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Objective@#Face-to-face evaluation is the most important in psychiatric evaluation, but smart healthcare, including non-face-to-face evaluation, can be beneficial considering the situation in which face-to-face evaluation is limited or the preventive aspect of mental illness. In this paper, we aimed to check whether mental health screening tests have the same significance as paper-based tests even when collected through mobile applications. @*Methods@#A smart mental healthcare screening test was conducted on the 1,327 community subjects. We measured two indicators of depression (Patient Health Questionnaire 9-item scale, PHQ-9) and anxiety (Generalized Anxiety Disorder 7-item scale, GAD-7) to check mental health conditions. @*Results@#The average Cronbach’s alpha value of the PHQ-9 questionnaire was good at 0.870. As a result of PHQ-9’s principal component analysis, one component with an eigenvalue of 1 or more was identified, which is suitable to be described as a single factor. The average Cronbach’s alpha value of the GAD-7 was 0.919. The structural validity of the GAD-7 was confirmed through principal component analysis. @*Conclusion@#Our results show that PHQ-9 and GAD-7 scales performed through mobile applications can have the same meaning as paper-based tests. Surveys using a tablet PC, or smartphone application can monitor residents’ mental health and accumulate data. Based on these data, smart mental health management can check the mental health of residents and treat mental illness in connection with medical services.
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Objectives@#Schizophrenia (SPR) is the most devastating mental illness that causes severe deterioration in social and occupational functioning, but, the aetiology remains unknown. The aim was to identify patterns of association and segregation for genetic variants and to identify the genes and signalling pathways that determine the risk of developing SPR, through a family-based Genome-wide association study. @*Methods@#We have recruited 27 probands(with SPR) with their parents and siblings whenever possible. DNA was extracted from blood sampling of 58 individuals in 27 families and analysed in an Illumina core exome single nucleotide polymorphism (SNP) array. A family-based association test was used to derive SNP association values across all chromosomes. @*Results@#Although none of the final 800,000 SNPs reached the genome-wide significant threshold of 5×10-8 , the most significant 3 SNPs were within the 10-5 -10-7 . @*Conclusions@#This confirms that SPR is not monogenic but results as a consequence of interactions between multiple host genes and possibly also environmental factors. The present approach provides novel insights into the mechanisms underlying SPR and raises the possibility of identifying individuals at risk of acquiring this condition. In this study, several possible susceptibility genes have been identified that are linked to a range of different pathways, which could reflect the mind-body interaction that is included in the psychiatric genomics consortium.
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We report a case of subacute psychotic symptoms in a patient with germ cell tumor (GCT). The 32-year-old male patient showed progressive psychotic symptoms with diagnosis of GCT. His psychotic symptoms included delusions of reference and persecution. Brain magnetic resonance imaging, electroencephalography, and laboratory examinations were performed to evaluate any other causes. The clinical, neuroimaging, and laboratory review in this case suggested that the progressively developed psychotic symptoms that led to chronic deterioration were caused by the GCT. This is the case report in which subacute atypical psychotic symptoms in his thirties could develop from a GCT based on previous basic research findings showing the correlations of psychotic symptoms with GCT although it has the limitation of so early speculation.
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Purpose@#This is a study to confirm the mediating effect of positive psychological capital in the relationship between the self-determination and grit of nursing students. @*Methods@#The subjects of the study were 122 university nursing department students in their junior and senior years. The data were collected from December 1 to 23, 2022. The collected data were analyzed by descriptive statistics, an independent t-test, Mann–Whitney U-test, Pearson’s correlation, and a hierarchical multiple regression analysis using IBM SPSS statistics version 26.0. @*Results@#A statistically significant correlation was observed between self-determination, positive psychological capital and grit (p<.001). The positive psychological capital had full mediation effects on the relationship between self-determination and grit. In other words, the higher levels of positive psychological capital were associated with better levels of grit among nursing students. @*Conclusion@#The study showed that positive psychological capital and self-determination have important effects on grit. To enhance the grit of nursing students, it is essential to implement educational programs aimed at improving self-determination and positive psychological capital.
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Purpose@#This study aimed to review our experience with the explantation of infected endovascular aneurysm repair (EVAR) grafts. @*Methods@#This single-center, retrospective, observational study analyzed the data of 12 consecutive patients who underwent infected aortic stent graft explantation following EVAR between January 1, 2010 and December 31, 2019, of which 11 underwent in situ graft reconstruction following graft removal. The presentation symptoms, infection route, original pathology of abdominal aortic aneurysms (AAA), graft materials, and clinical outcomes were analyzed. @*Results@#Six patients underwent total explantation, whereas 5 underwent removal of only the fabric portions. For in situ reconstructions, prosthetic grafts and banked allografts were used in 8 and 3 patients, respectively. Four mechanisms of graft infection were noted in 11 patients: 4 had bacteremia from systemic infections, 3 had persistent infections following EVAR of primary infected AAA, 3 had ascending infections from adjacent abscesses, and 1 had an aneurysm sac erosion resulting in an aortoenteric fistula. No infection-related postoperative complications or reinfections occurred during the mean 65.27-month (standard deviation, ±52.51) follow-up period. One patient died postoperatively because of the rupture of the proximal aortic wall pseudoaneurysm that had occurred during forceful bare stent removal. @*Conclusion@#Regardless of graft material, in situ graft reconstruction is safe for interposition in treating an infected aortic stent graft following EVAR. In our experience, the residual bare stent is no longer a risk factor for reinfection. Therefore, it is important not to injure the proximal aortic wall when removing the bare stent by force.
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Background@#The coronavirus disease 2019 (COVID-19) pandemic caused disruptions to healthcare systems, consequently endangering tuberculosis (TB) control. We investigated delays in TB treatment among notified patients during the first wave of the COVID-19 pandemic in Korea. @*Methods@#We systemically collected and analyzed data from the Korea TB cohort database from January to May 2020. Groups were categorized as ‘before-pandemic’ and ‘during-pandemic’ based on TB notification period. Presentation delay was defined as the period between initial onset of symptoms and the first hospital visit, and healthcare delay as the period between the first hospital visit and anti-TB treatment initiation. A multivariate logistic regression analysis was performed to evaluate factors associated with delays in TB treatment. @*Results@#Proportion of presentation delay > 14 days was not significantly different between two groups (48.3% vs. 43.7%, P = 0.067); however, proportion of healthcare delay > 5 days was significantly higher in the during-pandemic group (48.6% vs. 42.3%, P = 0.012). In multivariate analysis, the during-pandemic group was significantly associated with healthcare delay > 5 days (adjusted odds ratio = 0.884, 95% confidence interval = 0.715–1.094). @*Conclusion@#The COVID-19 pandemic was associated with healthcare delay of > 5 days in Korea. Public health interventions are necessary to minimize the pandemic’s impact on the national TB control project.
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The present study examined cortical cerebral microinfarcts (CMIs) on a 3T magnetic resonance imaging and investigated the impact of CMIs on the comprehensive functional outcomes during the post-stroke rehabilitation period. Patients with acute phase of firstever ischemic stroke were retrospectively recruited (n = 62) and divided into 2 groups with and without CMIs. Clinical parameters including age, sex, stroke lesion laterality, location, the National Institutes of Health Stroke Scale score, as well as history of hypertension, dyslipidemia, diabetes mellitus, and smoking were obtained. Functional outcomes were assessed twice at baseline and one month later with the Korean version of the MiniMental State Examination, the Berg balance scale (BBS), and the functional independence measure. Partial correlation and multiple linear regression analyses were used to examine the relationship between the presence of CMIs and the change in functional outcomes. At least one CMI was reported in 27 patients, who were older (p = 0.043). The presence of CMIs was significantly associated with functional impairment in all 3 functional outcomes, after controlling for confounding factors (p < 0.05). CMIs might contribute to poor functional outcomes during the post-stroke rehabilitation period. These results suggest that CMIs should be considered when establishing rehabilitation treatment strategies or making a prognosis.
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A 16-year-old, 7.4 kg, castrated male Cocker Spaniel presenting anorexia and weight loss was referred due to a splenic mass, and total splenectomy was performed to resolve clinical signs. Following surgery, the dog developed mild hyperkalemia (6.27 mmol/L) without any clinical symptoms. Further investigations were conducted to determine the cause of hyperkalemia. The serum-plasma potassium difference was measured (1.05 mmol/L), and pseudohyperkalemia was diagnosed. The cause of pseudohyperkalemia was considered as thrombocytosis after splenectomy. The dog did not receive any specific treatment to lower blood potassium. To our knowledge, we report the first case of post-splenectomy pseudohyperkalemia in a dog.
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Background@#Estrogen deficiency affects the structure and function of the salivary glands in women, leading to a decrease in salivary secretion and a change in the composition of saliva. Previous studies on changes in the salivary glands that cause estrogen deficiency have reported only partial results for the parotid and submandibular glands, and there are few comparative morphological studies of histological changes between the parotid and submandibular glands in ovariectomized rats (OVX) leading to estrogen deficiency. This study aimed to analyze the histopathological and histochemical changes in the parotid and submandibular salivary glands causing estrogen deficiency by using OVX, and to discuss the mechanism on these changes. @*Methods@#The parotid and submandibular glands from sacrificed control and OVX groups were fixed with cold 4% paraformaldehyde in phosphate buffer (pH 7.2). The tissues were dehydrated using a series of graded ethyl alcohol and embedded in paraffin. For histopathological analysis, sections cut to a thickness of 6 to 7 μm were stained with hematoxylin and eosin (H&E). For histochemical analysis, Periodic acid-Schiff (PAS), Alcian blue (AB, pH 2.5), and PAS+AB (pH 2.5 and pH 1) staining was performed. @*Results@#Histopathological analysis of OVX tissue showed that the parotid and submandibular salivary glands were broadly and clearly separated and divided into lobes. In OVX, acinar and ductal cells with condensed polymorphic or pyknotic nucleus, which are presumed to be characteristic of apoptotic cells, and degenerated cells with lipid deposition in cytoplasmic granules and ruptured membranes were increased. Histochemical analysis of OVX, confirmed an increase in the number and acidification of acinar secretory granules. @*Conclusion@#Histopathological and histochemical changes and the effects of estrogen deficiency are more evident in the submandibular salivary gland than in the parotid gland.
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Objectives@#：This study was aimed to investigate whether 1) sexual dimorphism in subcortical gray matter volumes (GMV) and the length ratio between the second and fourth digits (2D:4D) would be found and 2) 2D:4D would have associated with subcortical GMV in healthy elderly people. @*Methods@#：Sixty-two females aged 70.3±6.3 (mean±SD) years and 23 males aged 70.4±4.9 years were recruited from the Dementia Clinic in the Pusan National University Hospital. The subjects with the clinical dementia rating scale-sum of boxes (CDR-SB) total score greater than 2.0, any psychiatric or neurological disease, or any pathologic lesion on brain MRI other than micro-angiopathy were excluded. The 2D:4D of the left and right hands were measured 3 times each. Volumetric segmentation of T1-weighted MRI scans was done by Freesurfer software (v7.1.1.1). @*Results@#：2D:4Ds of males were smaller than those of females significantly on repeated measures ANOVA. The males’ thalamus, putamen, hippocampus in both hemispheres and the right amygdala were larger than females’. These differences were not significant after controlling for age, education and total intracranial volume (ICV). In the females, the left 2D:4D was negatively correlated with the left hippocampal volume. In the males, 2D:4D was positively correlated with the volumes of ipsilateral or contralateral thalamus, hippocampus, amygdala and accumbens. These correlations were not significant after Bonferroni’s correction, except for the right accumbens. @*Conclusions@#：Sexual dimorphism of 2D:4D is preserved in healthy elderly people. There is a significant correlation between the right 2D:4D and GMV of the accumbens in males.
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Objective@#Although previous studies have shown association between anterior corpus callosum (ACC) and various psychotic disorder, the effect of ACC on development on psychotic symptoms in Alzheimer’s disease (AD) is still unclear. The purpose of this study is to investigate the association of ACC with the development of psychosis in patients with AD. @*Methods@#This is a hospital based cross-sectional study of 241 AD patients. The main outcome measure is the volume of ACC that were measured as regions of interest with magnetic resonance imaging and the FreeSurfer analysis at baseline. Analysis of covariance and Logistic regression analysis conducted to assess the association between the volume of ACC and the presence of psychosis in AD, adjusting for age, education, Clinical Dementia Rating-Sum of Boxes, and total intracranial volume. @*Results@#We found that the volume of ACC is significantly reduced in AD with psychosis (AD+P) compared to AD without psychosis (AD-P) (774.27±142.96 vs. 833.09±142.04, p=0.005). The volume of ACC associated with the presence of psychosis in AD (odds ratio=0.995; 95% confidence interval=0.993-0.997; p=0.006). @*Conclusion@#We have found that reduced volume of ACC in AD+P, suggesting that ACC might play an important role in the underlying pathogenesis of development of psychotic symptoms in AD.
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Objective@#This study examined the volume of choroid plexus across AD without delusion (AD-D), AD with paranoid delusion (AD+PD), and AD with misidentification delusion (AD+MD). @*Methods@#This is a hospital based cross-sectional study of patients with AD. The main outcome measure is the volume of choroid plexus that were measured as regions of interest with magnetic resonance imaging and the FreeSurfer analysis at baseline. Analysis of covariance (ANCOVA) was conducted to compare the differences on the volume of choroid plexus across AD-D, AD+PD, and AD+MD after controlling demographics. @*Results@#There was no volume difference in the both choroid plexus between AD-D and AD+D. However, the volumes of both cho-roid plexus were significantly reduced in AD+MD compared to AD+PD. @*Conclusion@#Our study demonstrates that AD+MD has significantly reduced volumes of choroid plexus compared to AD+PD. These findings suggest that AD+MD and AD+PD may have different pathophysiological mechanisms related to neuroimmune re-sponses in the choroid plexus.
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Background and Objectives@#A lack of investigators for polysomnography has risen due to increased demand since health insurance started to cover the cost of the test. We examined the reliability of the automated scoring of polysomnography, which has been deployed to improve this imbalance.Subjects and Method We analyzed the data of 20 patients who underwent level 1 polysomnography from April 1 to July 27, 2019. The software from Noxturnal (Nox Medical) was used for the scoring of the Polysomnography data. Each of the polysomnographic data was scored both by the automated scoring system and by a skilled technician. @*Results@#Twenty patients were analyzed. There was no significant difference between automated scoring and manual scoring in sleep latency, apnea index, and rapid eye movement sleep stage ratio. However, the concordance rate of the sleep stage by epoch was 83.32%, and there was a significant difference with regards to apnea-hypoapnea index (AHI) and respiratory disturbance index (RDI). Two obvious errors were noted in the automated scoring that could be easily fixed; the failure to recognize wakefulness during sleep and the fragmentation of respiratory events. When two errors were corrected, many differences in polysomnography parameters, including AHI and RDI, were eliminated. @*Conclusion@#It showed 80% coincidence of epoch in the sleep stage between the automated scoring and manual scoring. However, there was no difference in AHI and RDI when the fragmented respiratory events of the automated scoring were adjusted. Therefore, automated scoring is considered to be useful if only a little modification could be made.
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Background@#The aim of this study was to analyze the public demand for information about the job of dental hygienists by mining text data collected from the online Q & A section on an Internet portal site. @*Methods@#Text data were collected from inquiries that were posted on the Naver Q & A section from January 2003 to July 2020 using “dental hygienist job recognition,” “role recognition,” “medical assistance,” and “scaling” as search keywords. Text mining techniques were used to identify significant Korean words and their frequency of occurrence. In addition, the association between words was analyzed. @*Results@#A total of 10,753 Korean words related to the job of dental hygienists were extracted from the text data. “Chi-lyo (treatment),” “chigwa (dental clinic),” “ske-illing (scaling),” “itmom (gum),” and “chia (tooth)” were the five most frequently used words. The words were classified into the following areas of job of the dental hygienist: periodontal disease treatment and prevention, medical assistance, patient care and consultation, and others. Among these areas, the number of words related to medical assistance was the largest, with sixty-six association rules found between the words, and “chi-lyo,” “chigwa,” and “ske-illing” as core words. @*Conclusion@#The public demand for information about the job of dental hygienists was mainly related to “chi-lyo,” “chigwa,” and “ske-illing” as core words, demonstrating that scaling is recognized by the public as the job of a dental hygienist. However, the high demand for information related to treatment and medical assistance in the context of dental hygienists indicates that the job of dental hygienists is recognized by the public as being more focused on medical assistance than preventive dental care that are provided with job autonomy.
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Background@#We aimed to investigate the effect of Citrous limon extract (CLE) on oxidative stress-induced cytotoxicity and nitric oxide (NO) generation and the tooth bleaching effect of CLE as a substitute for hydrogen peroxide (H2O2) and determine the feasibility and application of CLE as a safe and effective natural tooth bleaching agent. @*Methods@#The protective effect of CLE on H2O2-induced cytotoxicity in Raw264.7 macrophages was investigated by the MTT assay. The inhibitory effect of CLE on the generation of H2O2-induced NO was confirmed by the NO assay, and the changes in inducible nitric oxide synthase (iNOS) protein expression were confirmed by western blotting. Stained bovine teeth were treated with/without 15% and/or 35% CLE and H2O2, 15% sodium bicarbonate (NaHCO3) for 3 hours, and were irradiated with/without bleaching light (BL) for 15 minutes. The color change of the treated bovine tooth surface was measured using a colorimeter. @*Results@#The viability of Raw264.7 cells treated with each concentration of CLE and 500 µM H2O2 significantly increased as CLE increased, and NO generation and iNOS protein expression were significantly reduced in cells treated with 300 µg CLE+/500 µM H2O2+ and 300 µg CLE+/500 µM H2O2+/150 µg NaHCO3+. The bleaching effect of 35% CLE+ was higher than that of 15% CLE+ and 15% NaHCO3+, and the effect was similar to that of 15% H2O2+. The 35% CLE+/15% NaHCO3+ showed the greatest bleaching effect and was higher than that of the groups irradiated with the BL. The greatest bleaching effect was observed with 35% CLE+/15% NaHCO3+, followed by 35% H2O2+/BL+. @*Conclusion@#CLE inhibited oxidative stress-induced cytotoxicity and NO generation in Raw264.7 cells and, could replace H2O2, which causes side effects and risks in teeth breaching treatment. It showed greatest teeth bleaching effect when combined with NaHCO3. CLE is an effective and safe natural tooth bleaching substitute.
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Background@#Personality might be one of the important factors related to stress-coping in mood disorders. This study aimed to investigate the relationship between personality and stress-coping strategies in patients with bipolar and depressive disorders. @*Methods@#A total of 195 patients diagnosed with bipolar and depressive disorders according to the criteria mentioned in Diagnostic and Statistical Manual of Mental disorders’ 5th edition were included. Pearson’s correlation and multiple regression analyses were used to analyze the relationship between personality, measured by Temperament and Character Inventory and NEO-Five Factor Inventory, and coping strategies, measured by Coping Inventory for Stressful Situations. @*Results@#Self-directedness was reported to be positively associated with task-oriented coping in bipolar disorders, and harm avoidance was negatively associated with task-oriented coping in depressive disorders. Beck Depression Inventory score, neuroticism, and extroversion were found to be positively associated with emotion-oriented coping in bipolar disorders, and neuroticism was positively associated with emotion-oriented coping in depressive disorders. Extroversion was reported to be positively associated with avoidance-oriented coping in bipolar disorders, and extroversion, novelty seeking, and reward dependence were positively associated with avoidance-oriented coping in depressive disorders. @*Conclusion@#This study concluded that the relationship between personality and stress-coping strategies may vary based on the type of mood disorder that is diagnosed. The interaction between personality and stress-coping might be considered for the modification of coping strategies in mood disorders.
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Objectives@#：A recent study of a European sample implied that the 14 genes previously known to be related with schizophrenia may play little roles. But much work remains before dismissing these genes from their connection to schizophrenia. This is a pilot study for family based association test (FBAT) analysis of estrogen metabolism gene in a Korean population with schizophrenia. @*Methods@#：27 probands with schizophrenia were recruited with their parents and siblings. The subjects were interviewed using Korean versions of diagnostic interview for genetic studies and family interview for genetic studies. We analyzed 2 single nucleotide polymorphism (SNP) of ESR1, COMT gene. We performed FBAT and linkage disequilibrium analyses for each individual SNP. @*Results@#：We found a significant SNP of ESR1 gene in chromosome 6 for the qualitative phenotype of schizophrenia. That result was replicated for the quantitative phenotype of apparent onset, apparent onset of psychosis, and first treatment age. We also found a significant SNP of ESR1 gene in chromosome 6 for the quantitative phenotype of any delusions. @*Conclusions@#：Our results show that quantitative traits such as age of onset, any delusions, and any hallucinations could be continuous with qualitative trait in schizophrenia. But we should be very cautious because there are clear limitations in some nominal number of SNPs and the small incomplete pedigrees. In the future, FBAT analyses in families with subtyped schizophrenic probands according to personality, working memory, cognition will facilitate fine mapping analyses for searching candidate genes of schizophrenia.
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Dystonia is a movement disorder characterized by involuntary contraction of muscles resulting in repetitive or twisting movements. Dystonia is generally caused by basal ganglia dysfunction.Recent studies have reported an association between dystonia and brainstem disorders. However, the pathological mechanism is uncertain, and detailed management strategies are limited. Here, we report a case of hemidystonia with abnormal posture and impaired proprioception after pontine hemorrhage that was effectively treated with pharmacotherapy combined with early intensive comprehensive rehabilitation. A 45-year-old man presented with abnormal posture and dystonic movement in the right hand and foot after a pontine hemorrhagic stroke. Pharmacotherapy with clonazepam and benztropine was administered, and comprehensive rehabilitation programs were implemented intensively from the early stages of symptom onset. After 3 months, the patient was able to walk independently, go up and down a few stairs without the use of a handrail, and was able to perform activities of daily living with minimal assistance.
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Purpose@#This study aimed to investigate the effect of ursodeoxycholic acid (UDCA) on the biodistribution and excretion of technetium-99m (Tc-99m)-labeled radiopharmaceuticals. @*Materials and Methods@#Tc-99m hydroxy-methylene-diphosphonate (HDP), Tc-99m pertechnetate, and Tc-99m dimercaptosuccinic acid (DMSA) were injected via the tail vein of rats. After 30 min, the control group was administered saline, and the UDCA group was given UDCA orally. Scintigraphy images were acquired after 30 min and 1, 2, 3, and 4 h. Radioactivity and rate of change were compared. Tc-99m mercaptoacetyltriglycine (MAG3) imaging was also performed. @*Results@#In image analysis of Tc-99m HDP, radioactivity of the buttock was lower in the UDCA group at 4 h. Rates of change in the buttock were significantly different at 3 h–30 min and 4 h–30 min, and buttock radioactivity in the UDCA group had decreased more. In analysis of Tc-99m pertechnetate, radioactivity of the buttock was higher in the control group. Rates of change in the thyroid gland and buttock were different at 1 h–30 min, 3 h–30 min, and 4 h–30 min, with radioactivity in the UDCA group decreasing more. In the analysis of Tc-99m DMSA, while the radioactivity of the kidneys in the control group showed little decrease at 1 h–30 min, that in the UDCA group increased. In the analysis of Tc-99m MAG3 images, radioactivity and radioactivity/total body radioactivity (TBA) values for the kidneys were higher in the UDCA group at 2 min. At 5 and 10 min, radioactivity/TBA values for soft tissue in the UDCA group were lower than those in the control group. @*Conclusion@#This study demonstrated that administration of UDCA increases renal excretion and soft tissue clearance of radiopharmaceuticals. This investigation could contribute to the broadening of applications of UDCA.
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Background@#Pharmacological and non-pharmacological therapies have been used to treat patients with chemotherapy-induced peripheral neuropathy (CIPN). However, the effect of therapies in cancer patients has yet to be investigated comprehensively. We hypothesized that cyclic thermal therapy would improve blood flow and microcirculation and improve the symptoms driven by CIPN. @*Methods@#The criteria of assessment were blood volume in region of interest (ROI) in the images, and European Organization for Research and Treatment of Cancer–Quality of Life Questionnaire–Chemotherapy-Induced Peripheral Neuropathy 20 questionnaire scores. The blood volume was quantified by using red blood cell (RBC) scintigraphy. All patients were treated 10 times during 10 days. The thermal stimulations, between 15° and 41°, were repeatedly delivered to the patient’s hands. @*Results@#The total score of the questionnaires, the score of questions related to the upper limbs, the score of questions closely related to the upper limbs, and the score excluding the upper limbs questions was decreased. The blood volume was decreased, and the variance of blood volume was decreased. During cooling stimulation, the blood volume was decreased, and its variance was decreased. During warming stimulation, the blood volume was decreased, and its variance was decreased. @*Conclusions@#We suggest that cyclic thermal therapy is useful to alleviate CIPN symptoms by blood circulation improvement. RBC scintigraphy can provide the quantitative information on blood volume under certain conditions such as stress, as well as rest, in peripheral tissue.