7.8-15.1), with a statistically significant difference between regions (p < 0.0001). This study presents a high toxoplasma seropositivity in pregnant women at global, regional and country levels, with a consequential high risk of maternal and congenital toxoplasmosis.

Individual, business-related, and work environment factors associated with driving tired among taxi drivers in two metropolitan U.S. cities.

INTRODUCTION: Violence-related events and roadway incidents are the leading causes of injury among taxi drivers. Fatigue is under-recognized and prevalent in this workforce and is associated with both injury outcomes. We describe the association of individual, business-related, and work environment factors with driving tired among taxi drivers in two very different cities. METHOD: We developed a comprehensive survey for licensed taxi drivers. We trained surveyors to administer the 30-min survey using systematic sampling among taxi drivers waiting for fares in two large U.S. cities: the Southwest (City 1) and the West (City 2). A driving tired scale of the Occupational Driver Behavior Questionnaire was the outcome. Multivariate logistic models described driving tired behavior in city-specific models using adjusted Odds Ratios (ORadj). RESULTS: City 1 and City 2 had 496 and 500 participants, respectively. Each driving tired behavior was significantly more prevalent in City 2 than City 1 (p < .05). There were more variables and a greater diversity of variables in the models describing drowsy driving in City 1 than City 2. In City 1, variables describing negative safety climate (ORadj = 1.15), socio-demographic groups (identifying as Asian, educational attainment), passenger-related violence (ORadj = 1.79), and company tenure (ORadj =1.15) were associated with driving tired. In City 2, high perceived safety training usefulness (ORadj = 0.48) was associated with driving tired. A risk factor for driving tired that was common to both cities was job demands (ORadj = 1.21 in City 1; 1.43 in City 2). CONCLUSIONS: These findings represent two diverse taxi populations driving in two geographically distinct regions that differ in safety regulation. It is important that safety measures that include fatigue awareness training are reaching all drivers. Fatigue management training should be integrated into driver safety programs regardless of location. Practical applications: Fatigue management strategies that recognize individual factors, business-related characteristics, and work environment are an important component of road safety and are particularly relevant for occupational drivers.

Economic and sociocultural impacts of fisheries closures in two fishing-dependent communities following the massive 2015 U.S. West Coast harmful algal bloom.

In the spring of 2015, a massive harmful algal bloom (HAB) of the toxin-producing diatom Pseudo-nitzschia occurred on the U.S. West Coast, resulting in the largest recorded outbreak of the toxin domoic acid and causing fisheries closures. Closures extended into 2016 and generated an economic shock for coastal fishing communities. This study examines the economic and sociocultural impacts of the Dungeness crab and razor clam fisheries closures on two fishing-dependent communities. Semi-structured interviews were conducted with 36 community members from two communities impacted by the event - Crescent City, California and Long Beach, Washington. Interviewees included those involved in the fishing, hospitality, and retail industries, local government officials, recreational harvesters, and others. Interviews probed aspects of resilience in economic, social, institutional, and physical domains, based on the contention that community resilience will influence the communities' ability to withstand HAB events. Dimensions of vulnerability were also explored, encompassing sensitivity of the communities to HAB events and their adaptive capacity. Common themes that emerged from the interview responses indicate that economic hardships extended beyond fishing-related operations and permeated through other sectors, particularly the hospitality industry. Significant barriers to accessing financial and employment assistance during extended fisheries closures were identified, particularly for fishers. Long-held traditions surrounding crab and shellfish harvest and consumption were disrupted, threatening the cultural identities of the affected communities. Community members expressed a desire for clearer, more thorough, and more rapid dissemination of information regarding the management of fisheries closures and the health risks associated with HAB toxins. The likelihood of intensifying HABs under climate change heightens the need for actions to increase the resilience of fishing communities to the economic and sociocultural impacts caused by HAB-related fisheries closures.

The effect of range overlap on ecological niche divergence depends on spatial scale in monkeyflowers.

Patterns of niche divergence and geographical range overlap of closely related species provide insights into the evolutionary dynamics of ecological niches. When ranges overlap, shared selective pressures may preserve niche similarity along coarse-scale macrohabitat axes (e.g., bioclimates). Alternatively, competitive interactions may drive greater divergence along local-scale microhabitat axes (e.g., micro-topographical features). We tested these hypotheses in 16 species pairs of western North American monkeyflowers (Erythranthe and Diplacus, formerly Mimulus) with estimations of species' niches, geographic ranges, and a robust phylogeny. We found that macrohabitat niche divergence decreased with increasing range overlap, consistent with convergent selection operating at a coarse scale. No significant relationship was detected for microhabitat niches. Additionally, niche divergence was greater for recently diverged pairs along all macrohabitat niche axes, but greater for distantly diverged pairs along one microhabitat axis related to vegetation cover. For species pairs with partially overlapping ranges, greater microhabitat divergence was detected in sympatry than in allopatry for at least one niche axis for three of four pairs, consistent with character displacement in sympatry. Thus, coarse- and local-scale niche divergence show dissimilar patterns in relation to range overlap and divergence time, perhaps because the relative importance of convergent versus divergent selection depends on spatial scale.

Rectal Chlamydia trachomatis and Neisseria gonorrhoeae Infections Among Women Reporting Anal Intercourse.

OBJECTIVE: To examine the prevalence and treatment of rectal Chlamydia trachomatis and Neisseria gonorrhoeae infections among women reporting receptive anal intercourse in a network of sexually transmitted disease or sexual health clinics and estimate the proportion of missed infections if women were tested at the genital site only. METHODS: We conducted a cross-sectional analysis of C trachomatis and N gonorrhoeae test results from female patients reporting receptive anal intercourse in the preceding 3 months during visits to 24 sexually transmitted disease clinics from 2015 to 2016. Primary outcomes of interest were 1) anatomic site-specific C trachomatis and N gonorrhoeae testing and positivity among women attending selected U.S. sexually transmitted disease clinics who reported receptive anal intercourse and 2) the proportion of rectal infections that would have remained undetected if only genital sites were tested. RESULTS: Overall, 7.4% (3,743/50,785) of women reported receptive anal intercourse during the 2 years. Of the 2,818 women tested at both the genital and rectal sites for C trachomatis, 292 women were positive (61 genital only, 60 rectal only, and 171 at both sites). Of the 2,829 women tested at both the genital and rectal sites for N gonorrhoeae, 128 women were positive (31 genital only, 23 rectal only, and 74 at both sites). Among women tested at both anatomic sites, the proportion of missed C trachomatis infections would have been 20.5% and for N gonorrhoeae infections, 18.0%. CONCLUSION: Genital testing alone misses approximately one fifth of C trachomatis and N gonorrhoeae infections in women reporting receptive anal intercourse in our study population. Missed rectal infections may result in ongoing transmission to other sexual partners and reinfection.

Utility of a Stressed Single Nucleotide Polymorphism (SNP) Real-Time PCR Assay for Rapid Identification of Measles Vaccine Strains in Patient Samples.

Rapid differentiation of wild-type measles virus from measles vaccine strains is crucial during a measles outbreak and in a measles elimination setting. A real-time reverse transcription-PCR (rRT-PCR) for the rapid detection of measles vaccine strains was developed with high specificity and sensitivity equivalent to that of traditional measles genotyping methods. The "stressed" minor groove binder-TaqMan probe design approach achieves specificity to vaccine strains only, without compromising sensitivity. This assay, without requiring sequence genotyping, has proved to be extremely useful in outbreak settings for over 4 years at the Regional Measles Reference Laboratory for the Western Pacific Region.

Characterizing and Validating Stripe Rust Resistance Loci in US Pacific Northwest Winter Wheat Accessions (Triticum aestivum L.) by Genome-wide Association and Linkage Mapping.

Stripe rust resistance is a critical need for wheat cultivars in the US Pacific Northwest (PNW). Our previous genome-wide association study (GWAS) for stripe rust resistance in a set of PNW winter wheat accessions (Panel-2) identified multiple marker-trait associations (MTAs) for both all-stage and field resistance. In this study, we conducted additional GWAS using a different set of PNW winter wheat accessions (Panel-1) that contained recently bred soft white winter wheat breeding lines and cultivars. A total of 12 all-stage resistance MTAs and eight field resistance MTAs were identified. Within these MTAs, nine MTAs for all-stage resistance and two MTAs for field resistance were located distinctly from previously characterized genes and likely represent novel loci. Markers IWB60567 (1B), IWB24342 (2A), and IWB46564 (2B) explained the largest phenotypic variances for disease responses. The analysis confirmed that MTAs on chromosome 1B were indeed the same as identified in Panel-2 and that MTAs on chromosome 2A were likely and closely linked to another field resistance QTL, (Panel-2). Haplotypes for MTAs on chromosome 1B, , and linked loci on chromosome 2A provide useful information for marker development and introgression of these QTL into wheat breeding programs.

Genetic diversity and phylogenetic relations of salmon trematode Nanophyetus japonensis.

Nanophyetiasis is the severe zoonotic disease caused by parasitic worms from the genus Nanophyetus. Humans and carnivorous animals become infected when they ingest raw fish containing metacercariae, especially Pacific salmonids. Nanophyetiasis is detected in limited geographical areas which include the coastal regions of the North Pacific: the United States of America, Russian Federation and Japan. Despite the epidemiological significance, Nanophyetus species have not been well studied genetically. In this research, we for the first time explored genetic diversity of Nanophyetus japonensis from Japan in comparison with those of related species, N. salmincola from North America and N. schikhobalowi from the Russian Far East, based on sequence variation in the nuclear ribosomal gene family (18S, ITS1-5.8S-ITS2 and 28S) and mitochondrial nad1 gene, encoding subunit I of the respiratory chain NADH dehydrogenase. The results confirmed the independent species status for the compared flukes, demonstrated a greater genetic similarity of Asian species between themselves than each of them with the North American one, suggesting that N. japonensis and N. schikhobalowi are close sister species, and also revealed discrepancy between the levels of morphological and genetic differentiation.

Cumulative effects of wildfires on forest dynamics in the eastern Cascade Mountains, USA.

Wildfires pose a unique challenge to conservation in fire-prone regions, yet few studies quantify the cumulative effects of wildfires on forest dynamics (i.e., changes in structural conditions) across landscape and regional scales. We assessed the contribution of wildfire to forest dynamics in the eastern Cascade Mountains, USA from 1985 to 2010 using imputed maps of forest structure (i.e., tree size and canopy cover) and remotely sensed burn severity maps. We addressed three questions: (1) How do dynamics differ between the region as a whole and the unburned portion of the region? (2) How do dynamics vary among vegetation zones differing in biophysical setting and historical fire frequency? (3) How have forest structural conditions changed in a network of late successional reserves (LSRs)? Wildfires affected 10% of forests in the region, but the cumulative effects at this scale were primarily slight losses of closed-canopy conditions and slight gains in open-canopy conditions. In the unburned portion of the region (the remaining 90%), closed-canopy conditions primarily increased despite other concurrent disturbances (e.g., harvest, insects). Although the effects of fire were largely dampened at the regional scale, landscape scale dynamics were far more variable. The warm ponderosa pine and cool mixed conifer zones experienced less fire than the region as a whole despite experiencing the most frequent fire historically. Open-canopy conditions increased slightly in the mixed conifer zone, but declined across the ponderosa pine zone even with wildfires. Wildfires burned 30% of the cold subalpine zone, which experienced the greatest increase in open-canopy conditions and losses of closed-canopy conditions. LSRs were more prone to wildfire than the region as a whole, and experienced slight declines in late seral conditions. Despite losses of late seral conditions, wildfires contributed to some conservation objectives by creating open habitats (e.g., sparse early seral and woodland conditions) that otherwise generally decreased in unburned landscapes despite management efforts to increase landscape diversity. This study demonstrates the potential for wildfires to contribute to regional scale conservation objectives, but implications for management and biodiversity at landscape scales vary geographically among biophysical settings, and are contingent upon historical dynamics and individual species habitat preferences.

Literature review of the epidemiology of influenza B disease in 15 countries in the Asia-Pacific region.

Influenza control strategies focus on the use of trivalent influenza vaccines containing two influenza A virus subtypes and one of the two circulating influenza type B lineages (Yamagata or Victoria). Mismatches between the vaccine B lineage and the circulating lineage have been regularly documented in many countries, including those in the Asia-Pacific region. We conducted a literature review with the aim of understanding the relative circulation of influenza B viruses in Asia-Pacific countries. PubMed and Western Pacific Region Index Medicus were searched for relevant articles on influenza type B published since 1990 in English language for 15 Asia-Pacific countries. Gray literature was also accessed. From 4834 articles identified, 121 full-text articles were analyzed. Influenza was reported as an important cause of morbidity in the Asia-Pacific region, affecting all age groups. In all 15 countries, influenza B was identified and associated with between 0% and 92% of laboratory-confirmed influenza cases in any one season/year. Influenza type B appeared to cause more illness in children aged between 1 and 10 years than in other age groups. Epidemiological data for the two circulating influenza type B lineages remain limited in several countries in the Asia-Pacific, although the co-circulation of both lineages was seen in countries where strain surveillance data were available. Mismatches between circulating B lineages and vaccine strains were observed in all countries with available data. The data suggest that a shift from trivalent to quadrivalent seasonal influenza vaccines could provide additional benefits by providing broader protection.

Use of Alternative Medicine for Cancer and Its Impact on Survival.

There is limited available information on patterns of utilization and efficacy of alternative medicine (AM) for patients with cancer. We identified 281 patients with nonmetastatic breast, prostate, lung, or colorectal cancer who chose AM, administered as sole anticancer treatment among patients who did not receive conventional cancer treatment (CCT), defined as chemotherapy, radiotherapy, surgery, and/or hormone therapy. Independent covariates on multivariable logistic regression associated with increased likelihood of AM use included breast or lung cancer, higher socioeconomic status, Intermountain West or Pacific location, stage II or III disease, and low comorbidity score. Following 2:1 matching (CCT = 560 patients and AM = 280 patients) on Cox proportional hazards regression, AM use was independently associated with greater risk of death compared with CCT overall (hazard ratio [HR] = 2.50, 95% confidence interval [CI] = 1.88 to 3.27) and in subgroups with breast (HR = 5.68, 95% CI = 3.22 to 10.04), lung (HR = 2.17, 95% CI = 1.42 to 3.32), and colorectal cancer (HR = 4.57, 95% CI = 1.66 to 12.61). Although rare, AM utilization for curable cancer without any CCT is associated with greater risk of death.

Exposure history determines pteropod vulnerability to ocean acidification along the US West Coast.

The pteropod Limacina helicina frequently experiences seasonal exposure to corrosive conditions (Ωar < 1) along the US West Coast and is recognized as one of the species most susceptible to ocean acidification (OA). Yet, little is known about their capacity to acclimatize to such conditions. We collected pteropods in the California Current Ecosystem (CCE) that differed in the severity of exposure to Ωar conditions in the natural environment. Combining field observations, high-CO2 perturbation experiment results, and retrospective ocean transport simulations, we investigated biological responses based on histories of magnitude and duration of exposure to Ωar < 1. Our results suggest that both exposure magnitude and duration affect pteropod responses in the natural environment. However, observed declines in calcification performance and survival probability under high CO2 experimental conditions do not show acclimatization capacity or physiological tolerance related to history of exposure to corrosive conditions. Pteropods from the coastal CCE appear to be at or near the limit of their physiological capacity, and consequently, are already at extinction risk under projected acceleration of OA over the next 30 years. Our results demonstrate that Ωar exposure history largely determines pteropod response to experimental conditions and is essential to the interpretation of biological observations and experimental results.

Nursing Practice, Research and Education in the West: The Best Is Yet to Come.

PURPOSE: This paper celebrates the 60th anniversary of the Western Institute of Nursing, the nursing organization representing 13 states in the Western United States, and envisions a preferred future for nursing practice, research, and education. BACKGROUND: Three landmark calls to action contribute to transforming nursing and healthcare: the Patient Protection and Affordable Care Act of 2010; the Institute of Medicine report Future of Nursing: Leading Change, Advancing Health; and the report Advancing Healthcare Transformation: A New Era for Academic Nursing. Challenges abound: U.S. healthcare remains expensive, with poorer outcomes than other developed countries; costs of higher education are high; our profession does not reflect the diversity of the population; and health disparities persist. Pressing health issues, such as increases in chronic disease and mental health conditions and substance abuse, coupled with aging of the population, pose new priorities for nursing and healthcare. DISCUSSION: Changes are needed in practice, research, and education. In practice, innovative, cocreated, evidence-based models of care can open new roles for registered nurses and advanced practice registered nurses who have knowledge, leadership, and team skills to improve quality and address system change. In research, data can provide a foundation for clinical practice and expand our knowledge base in symptom science, wellness, self-management, and end-of-life/palliative care, as well as behavioral health, to demonstrate the value of nursing care and reduce health disparities. In education, personalized, integrative, and technology-enabled teaching and learning can lead to creative and critical thinking/decision-making, ethical and culturally inclusive foundations for practice, ensure team and communication skills, quality and system improvements, and lifelong learning. CONCLUSION: The role of the Western Institute of Nursing is more relevant than ever as we collectively advance nursing, health, and healthcare through education, clinical practice, and research.

Improved management of small pelagic fisheries through seasonal climate prediction.

Populations of small pelagic fish are strongly influenced by climate. The inability of managers to anticipate environment-driven fluctuations in stock productivity or distribution can lead to overfishing and stock collapses, inflexible management regulations inducing shifts in the functional response to human predators, lost opportunities to harvest populations, bankruptcies in the fishing industry, and loss of resilience in the human food supply. Recent advances in dynamical global climate prediction systems allow for sea surface temperature (SST) anomaly predictions at a seasonal scale over many shelf ecosystems. Here we assess the utility of SST predictions at this "fishery relevant" scale to inform management, using Pacific sardine as a case study. The value of SST anomaly predictions to management was quantified under four harvest guidelines (HGs) differing in their level of integration of SST data and predictions. The HG that incorporated stock biomass forecasts informed by skillful SST predictions led to increases in stock biomass and yield, and reductions in the probability of yield and biomass falling below socioeconomic or ecologically acceptable levels. However, to mitigate the risk of collapse in the event of an erroneous forecast, it was important to combine such forecast-informed harvest controls with additional harvest restrictions at low biomass.

Not just sticks and stones: Indirect ethnic discrimination leads to greater physiological reactivity.

OBJECTIVES: We examined the effect of indirect ethnic discrimination on physiological reactivity (i.e., cortisol, blood pressure, heart rate) in Latino emerging adults. METHOD: Participants (N = 32) were randomly assigned to be exposed to indirect ethnic discrimination (experimental condition) or not (control condition) while undergoing a cognitive stress task. RESULTS: Greater total cortisol output was observed in participants in the experimental condition, relative to those in the control condition. No significant differences in heart rate or blood pressure were noted. CONCLUSIONS: Results suggest that witnessing ethnic discrimination affects cortisol recovery responses, but not cardiovascular reactivity. Words that are not intentionally hurtful or directed at a specific person may still "hurt"-affecting biological processes associated with hypothalamic-pituitary-adrenocortical (HPA) axis and potentially leading to long-term health consequences. (PsycINFO Database Record