Differences in the diagnosis and management of systemic lupus erythematosus by primary care and specialist providers in the American Indian/Alaska Native population.

Objectives The objective of this study is to investigate differences in the diagnosis and management of systemic lupus erythematosus (SLE) by primary care and specialist physicians in a population-based registry. Methods This study includes individuals from the 2009 Indian Health Service lupus registry population with a diagnosis of SLE documented by either a primary care provider or specialist. SLE classification criteria, laboratory testing, and medication use at any time during the course of disease were determined by medical record abstraction. Results Of the 320 individuals with a diagnosis of SLE, 249 had the diagnosis documented by a specialist, with 71 documented by primary care. Individuals with a specialist diagnosis of SLE were more likely to have medical record documentation of meeting criteria for SLE by all criteria sets (American College of Rheumatology, 79% vs 22%; Boston Weighted, 82% vs 32%; and Systemic Lupus International Collaborating Clinics, 83% vs 35%; p < 0.001 for all comparisons). In addition, specialist diagnosis was associated with documentation of ever having been tested for anti-double-stranded DNA antibody and complement 3 and complement 4 ( p < 0.001). Documentation of ever receiving hydroxychloroquine was also more common with specialist diagnosis (86% vs 64%, p < 0.001). Conclusions Within the population studied, specialist diagnosis of SLE was associated with a higher likelihood of having SLE classification criteria documented, being tested for biomarkers of disease, and ever receiving treatment with hydroxychloroquine. These data support efforts both to increase specialist access for patients with suspected SLE and to provide lupus education to primary care providers.

Clinical investigation of biofilm in non-healing wounds by high resolution microscopy techniques.

OBJECTIVE: The aim of this study was to analyse wound biofilm from a clinical perspective. Research has shown that biofilm is the preferred microbial phenotype in health and disease and is present in a majority of chronic wounds. Biofilm has been linked to chronic wound inflammation, impairment in granulation tissue and epithelial migration, yet there lacks the ability to confirm the clinical presence of biofilm. This study links the clinical setting with microscopic laboratory confirmation of the presence of biofilm in carefully selected wound debridement samples. METHOD: Human wound debridement samples were collected from adult patients with chronic non-healing wounds who presented at the wound care centre. Sample choice was guided by an algorithm that was developed based on what is known about the characteristics of wound biofilm. The samples were then evaluated by light microscopy and scanning electron microscopy for the presence of biofilm. Details about subject history and treatment were recorded. Adherence to biofilm-based wound care (BBWC) strategies was inconsistent. Other standard antimicrobial dressings were used and no modern antiseptic wound dressings with the addition of proven antibiofilm agents were available for use. RESULTS: Of the patients recruited, 75% of the macroscopic samples contained biofilm despite the prior use of modern antiseptic wound dressings and in some cases, systemic antibiotics. Wounds found to contain biofilm were not all acutely infected but biofilm was present when infection was noted. The clinical histories associated with positive samples were consistent with ideas presented in the algorithm used to guide sample selection. CONCLUSION: Visual cues can be used by the clinician to guide suspicion of the presence of wound biofilm. This suspicion can be further enhanced with the use of a clinical algorithm. Standard antiseptic wound dressings used in this study demonstrated limited antibiofilm efficacy. This study also highlighted a need for the clinical team to focus on expiration of dressing action and consistent practice of BBWC strategies which includes the use of proven antibiofilm agents.

Glial cell line-derived neurotrophic factor in the rat pituitary gland.

The presence of glial cell line-derived neurotrophic factor (GDNF) is described within specific regions of the adult rat pituitary gland. Immune staining methods revealed a small number of GDNF-immunopositive cells in the anterior lobe, and in areas of the neural lobe, while no immunoreactive endocrine cells were observed in the intermediate lobe. In the neural lobe, immunofluorescence methods were also used to demonstrate that GDNF and glial fibrillary acidic protein (GFAP) are co-localized in the glial cells (pituicytes) of the neural lobe. GDNF was not co-localized with neurofilament (NF) in nerve fibers of the neural lobe, suggesting that it is not present in axonal fibers. Measurements of GDNF content in separated anterior and neurointermediate lobes were also performed, using an enzyme-linked immunoassay (ELISA). Values for GDNF were slightly higher in the neurointermediate lobe than those obtained for the anterior lobe. The presence of GDNF in areas of the pituitary is discussed in the context of its possible function to support and maintain hypothalamic innervation, as well as a potential autocrine factor within endocrine cells.

Synaptophysin immunoreactivity in the rat pituitary: alterations after 6-hydroxydopamine treatment.

Synaptophysin (SN) is a synaptic-vesicle-associated membrane protein whose presence is indicative of intact, functional synapses. This study examines the presence of SN in pituitary gland innervation after neurotoxin-induced denervation followed by reinnervation. Immunostaining of rat pituitary neurointermediate lobe tissue for SN reveals a pattern of dot-like densities in the intermediate lobe and intensely stained dispersed regions in the neural lobe of normal animals. In rats treated with 6-hydroxydopamine (6-OHDA), a catecholamine neurotoxin, by peripheral injection, there is a significant depletion of the SN immunostaining in the intermediate lobe, as well as a significant reduction of SN immunoreactivity in the neural lobe, in animals studied 1 wk after drug treatment, with computer analysis of the tissue sections. At 3 wk after 6-OHDA, there is a partial recovery of immunoreactivity for SN in the neural lobe in many tissue sections, and the intermediate lobe also contains only relatively sparse staining for the synaptic protein. Computer analysis revealed that at 3 wk after 6-OHDA, both lobes still had reduced SN immunoreactivity, but the difference in levels measured did not achieve statistical significance. These results contrast with the prior finding of significant recovery of immunoreactivity for GAP-43, a growth and regeneration-associated protein, in intermediate lobe innervation of rats treated with the same drug regimen. We suggest that 6-OHDA treatment damages synaptic vesicle integrity in both the intermediate and neural lobes of the pituitary, and that recovery is in progress, but not complete at 3 wk after the drug is administered.

Alloantigen-induced unresponsiveness in cord blood T lymphocytes is associated with defective activation of Ras.

Human umbilical cord blood T lymphocytes (CBTL) respond to primary allostimulation but they do not proliferate upon rechallenge with alloantigen. Using PKH-26-labeled cells created a proliferative block that was observed only in CBTL that have divided during primary stimulation (PKH-26(dim)) but not in unstimulated (PKH-26(bright)) CBTL. CBTL's secondary unresponsiveness resembles anergy and can be overcome by treatment with phorbol myristate acetate (PMA) and ionomycin or by high doses (50-100 units/ml) of interleukin 2. Addition of interleukin 2 to the primary cultures does not prevent the induction of secondary unresponsiveness. Defective Ras activation is detected in PKH-26(dim) CBTL during secondary response to alloantigen or after antibody-mediated T cell receptor stimulation whereas Ras is activated and proliferation is induced in CBTL during primary alloantigenic stimulation. Upon stimulation with PMA plus ionomycin, PMA plus alloantigen, but not alloantigen plus ionomycin, Ras is activated in PKH-26(dim) CBTL, and the block in proliferation is overcome. Correction of PKH-26(dim) CBTL's proliferative defect correlates with PMA-induced Ras activation, suggesting a defect in the signaling pathway leading to Ras. Ras-independent signals, necessary but not sufficient to induce PKH-26(dim) CBTL proliferation, are provided by alloantigen exposure, as evident by the ability of PMA plus alloantigen but not PMA alone to overcome the proliferative block. Functional signal transduction through CD28 in PKH-26(dim) CBTL is supported by detectable CD28-mediated PI-3 kinase activation after PKH-26(dim) CBTL's exposure to alloantigen or CD28 cross-linking. These results suggest that defective activation of Ras plays a key role in PKH-26(dim) CBTL's secondary unresponsiveness and point to a defect along the T cell receptor rather than the CD28 signaling pathway.

In situ global method for measurement of oxygen demand and mass transfer.

Two aerobic microorganisms, Saccharomycopsis lipolytica and Brevibacterium lactofermentum, have been used in a study of mass transfer and oxygen uptake from a global perspective, using a closed gas system. Oxygen concentrations in the gas and liquid were followed using oxygen electrodes; the results allowed for easy calculation of in situ oxygen transport. The cell yields on oxygen for S. lipolytica and B. lactofermentum were 1.01 and 1.53 g/g, respectively. The mass transfer coefficient was estimated as 10/h at 500 rpm for both fermentations. The advantages with this method are noticeable, since the use of model systems may be avoided, and the in situ measurements of oxygen demand assure reliable data for scale-up.

Demonstration-scale evaluation of a novel high-solids anaerobic digestion process for converting organic wastes to fuel gas and compost.

Early evaluations of the bioconversion potential for combined wastes such as tuna sludge and sorted municipal solid waste (MSW) were conducted at laboratory scale and compared conventional low-solids, stirred-tank anaerobic systems with the novel, high-solids anaerobic digester (HSAD) design. Enhanced feedstock conversion rates and yields were determined for the HSAD system. In addition, the HSAD system demonstrated superior resiliency to process failure. Utilizing relatively dry feedstocks, the HSAD system is approximately one-tenth the size of conventional low-solids systems. In addition, the HSAD system is capable of organic loading rates (OLRs) on the order of 20-25 g volatile solids per liter digester volume per d (gVS/L/d), roughly 4-5 times those of conventional systems. Current efforts involve developing a demonstration-scale (pilot-scale) HSAD system. A two-ton/d plant has been constructed in Stanton, CA and is currently in the commissioning/startup phase. The purposes of the project are to verify laboratory- and intermediate-scale process performance; test the performance of large-scale prototype mechanical systems; demonstrate the long-term reliability of the process; and generate the process and economic data required for the design, financing, and construction of full-scale commercial systems. This study presents conformational fermentation data obtained at intermediate-scale and a snapshot of the pilot-scale project.

Thrombopoietin upregulates the promoter conformation of p53 in a proliferation-independent manner coincident with a decreased expression of Bax: potential mechanisms for survival enhancing effects.

Thrombopoietin (Tpo) has proliferative and maturational effects on immature and more committed cells, respectively. We previously reported a role for Tpo as a survival factor in the factor-dependent human cell line M07e by demonstrating that Tpo suppresses apoptosis in the absence of induced proliferation. Wild-type p53 is a tumor suppressor gene that can play a vital role in mediating growth factor withdrawal-induced apoptosis in factor-dependent hematopoietic cells. Wild-type p53 can switch from a suppressor conformation, with an antiproliferative, pro-apoptotic phenotype, to a promoter conformation that has a diminished ability to mediate cell cycle arrest and apoptosis. In an effort to elucidate the mechanisms through which Tpo suppresses apoptosis, we investigated the effects of Tpo treatment on p53-mediated apoptosis in M07e cells. Tpo upregulated the expression of the promoter conformation of p53 in M07e cells coincident with a downregulation of Bax and Mdm2 protein levels. Protein levels of Bcl-2 and Bcl-xL did not significantly vary as a function of growth-factor stimulation. Conversely, the levels of suppressor conformation p53 were maximal when M07e was in a growth arrested state and decreased during factor stimulation. Furthermore, Tpo treatment induced an extranuclear buildup and greatly weakened the DNA binding capacity of p53. p53-specific antisense oligonucleotide treatment recapitulated the effects of Tpo treatment on the levels of Bax, Mdm-2, and Bcl-2. These results suggest that Tpo is suppressing growth factor withdrawal induced-apoptosis, at least in part, by downregulating the expression of pro-apoptotic Bax protein levels, through modulating the conformation of p53, which results in a functional inactivation of its pro-apoptotic abilities.

Cord blood CD16+56- cells with low lytic activity are possible precursors of mature natural killer cells.

Human natural killer (NK) cells are defined as being membrane CD3-, CD16+, and/or CD56+ lymphocytes; however, little is known about the ontogenic development and maturational pathways of human NK cells. The functional, phenotypic, and maturational characteristics of human umbilical cord blood (CB) NK cell subsets were studied to gain insight into the ontogenic and maturational pathways of human NK cells. We have previously shown that there is a novel subset of CD16+ CD56- NK cells present in CB. Here we further demonstrate differences in the expression of the NK-associated molecules CD2, CD7, CD8, and CD25 between CB and peripheral blood (PB) NK cells and between CB NK cell subsets. Although CB NK cell subsets were deficient in or had less lytic activity against K562 cells compared to PB NK cells, CB NK cells did possess the lytic molecules perforin and granzyme B and when artificially stimulated to secrete their granules during lytic assays, were capable of lytic activity equivalent to that of PB NK cells. Regardless of differences in phenotype and function of CB NK cell subsets, short-term and long-term incubation with cytokines induced functional (adult-like NK activity) and phenotypic (adult-like CD16+56+ or CD16-56+ surface antigen phenotype) maturation, respectively. Interleukin-2 (IL-2), IL-12, and IL-15, but not IL-7, interferon-gamma (IFN-gamma) nor tumor necrosis factor-alpha (TNF-alpha) induced functional and phenotypic maturation of CB NK cell subsets. Interestingly, culture of CB NK cell subsets with IL-2 or IL-15 led to acquisition of predominantly a CD16+56+ phenotype, while culture with IL-12 led to acquisition of both CD16+56+ and CD16-56+ phenotypes. Both functional and phenotypic maturation were not dependent upon proliferation. Studies using neutralizing anti-IFN-gamma and anti-TNF-alpha antibodies showed that survival and phenotypic maturation upon cytokine stimulation is influenced by endogenous production of TNF-alpha but not IFN-gamma. These results demonstrate that CB NK cell subsets are functionally and phenotypically immature but are capable of maturation. Additionally, CD16+56- NK cells are implicated as possible precursors of mature CD16+56+ and CD16-56+ NK cells.

Antitumor activity and immunotherapeutic properties of Flt3-ligand in a murine breast cancer model.

Flt3-Ligand (Flt3-L) is a stimulatory cytokine for a variety of hematopoietic lineages, including dendritic cells and B cells. The antitumor properties of Flt3-L were evaluated in C3H/HeN mice challenged with the syngeneic C3L5 murine breast cancer cell line. Eighty % of animals receiving 500 microg/kg/day of Chinese hamster ovary-derived human Flt3-L for 10 days were protected from tumor growth, whether the tumor challenge was administered on the first or fourth days of Flt3-L administration. The protection provided by soluble Flt3-L was transient. All tumor-free animals rechallenged 4 weeks after the primary challenge developed tumor. Transduction of C3L5 with retroviral vectors expressing human or murine Flt3-L did not influence in vitro growth or MHC expression but decreased in vivo tumor development to 0 and 10% of mice, respectively. This compares with tumor growth of 52% with interleukin-2 transduced C3L5 and over 85% with untransduced and control vector-transduced C3L5. Unlike animals treated with soluble Flt3-L, administration of Flt3-L as a tumor vaccine protected mice from a subsequent challenge with untransduced C3L5 in 60-78% of mice, compared to 0% of controls. Our initial work used the most common Flt3-L isoform, which is membrane bound but can undergo proteolytic cleavage to generate a soluble form. To evaluate the role of the various Flt3-L isoforms in preventing tumor formation, retroviral vectors encoding only the membrane-bound form or only the soluble isoform were evaluated in the C3L5 model. Tumor formation was similar with either isoform, preventing tumor formation in 80-90% of mice after the primary challenge and 88-89% after the secondary challenge. Splenocytes obtained 4 weeks after the secondary challenge conferred adoptive immunity to naive mice in 60% of animals. This initial report of antitumor activity by Flt3-L is consistent with its known stimulatory effect on antigen-presenting cells and suggests it may enhance the development of tumor vaccines.

Synaptophysin immunoreactivity in the aging rat pituitary gland.

The density of synaptophysin (SN)-immunoreactivity (IR) was examined in pituitary glands of aging male Sprague-Dawley rats. SN-IR was observed as dense dots among endocrine cells of the intermediate lobe, while the neural lobe contained numerous, highly dense immunopositive regions. Some anterior lobe secretory cells contained SN-IR within the cytoplasm, suggestive of the presence of the protein in secretory granules, but no dot-like staining was observed between endocrine cells of that region. A quantitative analysis of the dot-like SN-immunostaining within the intermediate lobe found that tissue from groups of rats aged 13 months, or 15-17 months, contained significantly fewer SN-immunopositive areas than did tissues from 8-month-old animals. Diminished SN immunostaining is suggestive of reduced numbers of synapses in the intermediate lobe, which may lead to alterations in regulation of pituitary hormone secretion from endocrine cells in the older animals.

Cord blood natural killer cells are functionally and phenotypically immature but readily respond to interleukin-2 and interleukin-12.

Human umbilical cord blood (CB) is being increasingly used both as an alternative to bone marrow to transplant children and for experimental insight into the ontogenic and maturational characteristics of blood cells. We studied the functional and phenotypic characteristics of CB natural killer (NK) cells because of the possibly important role such cells may play in a transplant setting and to gain insight into the little known ontogenic differences and maturational pathways of NK cells. It was found that CB NK lytic activity is usually deficient and that this deficiency cannot be fully explained by the presence of insufficient percentages of CD56+ cells. Although CD16+CD56+ and CD16-CD56+ NK cell subsets typical of adult peripheral blood (PB) are present, a significant population of CD16+CD56- cells also exists in CB. CB CD16+CD56- cells have little or no lytic capabilities; CB CD16+CD56+ cells vary in their lytic capabilities. Although a decreased ability to bind target cells may contribute to the deficient lytic activity of these CB NK cell subsets, studies suggest that other factors must also play a role. Short-term incubation with interleukin-2 (IL-2) or interleukin-12 (IL-12) substantially increases the lytic capabilities of CB NK cells, and long-term incubations induce lymphokine-activated killer (LAK) cell generation. Cell depletion experiments show that activated CD56+ NK cells are responsible for the lytic activity of CB LAK cells. Flow cytometric analysis reveals that during LAK cell generation, CB undergoes phenotypic changes similar to those of PB except that CD16+CD56- cells are still present.(ABSTRACT TRUNCATED AT 250 WORDS)

Alloantigen priming induces a state of unresponsiveness in human umbilical cord blood T cells.

Induction of alloreactivity in human adult and umbilical cord blood T cells was evaluated in mixed leukocyte culture by exposure to an allogeneic lymphoblastoid line that expresses known costimulatory molecules. Initial exposure to alloantigen-presenting cells (allo-APC) induced strong proliferative responses in both adult and cord blood T cells. However, in contrast to adult T cells, cord blood T cells exhibited little proliferation after restimulation with donor APC. Primed cord blood T cells could respond to interleukin 2 (IL-2), but unresponsiveness to alloantigen was not overcome by addition of exogenous IL-2. Unresponsiveness was long-lasting and appeared to be maintained by a combination of induction of anergy and activity of CD8+ suppressor cells. This information may contribute to use of human cord blood as an allogeneic source of transplantable stem cells.

Porcine peripheral blood CD4+/CD8+ dual expressing T-cells.

The porcine T-cell population is unique in that there is a large percentage of CD+CD8+ dual expressing peripheral T-cells. This paper reviews the data available on these porcine T-cells and compares them to the much rarer dual expressing T-cells in humans. The percent of dual expressing cells increases with activation in in vitro culture with various antigens including pseudorabies virus. The percent of resting dual expressing cells also increases with the age of the pig. Flow-cytometric-sorted dual expressing cells responded in culture to the super antigen staphylococcal enterotoxin B. Selected CD4+CD8- cells cultured in vitro developed expression of CD8 and maintained the dual expressing phenotype for the 12 weeks of culture. Dual expressing cells freshly prepared from porcine blood did not express the IL-2 receptor as demonstrated by their failure to bind FITC-IL-2 and an anti-porcine IL-2 receptor monoclonal antibody. In response to activation with phorbol myristic acetate, CD4, but not CD8, was down regulated on the dual expressing T-cells. In summary, porcine dual expressing T-cells constitute a substantial percentage of the porcine peripheral T-cell pool. These cells appear to contain the majority of the memory T-cell with their frequency increasing with blood donor age and in vitro culture. Although the receptor specificity is not known, they have a functional receptor. Finally, the function of the two accessory molecules CD4 and CD8 in these cells is not known, but their regulation is distinct, thereby suggesting no equivalent roles in immune function.

Proliferative and cytotoxic responses of human cord blood T lymphocytes following allogeneic stimulation.

On the basis of the success of recent cord blood transplants, we undertook a comparison of the proliferative and cytotoxic potential, following allogeneic stimulation, of E-rosetted T cells from cord blood or adult peripheral blood (PB3) or bone marrow (BM). The magnitude of the proliferative response of cord blood (CB) T cells to alloantigen was greater than or equal to that of adult PB or BM T cells. Proliferation following culture with IL-2, IL-4, or IL-7 produced a similar result. In contrast, the cytotoxic activity in 1(0), 2(0), or 3(0) mixed leukocyte culture of CB T cells was minimal, typically less than 20% at an effector:target ratio of 100:1. Cytometric analysis of CB T cell populations before and after culture with allostimulation demonstrated similar ratios of CD4+ and CD8+ cells in cultures of CB and adult T cells. Down-regulation of CD45RA antigen expression, a measure of CD4+ cell activation, was comparable in adult and CB cultures. Activation of CD8+ CTL effectors was assessed by the acquisition of CD28 antigen expression. After culture, a smaller proportion of CD8+CD28+ effector cells was present in CB cultures as compared to adult T cell cultures. Thus, following in vitro priming with alloantigen CB T cells generate a vigorous proliferative response yet produce little antigen-specific cytotoxicity. This diminished cytotoxicity may, in part, be related to the low incidence of graft vs host disease thus far noted in human CB transplants.

Allogeneic responses of human umbilical cord blood.

Human umbilical cord blood (CB) is increasingly used as an alternative to bone marrow as a source of stem and progenitor cells for pediatric patients. We have evaluated the alloreactive potential of cord blood T cells in vitro. Our findings demonstrate that in a primary mixed leukocyte culture CB T cells demonstrate strong proliferative responses to allogeneic stimulation but little to no generation of cytotoxic effector function. Furthermore, restimulation of primary cultures results in a state of proliferative unresponsiveness. Such diminished cytotoxic and proliferative responses may, in part, be related to the low incidence of graft vs. host disease thus far noted in human CB transplants.

Pupil size regulation of threshold of light-induced melatonin suppression.

The capacity of pupil dilation to affect light-induced plasma melatonin suppression was tested by exposing human subjects with freely constricting or pharmacologically dilated pupils to either 50 (n = 6), 100 (n = 8), or 200 lux (n = 5) of white light presented over the entire visual field. Pupil dilation significantly enhanced low level white light-induced melatonin suppression over that elicited with freely constricting pupils. Although 100 and 200 lux white light exposures resulted in significant melatonin suppression over control (no light) conditions, the effects of 50 lux were not strong enough to demonstrate statistically significant suppression with six subjects. Linear regression did not reveal a systematic relationship between theoretical retinal illuminance in Trolands and magnitude of melatonin suppression. These results suggest that pupil diameter may be a factor in the effectiveness of light stimuli used to shift circadian rhythms or to treat seasonal depression or sleep disorders.

Enterprise-wide network eliminates 'Tower of Babel'.

To plan an I/S strategy without sufficient communications capabilities omits a vital link to success. At Lehigh Valley Hospital in Allentown, Pa., information services experts are building a network foundation to support today's strategic plan as well as tomorrow's technology.

Bronchodilation with a potent and selective leukotriene D4 (LTD4) receptor antagonist (MK-571) in patients with asthma.

The sulfidopeptide leukotrienes LTC4, LTD4, and LTE4 can cause airway smooth muscle contraction and have been implicated in the pathophysiology of asthma. MK-571 is a selective, potent LTD4 receptor antagonist that could attenuate airway obstruction in asthma by inhibiting the actions of sulfidopeptides at the LTD4 receptor site. The objectives of this study were to investigate the potential for MK-571 to cause bronchodilation in asthma patients with existing airway obstruction and to evaluate its effect on the bronchodilation response to an inhaled beta 2-agonist (albuterol). Twelve male patients (ages 19 to 42 yr) with asthma (baseline FEV1 50 to 80% predicted) participated in this placebo-controlled, randomized, two-period, cross-over study. On separate treatment days, each patient received either MK-571 or placebo intravenously for 6 h; inhaled albuterol was administered at the fifth and sixth hour of MK-571/placebo treatment to achieve maximal bronchodilation on that study day. Spirometry (forced expiratory volume in 1 s, FEV1) was monitored at intervals throughout each study period. MK-571 caused clinically significant bronchodilation; the increase in FEV1 above baseline, 20 min after the start of the MK-571 infusion, was 22 +/- 3.9% compared with 1.3 +/- 2.3% for placebo (mean +/- SE, p < 0.01). This degree of bronchodilation was maintained throughout the MK-571 infusion. In addition, bronchodilation from inhaled albuterol appeared additive with MK-571. Finally, baseline airway obstruction correlated with the degree of bronchodilation achieved with MK-571 (r = -0.73; p = 0.007).(ABSTRACT TRUNCATED AT 250 WORDS)