Implementation of a novel program to support colorectal cancer screening in a community health center consortium before and after the onset of COVID-19: a qualitative study of stakeholders' perspectives.

BACKGROUND: In 2017, the San Francisco Cancer Initiative (SF CAN) established the Colorectal Cancer (CRC) Screening Program to provide technical assistance and financial support to improve CRC screening processes, and outcomes in a consortium of community health centers (CHCs) serving low-income communities in San Francisco. The purpose of this study was twofold: to evaluate the perceived influence of the support provided by the CRC Screening Program's Task Force on CRC screening processes and outcomes in these settings and to identify facilitators and barriers to SF CAN-supported CRC screening activities before and after the onset of the COVID-19 pandemic. METHODS: Semi-structured key informant interviews were conducted with consortium leaders, medical directors, quality improvement team members, and clinic screening champions. Interviews were audio-recorded, professionally transcribed, and analyzed for themes. The Consolidated Framework for Implementation Research (CFIR) was used to develop the interview questions and organize the analysis. RESULTS: Twenty-two participants were interviewed. The most commonly cited facilitators of improved screening processes included the expertise, funding, screening resources, regular follow-up, and sustained engagement with clinic leaders provided by the task force. The most salient barriers identified were patient characteristics, such as housing instability; staffing challenges, such as being understaffed and experiencing high staff turnover; and clinic-level challenges, such as lack of ability to implement and sustain formalized patient navigation strategies, and changes in clinic priorities due to the COVID-19 pandemic and other competing health care priorities. CONCLUSIONS: Implementing CRC screening programs in a consortium of CHCs is inherently challenging. Technical assistance from the Task Force was viewed positively and helped to mitigate challenges both before and during the pandemic. Future research should explore opportunities to increase the robustness of technical assistance offered by groups such as SF CAN to support cancer screening activities in CHCs serving low-income communities.

Safety of spinal anesthesia in pregnant vaccinated with one or two doses of the BNT162b2 vaccine: A retrospective observational cohort study.

Purpose: To evaluate the safety of spinal anesthesia in pregnant women who underwent cesarean section during the Covid-19 pandemia and were immunized with the BNT162b2 vaccine. Methods: Historical cohort study that included three groups: non-vaccinated pregnant with no history of acute or previous Covid-19 [NV (n = 70)], vaccinated with one dose [1D (n = 65)] or two doses of BNT162b2 [2D (n = 45)], who underwent cesarean section with spinal anesthesia. Variables with normal distribution were analyzed with ANOVA. When one or more groups had non-normal distribution, the Kruskal-Wallis test was used. For categorical variables, the chi-square test or Kruskal-Wallis test was performed. When any variable had a frequency of less than five, the two-tailed Fisher's exact test with the Freeman-Halton extension was used. The significance level considered was p < .05. Results: Apparently there is no interaction between BNT162b2 and the drugs most commonly used in spinal anesthesia for cesarean delivery. Conclusion: Performing spinal anesthesia in patients immunized with BNT162b2 does not seem to result in significant differences in outcomes compared to those not vaccinated. Apparently there is no need to change the standards of performing spinal anesthesia in patients vaccinated with the BNT162b2 vaccine.

Use of Monoclonal Antibodies in a Pediatric Patient With Severe Combined Immunodeficiency and Persistent SARS-CoV-2 Infection.

We describe the use of monoclonal antibodies for the treatment of persistent SARS-CoV-2 infection in a pediatric patient with severe combined immunodeficiency who required urgent stem cell transplantation to cure his disease.

Drinking during social isolation: investigating associations between stress, inhibitory control, boredom, drinking motives, and alcohol use

Background: We aimed to assess whether stress, boredom, drinking motives, and/or inhibitory control were related to alcohol use during a period of social isolation. Method: Analyses were carried out on questionnaire data (N = 337) collected during the first wave of the COVID-19 pandemic (7 April–3 May 2020). We first assessed changes in drinking behavior, stress and boredom. We then regressed drinking behavior on drinking motives, inhibitory control, stress, and boredom. We also investigated interactions between change in stress/boredom and inhibitory control. Results: A minority of respondents reported increased alcohol use (units = 23.52%, drinking days = 20.73%, heavy days = 7.06%), alcohol-related problems (9.67%), and stress (36.63%). Meanwhile, most respondents reported increased boredom (67.42%). Similarly, boredom significantly increased (B = 21.22, p <.001), on average, while alcohol-related problems decreased (B = −1.43 p <.001). Regarding drinking motives, decreased alcohol-related problems were associated with social drinking motives (B = −0.09, p =.005). Surprisingly, risk-taking was associated with decreased alcohol-related problems (B = −0.02, p =.008) and neither stress nor boredom independently predicted changes in alcohol use. Finally, several significant interactions suggested that those who were more impulsive and less bored were more likely to report increased alcohol use and vice versa. Conclusions: These data provide a nuanced overview of changes in drinking-related behavior during the COVID-19-induced period of social isolation. While most people reduced their drinking, there was evidence of complex interactions between impulsivity and boredom that may be explored in future studies.

COVID-19 associated development of antibody mediated rejection in orthotopic heart transplantation patients.

Solid organ transplant candidates encountered increased wait times and mortality rates during the coronavirus 2019 (COVID-19) pandemic. Despite improvement in medical management and vaccination efficacy, this patient population remains at increased risk for complications post COVID-19 including organ rejection. We describe the development of antibody mediated rejection with or without cellular rejection in heart transplant (HT) recipients and previous COVID-19 infection or vaccination. Although centers have changed their management of outpatient follow-up for orthotopic heart transplant patients, little is known on surveillance of rejection and management of HT recipients after COVID-19 infection. We recommend frequent surveillance for rejection or allograft dysfunction after COVID-19 infection. We have adopted a transplant surveillance protocol for HT recipients with COVID-19 infection, given our recent experience with transplanted patients affected of COVID-19.

Contralateral Recurrences of Post-vaccination Multiple Evanescent White Dot Syndrome.

We report on a case of multiple evanescent white dot syndrome (MEWDS) following the simultaneous administration of the human papillomavirus and meningococcal (conjugate) vaccines and two recurrences of MEWDS following the administration of the second dose of the human papillomavirus (HPV) vaccine and the COVID-19 vaccine and COVID-19 viral infection. A 17-year-old Hispanic female presented with a one-week history of photopsia and blurred vision in her left eye following the simultaneous administration of the human papillomavirus and meningococcal (conjugate) vaccines. Upon a comprehensive examination, her best-corrected visual acuity was 20/20 in the right eye and 20/100 in the left eye. A left fundus examination revealed multiple white dots in the macula and nasal periphery, consistent with a diagnosis of MEWDS. Ancillary testing, including fundus autofluorescence, fluorescein angiography, indocyanine green angiography, and optical coherence tomography, supported the diagnosis. One month following her initial diagnosis, the patient's symptoms had resolved without any therapy, and a fundus examination revealed multiple relatively ill-defined brown-colored subretinal lesions in the nasal midperiphery, corresponding to the location of the previous MEWDS lesions. Subsequently, she received the second dose of the HPV vaccine and then developed a mild COVID-19 infection. Four months after the initial presentation, she received the first dose of the BNT162b2 COVID-19 vaccine, followed by the second dose a month later. Eight months following her initial presentation, she presented with photopsia in the right eye. Her visual acuity remained 20/20 in the right eye and improved to 20/20 in the left eye, and white dots were identified nasal to the disk and surrounding the peripapillary region; the contralateral MEWDS diagnosis was confirmed by the previously mentioned ancillary tests. At her one-month follow-up, she presented new onset photopsia of the right eye. Her visual acuity remained 20/20 in both eyes, and a fundus examination revealed white lesions suggestive of active MEWDS temporal to the macula and brown-colored spots nasal to the disk, suggestive of recovering MEWDS, nasally. The aforementioned testing confirmed the coexistence of new and resolving lesions; nonetheless, the patient's symptoms resolved without any therapy, and she received the third dose of the BNT162b2 COVID-19 vaccine 11 months after her initial presentation. Our case suggests that vaccines may serve as immunological triggers of MEWDS. Recurrent MEWDS may occur when an individual is exposed to a powerful immune challenge, such as receiving a wide array of vaccinations in a short period of time. We believe this case constitutes a previously undescribed finding of multiple relatively ill-defined brown-colored subretinal lesions present in late MEWDS.

The United States public health services failure to control the coronavirus epidemic.

The unprecedented COVID-19 epidemic in the United States (US) and worldwide, caused by a new type of coronavirus (SARS-CoV-2), occurred mostly because of higher-than-expected transmission speed and degree of virulence compared with previous respiratory virus outbreaks, especially earlier Coronaviruses with person-to-person transmission (e.g., MERS, SARS). The epidemic's size and duration, however, are mostly a function of failure of public health systems to prevent/control the epidemic. In the US, this failure was due to historical disinvestment in public health services, key players equivocating on decisions, and political interference in public health actions. In this communication, we present a summary of these failures, discuss root causes, and make recommendations for improvement with focus on public health decisions.

Factors associated to emotional impact of COVID-19 pandemic on health professional

The aim of this study was to explore the emotional impact of Covid-19 on healthcare professionals at the Clinical and University Hospital of Valencia (Spain), and to identify the associated variables. A total of 228 professionals completed an ad hoc online survey in May 2020. The healthcare professionals experienced symptoms of stress (32%), depression (26%), anxiety (14%) and intrusive memories (7.5%). A higher frequency of sadness and anxiety was observed in women and in professionals who had presented Covid-19 symptoms. The professional category with the most frequent emotional symptoms was that of auxiliary nurses, and for stress also nurses and residents. The most affected were the first line units. The psychological variables that were negatively associated with the frequency of all symptomatic manifestations were: self-care, self-esteem, resilience and use of active coping strategies, together with self-efficacy and social support for stress and depression. Despite the limitations of the study, the results may contribute to guide preventive programs for health professionals in future health crises. (PsycInfo Database Record (c) 2022 APA, all rights reserved) (Spanish) El objetivo de este trabajo fue explorar el impacto emocional de la Covid-19 en profesionales sanitarios del Hospital Clinico Universitario de Valencia, e identificar las variables asociadas. Participaron 228 profesionales que cumplimentaron en mayo de 2020 una encuesta online elaborada ad hoc. Los profesionales sanitarios experimentaron sintomas de estres (32%), depresion (26%), ansiedad (14%) y recuerdos intrusos (7,5%). Se observo mayor frecuencia de tristeza y ansiedad en mujeres y en profesionales que habian presentado sintomas de Covid-19. La categoria profesional con sintomas emocionales mas frecuentes fue el de auxiliar de enfermeria, y para estres tambien enfermeros y residentes. Las unidades con mayor afectacion fueron las de primera linea. Las variables psicologicas que se asociaron negativamente con la frecuencia de todas las manifestaciones sintomaticas fueron: autocuidado, autoestima, resiliencia y uso de estrategias de afrontamiento activas, junto a autoeficacia y apoyo social para estres y depresion. Pese a las limitaciones del estudio, los resultados pueden contribuir a orientar programas preventivos para profesionales sanitarios en futuras crisis sanitarias. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Value of quantitative airspace disease measured on chest CT and chest radiography at initial diagnosis compared to clinical variables for prediction of severe COVID-19.

Purpose: Rapid prognostication of COVID-19 patients is important for efficient resource allocation. We evaluated the relative prognostic value of baseline clinical variables (CVs), quantitative human-read chest CT (qCT), and AI-read chest radiograph (qCXR) airspace disease (AD) in predicting severe COVID-19. Approach: We retrospectively selected 131 COVID-19 patients (SARS-CoV-2 positive, March to October, 2020) at a tertiary hospital in the United States, who underwent chest CT and CXR within 48 hr of initial presentation. CVs included patient demographics and laboratory values; imaging variables included qCT volumetric percentage AD (POv) and qCXR area-based percentage AD (POa), assessed by a deep convolutional neural network. Our prognostic outcome was need for ICU admission. We compared the performance of three logistic regression models: using CVs known to be associated with prognosis (model I), using a dimension-reduced set of best predictor variables (model II), and using only age and AD (model III). Results: 60/131 patients required ICU admission, whereas 71/131 did not. Model I performed the poorest ( AUC = 0.67 [0.58 to 0.76]; accuracy = 77 % ). Model II performed the best ( AUC = 0.78 [0.71 to 0.86]; accuracy = 81 % ). Model III was equivalent ( AUC = 0.75 [0.67 to 0.84]; accuracy = 80 % ). Both models II and III outperformed model I ( AUC difference = 0.11 [0.02 to 0.19], p = 0.01 ; AUC difference = 0.08 [0.01 to 0.15], p = 0.04 , respectively). Model II and III results did not change significantly when POv was replaced by POa. Conclusions: Severe COVID-19 can be predicted using only age and quantitative AD imaging metrics at initial diagnosis, which outperform the set of CVs. Moreover, AI-read qCXR can replace qCT metrics without loss of prognostic performance, promising more resource-efficient prognostication.

FACTORES ASOCIADOS AL IMPACTO EMOCIONAL DE LA PANDEMIA POR COVID-19 EN PROFESIONALES SANITARIOS

El objetivo de este trabajo fue explorar el impacto emocional de la Covid-19 en profesionales sanitarios del Hospital Clínico Universitario de Valencia, e identificar las variables asociadas. Participaron 228 profesionales que cumplimentaron en mayo de 2020 una encuesta online elaborada ad hoc. Los profesionales sanitarios experimentaron síntomas de estrés (32%), depresión (26%), ansiedad (14%) y recuerdos intrusos (7,5%). Se observó mayor frecuencia de tristeza y ansiedad en mujeres y en profesionales que habían presentado síntomas de Covid-19. La categoría profesional con síntomas emocionales más frecuentes fue el de auxiliar de enfermería, y para estrés también enfermeros y residentes. Las unidades con mayor afectación fueron las de primera línea. Las variables psicológicas que se asociaron negativamente con la frecuencia de todas las manifestaciones sintomáticas fueron: autocuidado, autoestima, resiliencia y uso de estrategias de afrontamiento activas, junto a autoeficacia y apoyo social para estrés y depresión. Pese a las limitaciones del estudio, los resultados pueden contribuir a orientar programas preventivos para profesionales sanitarios en futuras crisis sanitarias.Alternate :The aim of this study was to explore the emotional impact of Covid-19 on healthcare professionals at the Clinical and University Hospital of Valencia (Spain), and to identify the associated variables. A total of 228 professionals completed an ad hoc online survey in May 2020. The healthcare professionals experienced symptoms of stress (32%), depression (26%), anxiety (14%) and intrusive memories (7.5%). A higher frequency of sadness and anxiety was observed in women and in professionals who had presented Covid-19 symptoms. The professional category with the most frequent emotional symptoms was that of auxiliary nurses, and for stress also nurses and residents. The most affected were the first line units. The psychological variables that were negatively associated with the frequency of all symptomatic manifestations were: self-care, self-esteem, resilience and use of active coping strategies, together with self-efficacy and social support for stress and depression. Despite the limitations of the study, the results may contribute to guide preventive programs for health professionals in future health crises.

Case of COVID mRNA Vaccine linked Antiphospholipid Syndrome (preprint)

There have been several reports of thrombotic adverse events after administration of the mRNA COVID vaccine [1] [2]. The onset of autoimmune disease has also been reported following viral illness as well as following vaccination [3]. The antiphospholipid syndrome is an autoimmune hypercoagulable state that can result in thrombotic events such as deep venous thrombosis, pulmonary embolus, and stroke [4]. The antiphospholipid syndrome has also been reported following natural Covid infection [5]. Herein we present a case of “antiphospholipid syndrome” following COVID mRNA vaccination and associated with life threatening thrombosis.

Applying Exploratory Testing and Ad-Hoc Usability Inspection to Improve the Ease of Use of a Mobile Power Consumption Registration App: An Experience Report

As the number of mobile devices has increased, software development teams have focused on releasing mobile applications, allowing users to carry out transactions, access information and improve their lifestyle more efficiently. Nevertheless, even when providing useful means for carrying out daily tasks, users report dissatisfaction or frustration when using these applications. For energy companies, mobile applications that fail to provide both usefulness and ease of use may reduce their adoption and an increase in the company’s workload, as users will require company workers to solve problems they could solve on their own. In this paper, we report how we applied exploratory testing and ad-hoc usability inspection to identify improvement opportunities during the development of a mobile application that would allow users to measure their power consumption, supporting social distancing in the context of the COVID-19 pandemic. After identified a set of functional and usability problems, the development team redesigned the application, which was perceived as both useful and easy to use from the point of view of the managers that requested it. Also, we report lessons learned that are useful for practitioners willing to replicate this experience. © 2021, Springer Nature Switzerland AG.

APTES-Based Silica Nanoparticles as a Potential Modifier for the Selective Sequestration of CO2 Gas Molecules.

In this work, we have described the characterization of hybrid silica nanoparticles of 50 nm size, showing outstanding size homogeneity, a large surface area, and remarkable CO2 sorption/desorption capabilities. A wide battery of techniques was conducted ranging from spectroscopies such as: UV-Vis and IR, to microscopies (SEM, AFM) and CO2 sorption/desorption isotherms, thus with the purpose of the full characterization of the material. The bare SiO2 (50 nm) nanoparticles modified with 3-aminopropyl (triethoxysilane), APTES@SiO2 (50 nm), show a remarkable CO2 sequestration enhancement compared to the pristine material (0.57 vs. 0.80 mmol/g respectively at 50 °C). Furthermore, when comparing them to their 200 nm size counterparts (SiO2 (200 nm) and APTES@SiO2 (200 nm)), there is a marked CO2 capture increment as a consequence of their significantly larger micropore volume (0.25 cm3/g). Additionally, ideal absorbed solution theory (IAST) was conducted to determine the CO2/N2 selectivity at 25 and 50 °C of the four materials of study, which turned out to be >70, being in the range of performance of the most efficient microporous materials reported to date, even surpassing those based on silica.

Predicting coronavirus disease (COVID-19) outcomes in the United States early in the epidemic.

By 21 October 2020, the coronavirus disease (COVID-19) epidemic in the United States (US) had infected 8.3 million people, resulting in 61,364 laboratory-confirmed hospitalizations and 222,157 deaths. Currently, policymakers are trying to better understand this epidemic, especially the human-to-human transmissibility of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in relation to social, populational, air travel related and environmental exposure factors. Our study used 50 US states' public health surveillance datasets (January 1-April 1, 2020) to measure associations of confirmed COVID-19 cases, hospitalizations and deaths with these variables. Using the resulting associations and multivariate regression (Negative Binomial and Poisson), predicted cases, hospitalizations and deaths were generated for each US state early in the epidemic. Factors associated with a significantly increased risk of COVID-19 disease, hospitalization and death included: population density, enplanement, Black race and increased sun exposure; in addition, COVID-19 disease and hospitalization were also associated with morning humidity. Although predictions of the number of cases, hospitalizations and deaths due to COVID-19 were not accurate for every state, those states with a combination of large number of enplanements, high population density, high proportion of Black residents, high humidity or low sun exposure may expect more rapid than expected growth in the number of COVID-19 events early in the epidemic.

Integrating Social Determinants in Decision-Making Processes for Health: Insights from Conceptual Frameworks-the 3-D Commission.

The inclusion of social determinants of health offers a more comprehensive lens to fully appreciate and effectively address health. However, decision-makers across sectors still struggle to appropriately recognise and act upon these determinants, as illustrated by the ongoing COVID-19 pandemic. Consequently, improving the health of populations remains challenging. This paper seeks to draw insights from the literature to better understand decision-making processes affecting health and the potential to integrate data on social determinants. We summarised commonly cited conceptual approaches across all stages of the policy process, from agenda-setting to evaluation. Nine conceptual approaches were identified, including two frameworks, two models and five theories. From across the selected literature, it became clear that the context, the actors and the type of the health issue are critical variables in decision-making for health, a process that by nature is a dynamic and adaptable one. The majority of these conceptual approaches implicitly suggest a possible role for data on social determinants of health in decision-making. We suggest two main avenues to make the link more explicit: the use of data in giving health problems the appropriate visibility and credibility they require and the use of social determinants of health as a broader framing to more effectively attract the attention of a diverse group of decision-makers with the power to allocate resources. Social determinants of health present opportunities for decision-making, which can target modifiable factors influencing health-i.e. interventions to improve or reduce risks to population health. Future work is needed to build on this review and propose an improved, people-centred and evidence-informed decision-making tool that strongly and explicitly integrates data on social determinants of health.

Poor Ventilation Habits in Nursing Homes Have Favoured a High Number of COVID-19 Infections

Residents of nursing homes have been significantly affected by COVID-19 in Spain. The factors that have contributed to the vulnerability of this population are very diverse. In this study, physical agents, chemical pollutants, population density and different capacities of residences were analysed to understand their influence on the number of elderly people who have died in geriatric centres in different autonomous communities (AACCs) of Spain. A statistical analysis was carried out on the variables observed. The results show that many residences with a larger number of deaths were private, with some exceptions. Physical agents and pollutants were found to be determining factors, especially for the communities of Extremadura and Castilla–La Mancha, although the large number of factors involved makes this study complicated. The compromise between air quality and energy efficiency is of great importance, especially when human health is at stake.

Tackling Dissipative Components Based on the SPECO Approach: A Cryogenic Heat Exchanger Used in Natural Gas Liquefaction

The cryogenic industry has been experiencing continuous progress in recent years, primarily due to the global development of oil and gas activities. Natural gas liquefaction is a cryogenic process, with the refrigeration system being crucial to the overall process. The objective of the study presented herein is to carry out an exergoeconomic assessment for a dual nitrogen expander process used to liquefy natural gas, employing the SPecific Exergy COsting (SPECO) methodology. The air coolers and throttling valve are dissipative components, which present fictitious unit cost rates that are reallocated to the final product (Liquefied Natural Gas). The liquefaction process has an exergy efficiency of 41.89%, and the specific cost of liquefied natural gas is 292.30 US$/GJ. It was verified that this cost increased along with electricity. The highest exergy destruction rates were obtained for Expander 1 and Air cooler 2. The highest average cost per exergy unit of fuel was obtained for the vertical separator, followed by Air coolers 1 and 2. An assessment of the exergoeconomic factor indicated that both expanders could benefit from a decrease in exergy destruction, improving the exergoeconomic performance of the overall system. Regarding the relative cost difference, all compressors presented high values and can be enhanced with low efforts.

Safety and efficacy of a COVID-19 treatment with nebulized and/or intravenous neutral electrolyzed saline combined with usual medical care vs. usual medical care alone: A randomized, open-label, controlled trial

Coronavirus disease 2019 (COVID-19) is currently the major public health problem worldwide. Neutral electrolyzed saline solution that contains reactive chlorine and oxygen species may be an effective therapeutic. In the present study, the treatment efficacy of intravenous and/or nebulized neutral electrolyzed saline combined with usual medical care vs. usual medical care alone was evaluated in ambulatory patients with COVID-19. A prospective, 2-arm, parallel-group, randomized, open-label, multi-center, phase I-II clinical trial including 214 patients was performed. The following two outcomes were evaluated during the 20-day follow-up: i) The number of patients with disease progression;and ii) the patient acceptable symptom state. Serial severe acute respiratory syndrome coronavirus 2 naso/oro-pharyngeal detection by reverse transcription-quantitative (RT-q) PCR was performed in certain patients of the experimental group. Biochemical and hematologic parameters, as well as adverse effects, were also evaluated in the experimental group. The experimental treatment decreased the risk of hospitalization by 89% [adjusted relative risk (RR)=0.11, 95% confidence interval (CI): 0.03-0.37, P<0.001] and the risk of death by 96% (adjusted RR=0.04, 95% CI: 0.01-0.42, P=0.007) and also resulted in an 18-fold higher probability of achieving an acceptable symptom state on day 5 (adjusted RR=18.14, 95% CI: 7.29-45.09, P<0.001), compared with usual medical care alone. Overall, neutral electrolyzed saline solution was better than usual medical care alone. Of the patients analyzed, >50% were negative for the virus as detected by RT-qPCR in naso/oro-pharyngeal samples on day 4, with only a small number of positive patients on day 6. Clinical improvement correlated with a decrease in C-reactive protein, aberrant monocytes and increased lymphocytes and platelets. Cortisol and testosterone levels were also evaluated and a decrease in cortisol levels and an increase in the testosterone-cortisol ratio were observed on days 2 and 4. The experimental treatment produced no serious adverse effects. In conclusion, neutral electrolyzed saline solution markedly reduced the symptomatology and risk of progression in ambulatory patients with COVID-19. The present clinical trial was registered in the Cuban public registry of clinical trials (RPCEC) database (May 5, 2020;no. TX-COVID19: RPCEC00000309). [ABSTRACT FROM AUTHOR] Copyright of Experimental & Therapeutic Medicine is the property of Spandidos Publications UK Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)