Nrg1 intracellular signaling regulates the development of interhemispheric callosal axons in mice.

Schizophrenia is associated with altered cortical circuitry. Although the schizophrenia risk gene NRG1 is known to affect the wiring of inhibitory interneurons, its role in excitatory neurons and axonal development is unclear. Here, we investigated the role of Nrg1 in the development of the corpus callosum, the major interhemispheric connection formed by cortical excitatory neurons. We found that deletion of Nrg1 impaired callosal axon development in vivo. Experiments in vitro and in vivo demonstrated that Nrg1 is cell-autonomously required for axonal outgrowth and that intracellular signaling of Nrg1 is sufficient to promote axonal development in cortical neurons and specifically in callosal axons. Furthermore, our data suggest that Nrg1 signaling regulates the expression of Growth Associated Protein 43, a key regulator of axonal growth. In conclusion, our study demonstrates that NRG1 is involved in the formation of interhemispheric callosal connections and provides a novel perspective on the relevance of NRG1 in excitatory neurons and in the etiology of schizophrenia.

Efficacy of Omalizumab for the treatment of Bullous Pemphigoid. Spanish multicenter real-world experience.

BACKGROUND: Bullous Pemphigoid (BP) is the most common autoimmune blistering disease. Most patients are elderly and associate multiple comorbidities. Topical and systemic corticosteroids are considered as the first-line treatment for BP and immunosuppressors are used as steroid-sparing treatments but both have side effects and contraindications which are even more common in this elderly population. New treatments targeting interleukins and receptors related to BP pathogenesis have been proposed to decrease this side effects while achieving equal or better effectiveness response rates.Omalizumab is a monoclonal antibody that targets IgE that has been proposed for the treatment of BP due to the evidence that IgE autoantibodies play an essential role in BP pathogenesis. OBJECTIVES AND METHODOLOGY: To assess the efficacy and security of Omalizumab for the treatment of BP, we carried out a multicenter, retrospective, observational study including patients diagnosed of BP who received omalizumab for at least 3 months from 15 tertiary hospitals in Spain. IgE levels prior to treatment was measured and we evaluate the possible correlation with clinical response. We excluded patients treated with Omalizumab for less than 3 months as we consider this duration is insufficient for a comprehensive assessment of its efficacy. To evaluate the effectiveness of the treatment we used the percentage of BSA improvement. RESULTS: We included 36 patients. The vast majority associate multiple comorbidities and all patients had used other systemic therapies apart from corticoids before Omalizumab.83% experienced some kind of treatment response and 42% of all patient treated achieved complete response.We did not find any correlation between higher levels and a better response (p=0,1791).All patients tolerated Omalizumab without reported side-effects. CONCLUSIONS: Omalizumab is a good therapeutic alternative for BP as it obtained clinical response in most patients and nearly half of the cases achieving complete response. It showed no side effects which is crucial in elderly patients suffering from BP.

Cutaneous immune-related adverse events: incidence rates, risk factors and association with extracutaneous toxicity. A prospective study of 189 patients treated with checkpoint inhibitors in a Spanish tertiary care hospital.

BACKGROUND: Clinicians are increasingly prescribing immune checkpoint inhibitors (ICIs) to treat cancer, but the real-world incidence, characteristics and risk factors of cutaneous immune-related adverse events (cirAEs) are unclear. OBJECTIVE: To determine the incidence, features and risk factors of cirAEs and measure their possible association with extracutaneous toxicity. METHODS: We conducted a prospective observational study in a Spanish tertiary care hospital, including people who started an ICI between March 2020 and May 2022. We used a survival analysis and a log-rank test to obtain and compare incidence rates, and a multivariate Cox model to detect risk factors of cirAEs. RESULTS: We included 189 patients, of whom 82 (43.4%) presented cutaneous toxicity. The incidence of cirAEs was 75.0 per 100 person-years, with a 50% probability of cirAE appearance at 10 months of follow-up. The most frequent cirAE category was inflammatory dermatoses, and the most frequent types were pruritus, eczema and maculopapular eruptions. ICI combination therapy, family history of psoriasis and rheumatologic and pulmonary irAEs increased the risk of cirAEs. Limitations: Single-center design. CONCLUSION: We found a high incidence of cirAEs, and they occurred early in follow-up. Dermatologists should be involved in the management of cirAEs, especially in people with risk factors.

Frailty in hemodialysis patients: results of a screening program and multidisciplinary interventions.

Background: The number of frail patients of advanced age with end-stage kidney disease (ESKD) undergoing hemodialysis is increasing globally. Here we evaluated a frailty screening program of ESKD patients starting hemodialysis, and subsequent multidisciplinary interventions. Methods: This was a prospective observational study of ESKD patients in a hemodialysis program. Patients were evaluated for frailty (Fried frail phenotype) before and after a 12-month period. Patients followed standard clinical practice at our hospital, which included assessment and multidisciplinary interventions for nutritional (malnutrition-inflammation score, protein-energy wasting), physical [short physical performance battery (SPPB)] and psychological status. Results: A total of 167 patients (mean ± standard deviation age 67.8 ± 15.4 years) were screened for frailty, and 108 completed the program. At screening, 27.9% of the patients were frail, 40.0% pre-frail and 32.1% non-frail. Nutritional interventions (enrichment, oral nutritional supplements, intradialytic parenteral nutrition) resulted in stable nutritional status for most frail and pre-frail patients after 12 months. Patients following recommendations for intradialytic, home-based or combined physical exercise presented improved or stable in SPPB scores after 12 months, compared with those that did not follow recommendations, especially in the frail and pre-frail population (P = .025). A rate of 0.05 falls/patient/year was observed. More than 60% of frail patients presented high scores of sadness and anxiety. Conclusions: Frailty screening, together with coordinated interventions by nutritionists, physiotherapists, psychologists and nurses, preserved the health status of ESKD patients starting hemodialysis. Frailty assessment helped in advising patients on individual nutritional, physical or psychological needs.

Psychometric properties of the Spanish SABA Reliance Questionnaire (SRQ) among patients with asthma.

Background: Patient beliefs about their asthma and its treatment may contribute to overreliance on short-acting ß2-agonist (SABA) therapy, leading to increased risk for potentially life-threatening exacerbations. The SABA Reliance Questionnaire (SRQ) is a validated tool for evaluating patients beliefs about SABAs that may lead to overreliance and overuse. Objective: Our aim was to evaluate the psychometric properties of the Spanish version of the SRQ. Methods: This was an observational, cross-sectional, single-country questionnaire validation study in adults with asthma. Reliability (ordinal α) and validity (convergent and discriminant) of SRQ were evaluated. Concurrent validity was assessed with the Beliefs about Medication Questionnaire, the Treatment Satisfaction Questionnaire for Medication, and a visual analog scale item to assess patients' perceptions of the importance of their reliever inhaler. Discriminant validity was assessed through differences in mean SRQ sum score between patients with high adherence to inhaled corticosteroids and those with low adherence, as measured by the Medication Adherence Report Scale-9 and the Test of Adherence to Inhalers. Results: The Spanish-SRQ exhibited good psychometric properties among 131 patients with asthma. Internal consistency was confirmed with an ordinal α of 0.85. All 5 items were useful for measuring patients' beliefs about SABAs that may lead them to be overreliant on SABAs. Concurrent validity with the Beliefs about Medication Questionnaire, Treatment Satisfaction Questionnaire for Medication, and a visual analog scale item assessing patients' perceptions of the importance of their reliever inhaler was demonstrated. Conclusion: The Spanish version of the SRQ is a valid tool for evaluating potential overreliance on SABAs in Spanish-speaking patients to enable early intervention and support.

Accompanying mental health problems at home: Preliminary data from a crisis resolution and home treatment team in Catalonia.

WHAT IS KNOWN ON THE SUBJECT?: Home treatment teams help people in a mental health crisis to recover. The staff goes to the person's home, avoiding the need to go to the hospital and providing care in the person's environment. The teams have been created in our country in recent years, becoming part of the mental health care network. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The paper presents the functioning of a CRHTT, the type of care it provides, and the coordination with the rest of the care network. It also shows the clinical results obtained in the first two years since its creation, supporting the CRHTT's effectiveness in accompanying people with mental health crises and reducing the need for hospital care. The outstanding factors in the team operation were coordination fluidity with referral services (facilitating accessibility), a prolonged care time (about two months), and continuity of care during the CRHTT intervention (the same CRHTT professionals visited the user and the family at home) and upon discharge (CRHTT staff organized joint visits with the professionals who would care for the user and the family after home treatment). The CRHTT followed a person-centered orientation based on horizontality and dialogue. The CRHTT fostered the inclusion of the family and social network in the treatment and a deep understanding of the crisis considering social determinants. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Flexibility, approach to the person's environment, dialogue, shared decision-making, and the inclusion of the family and social network in the treatment are central factors in CRHTT functioning. It helps the person regain control over their life and enhance their resources to face possible future crises. Training in crisis management, community mental health and family care, and teamwork (which implies joint home visits and co-responsibility with the rest of the staff, user, and the family) are relevant for CRHTT professionals. ABSTRACT: INTRODUCTION: Crisis resolution and home treatment teams (CRHTTs) provide intensive home care to people in a mental health crisis, becoming an increasingly widespread alternative to hospital admissions. However, there are wide variations in service delivery, organization, and outcomes, and little literature on how these teams work in clinical practice and different settings. AIM: To share the organizational functioning, the therapeutic approach, and the outcomes obtained in a CRHTT in Catalonia, Spain. METHOD: A descriptive analysis of the functioning of a home treatment team, the characteristics of the people served, and the clinical results from November 2017 to December 2019 are presented. RESULTS: One hundred and five people were served, with an average stay of 57 days. And 55.24% were women, and the mean age was 41. Most people could overcome the crisis at home, and 5.71% required hospital admission during home care. A statistically significant improvement was observed in the results of the GAF and HoNOS scales at admission and discharge. DISCUSSION: Despite reduced staff, home care was an alternative to hospital admission for most people treated. IMPLICATIONS FOR PRACTICE: Flexibility, teamwork, and collaboration with the social network are relevant factors when accompanying the recovery process at home.

Development of an Automated Design Tool for FEM-Based Characterization of Solid and Hollow Microneedles.

Microneedle design for biomedical applications, such as transdermal drug delivery, vaccination and transdermal biosensing, has lately become a rapidly growing research field. In this sense, finite element analysis has been extendedly used by microneedle designers to determine the most suitable structural parameters for their prototypes, and also to predict their mechanical response and efficiency during the insertion process. Although many proposals include computer-aided tools to build geometrical models for mechanical analysis, there is a lack of software utilities intended to automate the design process encompassing geometrical modeling, simulation setup and postprocessing of results. This work proposes a novel MATLAB-based design tool for microneedle arrays that permits personalized selection of the basic characteristics of a mechanical model. The tool automatically exports the selected options to an ANSYS batch file, including instructions to run a static and a linear buckling analysis. Later, the subsequent simulation results can be retrieved for on-screen display and potential postprocessing. In addition, this work reviews recent proposals (2018-2022) about finite element model characterization of microneedles to establish the minimum set of features that any tool intended for automating a design process should provide.

Spontaneous Thalamic Activity Modulates the Cortical Innervation of the Primary Visual Nucleus of the Thalamus.

Sensory processing relies on the correct development of thalamocortical loops. Visual corticothalamic axons (CTAs) invade the dorsolateral geniculate nucleus (dLGN) of the thalamus in early postnatal mice according to a regulated program that includes activity-dependent mechanisms. Spontaneous retinal activity influences the thalamic incursion of CTAs, yet the perinatal thalamus also generates intrinsic patterns of spontaneous activity whose role in modulating afferent connectivity remains unknown. Here, we found that patterned spontaneous activity in the dLGN contributes to proper spatial and temporal innervation of CTAs. Disrupting patterned spontaneous activity in the dLGN delays corticogeniculate innervation under normal conditions and upon eye enucleation. The delayed innervation was evident throughout the first two postnatal weeks but resumes after eye-opening, suggesting that visual experience is necessary for the homeostatic recovery of corticogeniculate innervation.

Input-dependent segregation of visual and somatosensory circuits in the mouse superior colliculus.

Whereas sensory perception relies on specialized sensory pathways, it is unclear whether these pathways originate as modality-specific circuits. We demonstrated that somatosensory and visual circuits are not by default segregated but require the earliest retinal activity to do so. In the embryo, somatosensory and visual circuits are intermingled in the superior colliculus, leading to cortical multimodal responses to whisker pad stimulation. At birth, these circuits segregate, and responses switch to unimodal. Blocking stage I retinal waves prolongs the multimodal configuration into postnatal life, with the superior colliculus retaining a mixed somato-visual molecular identity and defects arising in the spatial organization of the visual system. Hence, the superior colliculus mediates the timely segregation of sensory modalities in an input-dependent manner, channeling specific sensory cues to their appropriate sensory pathway.

Cross-Modal Plasticity in Brains Deprived of Visual Input Before Vision.

Unimodal sensory loss leads to structural and functional changes in both deprived and nondeprived brain circuits. This process is broadly known as cross-modal plasticity. The evidence available indicates that cross-modal changes underlie the enhanced performances of the spared sensory modalities in deprived subjects. Sensory experience is a fundamental driver of cross-modal plasticity, yet there is evidence from early-visually deprived models supporting an additional role for experience-independent factors. These experience-independent factors are expected to act early in development and constrain neuronal plasticity at later stages. Here we review the cross-modal adaptations elicited by congenital or induced visual deprivation prior to vision. In most of these studies, cross-modal adaptations have been addressed at the structural and functional levels. Here, we also appraise recent data regarding behavioral performance in early-visually deprived models. However, further research is needed to explore how circuit reorganization affects their function and what brings about enhanced behavioral performance.

Dynamic interplay between thalamic activity and Cajal-Retzius cells regulates the wiring of cortical layer 1.

Cortical wiring relies on guidepost cells and activity-dependent processes that are thought to act sequentially. Here, we show that the construction of layer 1 (L1), a main site of top-down integration, is regulated by crosstalk between transient Cajal-Retzius cells (CRc) and spontaneous activity of the thalamus, a main driver of bottom-up information. While activity was known to regulate CRc migration and elimination, we found that prenatal spontaneous thalamic activity and NMDA receptors selectively control CRc early density, without affecting their demise. CRc density, in turn, regulates the distribution of upper layer interneurons and excitatory synapses, thereby drastically impairing the apical dendrite activity of output pyramidal neurons. In contrast, postnatal sensory-evoked activity had a limited impact on L1 and selectively perturbed basal dendrites synaptogenesis. Collectively, our study highlights a remarkable interplay between thalamic activity and CRc in L1 functional wiring, with major implications for our understanding of cortical development.

Insuficiencia suprarrenal secundaria persistente tras tratamiento prolongado con corticoides / Chronic secondary suprarrenal failure after prolonged corticosteroid treatment

Los glucocorticoides son fármacos frecuentemente usados de forma crónica para el tratamiento de enfermedades autoinmunes, hematológicas y neoplasias avanzadas. Sin embargo, representan una causa común de insuficiencia suprarrenal terciaria. Por lo tanto, la terapia de reemplazo corticoidea puede ser frecuente tras la administración crónica de glucocorticoides. Presentamos el caso clínico de una paciente de 65 años en tratamiento crónico con glucocorticoides debido a una sarcoidosis pulmonar diagnosticada en 2012. A pesar de la reducción gradual del tratamiento, una vez que la patología estaba en remisión, la paciente es diagnosticada de insuficiencia suprarrenal ante la persistencia de clínica de astenia intensa y sudoración profusa y haber descartado una reactivación de su proceso. Se debe sospechar Insuficiencia suprarrenal en todo paciente que ha estado en tratamiento crónico con tratamiento glucocorticoideo. La retirada gradual del tratamiento con glucocorticoides a lo largo de las semanas es una práctica comúnmente extendida que minimiza el riesgo de Insuficiencia suprarrenal pero no lo anula. La determinación del cortisol basal al menos 18 horas de la última dosis de glucocorticoides puede ser útil para evaluar el eje hipofisario-adrenal y retirar con seguridad el tratamiento con glucocorticoides.(AU)

Glucocorticoids are drugs widely used chronically to treat various autoimmune, haematological conditions and advanced malignancies. Nevertheless, glucocorticoids are considered a common cause of tertiary adrenal insufficiency. Therefore, patients may require glucocorticoid replacement therapy after chronic use of glucocorticoids. We report the clinical case of a 65-year-old patient on chronic glucocorticoid treatment due to pulmonary sarcoidosis diagnosed in 2012. Despite gradual tapering of treatment once the main disease was in remission, the patient was diagnosed with adrenal insufficiency due to persistent clinical symptoms of intense asthenia and profuse sweating once reactivation of her disease was ruled out. Adrenal insufficiency should be suspected in every patient on chronic glucocorticoid treatment. Gradual tapering of glucocorticoid treatment over weeks is a common clinical practice that minimizes the risk of adrenal insufficiency but does not eliminate it completely. Determination of basal cortisol at least 18 hours after the last dose of glucocorticoid may be useful to evaluate the pituitary-adrenal axis and safely withdraw glucocorticoid treatment.(AU)

Atypical pediatric presentation of lymphocytic thrombophilic arteritis: Diagnostic difficulties and recent nosological clarification.

A 4-year-old girl presented with a 2-month history of round, hypopigmented, slightly scaly patches measuring 1-6 cm and encircled by an erythematous halo, first appearing on the lower limbs then spreading to the whole body. Three biopsies were taken as the condition progressed, each showing a lymphocytic infiltrate affecting a medium-sized artery at the dermal-subcutaneous junction, with a concentric fibrin ring. These findings are characteristic of lymphocytic thrombophilic arteritis (LTA). The young age of our patient and the type of skin lesions she developed make this an atypical presentation of LTA, which usually manifests as hyperpigmented macules on the lower extremities, predominantly in dark-skinned women.

A New Methodology to Design Sustainable Archimedean Screw Turbines as Green Energy Generators.

Current energy demand and climate target plans are leading to green energy facilities which are efficient and sustainable. Archimedean screw turbines (ASTs) are used to generate hydroelectricity in low heads. They have been manufactured and installed worldwide. However, there is a lack of knowledge about how to design them efficiently. In this study, the performance of ASTs is analyzed using an analogy between ASTs and bucket elevators. Based on this analogy, a theoretical hypothesis on how to produce efficient ASTs is proposed. The new methodology for the design of ASTs is based on two considerations: the filling level of the AST buckets must be 85% and the increase of leakage losses must be minimized. This hypothesis is numerically and experimentally studied. Two experimental prototypes were developed and installed in the north of Spain. The numerical and experimental results are provided. A discussion comparing the results of this work and other results from the literature is presented. Finally, conclusions are drawn from this work that contribute to the improvement of AST technology as a sustainable facility to generate green energy.

The Inclusion of the Microalga Scenedesmus sp. in Diets for Rainbow Trout, Onchorhynchus mykiss, Juveniles.

A nutritional study was conducted to evaluate the inclusion of the green microalga Scenedesmus sp. at 5% (SCE-5) as an alternative fishmeal ingredient. This microalga was tested with four replicates during 45 days using isolipidic (18%), isoproteic (48%), and isoenergetic (1.9 MJ kg-1) diets. Fish fed Scenedesmus sp. showed similar growth and feed efficiency parameters as the control group. Regarding the digestive function, the SCE-5 diet enhanced the activity of alkaline pancreatic proteases, whereas it did not affect that of intestinal enzymes involved in nutrient absorption. No histological alterations were found in fish fed the SCE-5 diet, although a higher density of goblet cells in the anterior intestine and changes in gut microbiome diversity were found in this group, which collectively suggests positive effects of this green microalga on the intestine. Dietary Scenedesmus sp. improved the fillet's nutritional quality in terms of n-3 polyunsaturated fatty acid (PUFA) levels, although it also increased its yellowish color. The overall results of this study showed that Scenedesmus sp. is a safe ingredient for compound feeds in rainbow trout when considering fish growth performance, animal condition, and health parameters, although it substantially affected the color of the fillet that may potentially affect consumers' preferences.

No SARS-CoV-2 antibody response in 25 patients with pseudo-chilblains.

Chilblain-like acral lesions have been identified in some coronavirus disease 2019 (COVID-19) patients. It has been suggested that these pseudo-chilblains could be a specific marker of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Most patients with these lesions have had negative polymerase chain reactions (PCRs), but some authors believe serology tests are likely to give positive results. We designed a prospective study including all patients with pseudo-chilblains treated in outpatient department in April and May 2020 and then performed SARS-CoV-2 PCR and serology tests on all available patients. We evaluated 59 patients, of whom 17 had undergone PCR before the study period, all with negative results. For the present study, we performed 20 additional PCRs, serology tests in 25 patients, and a parvovirus B19 antibody test in 15 patients. All results were negative. Our findings counter the hypothesis that serology is likely to reveal SARS-CoV-2 infection in patients with pseudo-chilblains. One hypothesis for our negative results is that the time period between symptom onset and antibody production is longer in these patients; another is that the lesions are caused by behavioral changes during lockdown rather than SARS-CoV-2 infection. We nevertheless maintain that COVID-19 should be ruled out in people presenting with chilblain-like lesions.

La satisfacción laboral de los profesionales como pieza clave en la calidad asistencial / Job Satisfaction of Professionals as a Key Element in Quality of Care

OBJETIVO: determinar el nivel de satisfacción laboral del personal dependiente de la Dirección de Enfermería del Complejo Asistencial Universitario de Burgos (CAUB). MÉTODO: se diseñó un estudio descriptivo transversal. La muestra de estudio (n= 1.844) se conformó con los profesionales activos, dependientes de la Dirección de Enfermería del CAUB en la fecha de estudio, excluyendo a los liberados sindicales o a los que estaban de vacaciones. Se usó el cuestionario Font Roja validado en el ámbito hospitalario, incluyendo variables sociodemográficas y laborales, y una pregunta sobre satisfacción global (de 0 a 10). Se realizó análisis univariante y bivariante. La relación entre las distintas variables se evaluó mediante pruebas estadísticas. RESULTADOS: se recogieron 1.089 encuestas. La edad media fue de 46 años (DE: 10,677). El 96% (n= 904) de los encuestados era mujer. El 59% (n= 563) de las encuestas analizadas fue respondida por enfermeras. El 93% (n= 889) llevaba ejerciendo la profesión más de cinco años. Un 53% (n= 506) de la muestra del estudio llevaba más de cinco años trabajando en la misma unidad. La puntuación media de la satisfacción global autopercibida fue de 6,74 (DE: 1,925). Las variables edad, tiempo desde la finalización de los estudios, tiempo de ejercicio de profesión, categoría profesional y área de trabajo mostraron relaciones estadísticamente significativas (p< 0,05) con la percepción de satisfacción global. Por dimensiones, la satisfacción es baja para la mayoría de los profesionales en casi todas excepto en contenido de su trabajo relación interprofesional. CONCLUSIONES: los profesionales se declaran satisfechos en su situación laboral global autopercibida. Las dimensiones mejor valoradas son las que se refieren a la relación interprofesional con superiores y al contenido del trabajo. Por su parte, la presión de trabajo, monotonía laboral y promoción/expectativas fueron los aspectos con los que los profesionales se sienten menos satisfechos

OBJECTIVE: to determine the level of job satisfaction among the staff under the Nursing Management of the Complejo Asistencial Universitario de Burgos (CAUB). METHOD: a cross-sectional descriptive study was designed. The study sample (n= 1,844) was formed with those active professionals under the authority of the Nursing Management of the CAUB at the time of the study, excluding full-time union representatives or those on holidays. The Font Roja questionnaire validated in the hospital setting was used, including sociodemographical and occupational variables, and one question on overall satisfaction (on a scale from 0 to 10). Univariate and bivariate analyses were conducted, and the relationship between different variables was evaluated through statistical tests. RESULTS: in total, 1,098 surveys were collected; the mean age was 46-year-old (SD: 10.677), and 96% (n= 904) of the survey participants were female. Of the surveys analyzed, 59% (n= 563) were answered by nurses; 93% (n= 889) of them had been in practice for over five years, and 53% (n= 506) of the study sample had been working in the same hospital unit for over five years. The mean score for self-perceived overall satisfaction was 6.74 (SD: 1.925). The following variables: age, time since completing their education, time of professional practice, professional job category and area of work, showed a statistically significant relationship (p< 0.05) with the perception of overall satisfaction. By dimensions, the level of satisfaction was low for the majority of professionals in almost all of them, except in job content and interprofessional relationship. CONCLUSIONS: professionals stated that they were satisfied in terms of their self-perceived overall working situation. The best valued dimensions were those regarding interprofessional relationship with superiors and job content; on the other hand, work pressure, monotony of tasks and promotion/expectations were the aspects with which professionals were less satisfied