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Effect Of Ginkgo Biloba On Brain Volume After Carotid Artery Occlusion In Rats: A Stereological And Histopathological Study, Zeynep Aktürk, Ersan Odaci, Ayşe İki̇nci̇, Orhan Baş, Si̇nan Canpolat, Serdar Çolakoğlu, Osman Fi̇kret Sönmez

Turkish Journal of Medical Sciences

This study investigated the effect of Ginkgo biloba (GB) on brain volume in cerebral ischemia induced by stopping carotid artery blood flow. Materials and methods: Twenty-four adult male rats were divided into 4 groups of 6 rats each. No procedure was performed on the control group. Ischemia was applied to the rats in the ischemia and ischemia + GB groups by clamping the arteria carotis communis for 30 min. The rats in the ischemia + GB group were given 100 mg/kg drops (Tebokan Fort Drop, Abdi İbrahim İlaç Sanayi A.Ş., Turkey) containing dry GB leaf extract orally, every day for …

Comparison In Clinical Features And Life Impact Between Juvenile-Onset And Adult-Onset Ankylosing Spondylitis, Mingqiang Guan, Jian Wang, Zhigang Zhu, Jun Xiao, Liang Zhao, Zhihan Li, Zhanjun Shi

Turkish Journal of Medical Sciences

To compare the differences in clinical characteristics and disease impact on life between patients with juvenile-onset ankylosing spondylitis (JoAS) and patients with adult-onset AS (AoAS). Materials and methods: Demographic and clinical data were collected from 139 AS patients. Disease activity was defined with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI). Functional status was assessed with the Bath Ankylosing Spondylitis Functional Index (BASFI). Status of quality of life was evaluated with the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. Results: There were 50 patients with JoAS (36.0%) and 89 with AoAS (64.0%). The JoAS group showed more onset with peripheral …

Effects Of Osteocytes On Vibration-Induced Reflex Muscle Activity In Postmenopausal Women, Şafak Sahi̇r Karamehmetoğlu, İlhan Karacan, Muharrem Çi̇dem, Suat Hayri̇ Küçük, Hakan Ekmekçi̇, Cengi̇z Bahadir

Turkish Journal of Medical Sciences

To assess whether osteocytes have an effect on reflex myoelectrical activity during whole-body vibration (WBV) in postmenopausal women. Materials and methods: Participants were classified into 2 groups: the low bone mineral density (BMD) group (n = 37) and normal BMD group (n = 43). Hip BMD was measured using dual-energy X-ray absorptiometry. Surface electromyography data recorded from the adductor longus muscle were processed to obtain vibration-induced reflex myoelectrical activity. Changes in plasma sclerostin (SOST) levels with WBV were expressed as a standardized vibration-induced SOST index. Results: The standardized vibration-induced SOST index was 1.03 ± 0.24 in the low BMD group …

Attitudes Towards Influenza Vaccination In High Socioeconomic Status Turkish Parents, Suzan Gündüz, Çi̇ğdem Nüket Yüksel, Hale Bozkurt Aktoprak, Meti̇n Canbal, Mehmet Kaya

Turkish Journal of Medical Sciences

To better understand the knowledge, attitudes, and demographic factors that influence the rate of influenza vaccination among high socioeconomic status parents. Materials and methods: questionnaire exploring the attitudes of parents to the influenza vaccine, and their knowledge about influenza and its vaccination, was given to parents of children from 1 through 16 years of age attending the Turgut Özal University Hospital after the 2011/12 influenza season. Results: In the present study, 285 mothers and their children participated and 8.8% (n = 25) of children had the influenza vaccination. Between the vaccinated and nonvaccinated groups, there were statistically significantly differences for …

A Nonrigid Registration Method For Correcting Brain Deformation Induced By Tumor Resection, Yixun Liu, Chengjun Yao, Fotis Drakopoulos, Jinsong Wu, Liangfu Zhou, Nikos Chrisochoides

Computer Science Faculty Publications

Purpose: This paper presents a nonrigid registration method to align preoperative MRI with intraoperative MRI to compensate for brain deformation during tumor resection. This method extends traditional point-based nonrigid registration in two aspects: (1) allow the input data to be incomplete and (2) simulate the underlying deformation with a heterogeneous biomechanical model.

Methods: The method formulates the registration as a three-variable (point correspondence, deformation field, and resection region) functional minimization problem, in which point correspondence is represented by a fuzzy assign matrix; Deformation field is represented by a piecewise linear function regularized by the strain energy of a heterogeneous biomechanical …

Hypothesis Testing In Normal Admixture Models To Detect Heterogeneous Genetic Signals, Qian Fan, Richard Charnigo, Zohreh Talebizadeh, Hongying Dai

Manuscripts, Articles, Book Chapters and Other Papers

In this work we consider a three-component normal mixture model in which one component is known to have mean zero and the other two contaminating components have a nonnegative and a nonpositive mean respectively, while all three components share a common unknown variance parameter. One potential application of this model may be in prioritizing statistical scores obtained in biological experiments, including genetics data. Such a mixture model may be useful in describing the distribution of numerous Z test statistics corresponding to different genes or SNPs, such that a “significant” Z test statistic for a particular gene suggests its connection to …

American And Brazilian Children With Primary Urolithiasis: Similarities And Disparities., Maria Goretti Moreira Guimarães Penido, Marcelo De Sousa Tavares, Milena Maria Moreira Guimarães, Tarak Srivastava, Uri S. Alon

Manuscripts, Articles, Book Chapters and Other Papers

Objectives. Considering the differences in location, socioeconomic background, and cultural background, the aim of this study was to try to identify possible factors associated with the increased incidence of urolithiasis by comparing American and Brazilian children with stones.
Methods. Data of 222 American and 190 Brazilian children with urolithiasis were reviewed including age, gender, body mass index, imaging technique used (ultrasound and computed tomography), and 24-hour urine volume and chemistries.
Results. There were no differences between age and gender at diagnosis. Brazilian children were leaner but in no population did obesity rate exceed that of the general population. Ultrasound was …

Attitudes Of Medical Students Towards Incentives Offered By Pharmaceutical Companies -- Perspective From A Developing Nation -- A Cross-Sectional Study, Usman Tariq Siddiqui, Amarah Shakoor, Sarah Kiani, Farwa Ali, Maryam Sharif, Arun Kumar, Qasim Raza, Naseer Khan, Sardar Mohammed Alamzaib, Syed Farid-Ul-Husnain

Medical College Documents

Background: A training physician has his first interaction with a pharmaceutical representative during medical school. Medical students are often provided with small gifts such as pens, calendars and books, as well as free lunches as part of drug promotion offers. Ethical impact of these transactions as perceived by young medical students has not been investigated in Pakistan before. This study aimed to assess the association of socio-demographic variables with the attitudes of medical students towards pharmaceutical companies and their incentives.Methods: As part of a cross-sectional survey, a validated questionnaire previously used for assessing attitude of medical students towards pharmaceutical industry, …

Empirical Models Of Scalp-Eeg Responses Using Non-Concurrent Intracranial Responses, Komalpreet Kaur, Jerry J. Shih, Dean J. Krusienski

Electrical & Computer Engineering Faculty Publications

Objective- This study presents inter-subject models of scalp-recorded electroencephalographic (sEEG) event-related potentials (ERPs) using intracranially recorded ERPs from electrocorticography and stereotactic depth electrodes in the hippocampus, generally termed as intracranial EEG (iEEG).

Approach- The participants were six patients with medically-intractable epilepsy that underwent temporary placement of intracranial electrode arrays to localize seizure foci. Participants performed one experimental session using a brain-computer interface matrix spelling paradigm controlled by sEEG prior to the iEEG electrode implantation, and one or more identical sessions controlled by iEEG after implantation. All participants were able to achieve excellent spelling accuracy using sEEG, four of the participants …

Global Analysis Of Chlorella Variabilis Nc64a Mrna Profiles During The Early Phase Of Paramecium Bursaria Chlorella Virus-1 Infection, Janet M. Rowe, Adrien Jeanniard, James R. Gurnon, Yuannan Xia, David D. Dunigan, James L. Van Etten, Guillaume Blanc

Nebraska Center for Virology: Faculty Publications

The PBCV-1/Chlorella variabilis NC64A system is a model for studies on interactions between viruses and algae. Here we present the first global analyses of algal host transcripts during the early stages of infection, prior to virus replication. During the course of the experiment stretching over 1 hour, about a third of the host genes displayed significant changes in normalized mRNA abundance that either increased or decreased compared to uninfected levels. The population of genes with significant transcriptional changes gradually increased until stabilizing at 40 minutes post infection. Functional categories including cytoplasmic ribosomal proteins, jasmonic acid biosynthesis and anaphase promoting …

Glutaredoxin-2 Is Required To Control Oxidative Phosphorylation In Cardiac Muscle By Mediating Deglutathionylation Reactions, Mary-Ellen Harper, Ryan J. Mailloux, Jian Ying Xuan, Skye Mcbride, Wael Maharsy, Stephanie Thorn, Chet E. Holterman, Christopher R.J. Kennedy, Peter Rippstein, Robert Dekemp, Jean Da Silva, Mona Nemer, Marjorie Lou

School of Veterinary and Biomedical Sciences: Faculty Publications

Glutaredoxin-2 (Grx2) modulates the activity of several mitochondrial proteins in cardiac tissue by catalyzing deglutathionylation reactions. However, it remains uncertain whether Grx2 is required to control mitochondrial ATP output in heart. Here, we report that Grx2 plays a vital role modulating mitochondrial energetics and heart physiology by mediating the deglutathionylation of mitochondrial proteins. Deletion of Grx2 (Grx2−/−) decreased ATP production by complex I-linked substrates to half that in wild type (WT) mitochondria. Decreased respiration was associated with increased complex I glutathionylation diminishing its activity. Tissue glucose uptake was concomitantly increased. Mitochondrial ATP output and complex I activity could be recovered …

Evaluating The Clinical And Physiological Effects Of Long Term Ultraviolet B Radiation On Guinea Pigs (Cavia Porcellus), Megan K. Watson, Adam W. Stern, Amber L. Labelle, Stephen Joslyn, Timonthy M. Fan, Katie Leister, Micah Kohles, Kemba Marshall, Mark A. Mitchell

School of Veterinary and Biomedical Sciences: Faculty Publications

Vitamin D is an important hormone in vertebrates. Most animals acquire this hormone through their diet, secondary to exposure to ultraviolet B (UVB) radiation, or a combination thereof. The objectives for this research were to evaluate the clinical and physiologic effects of artificial UVB light supplementation on guinea pigs (Cavia porcellus) and to evaluate the long-term safety of artificial UVB light supplementation over the course of six months. Twelve juvenile acromelanic Hartley guinea pigs were randomly assigned to one of two treatment groups: Group A was exposed to 12 hours of artificial UVB radiation daily and Group B …

Gender Differences In High Sensitivity C - Reactive Protein And Self-Reported Muscle Strengthening Activity Among U.S. Adults, Michael R. Richardson

UNF Graduate Theses and Dissertations

Objectives: We sought to examine the gender differences between C - reactive protein (CRP) and muscle strengthening activity (MSA) in U.S. adults (≥20 years of age)

Background: Elevated levels of CRP have been shown to be associated with an increase in risk of cardiovascular disease (CVD). Studies analyzing the relationship between physical activity (PA) and CRP by gender have produced mixed results.

Methods: The sample (n=9,135) included participants in the 1999-2004 National Health and Nutrition Examination Survey (NHANES). Three categories of reported MSA participation were created: no MSA (referent group), some MSA (≥1 to/wk), and meeting the …

Nonnutritive Sweetener And Weight Management: A Potential Paradox In Modern Dieting, Katharine Mary Wright

UNF Graduate Theses and Dissertations

Obesity is a serious health concern in modern society. One way to reduce caloric intake is with nonnutritive sweeteners (NNS). However, recent research suggests they may be compounding the obesity problem. Nonnutritive sweeteners have been linked to increased body mass in a few studies and may be a barrier to effective weight management for some individuals.

Under the framework of the health belief model, the research question was: Does this pattern of NNS-BMI covariance exist in young adults at the University of North Florida and, if so, are there other dietary or activity differences that might partially explain this relationship? …

Prevalence And Prevention Of The Female Athlete Triad, Elizabeth Dachenhaus

Honors Projects

A study was composed to analyze the three components of the female athlete triad: disordered eating, amenorrhea, and osteoporosis. The cyclic behavior of these three components and determination of which of the pillars of the triad is the most dangerous was also focused on. In order to test the prevalence of disordered eating among women’s collegiate teams, a brief survey was distributed and analyzed among athletes at Bowling Green State University. In addition to confirming that women in aesthetic sports experience a greater amount of disordered eating on the team, the survey also identified women that participated in sports perceived …

The Toxoplasma Gondii Cyst Wall Protein Cst1 Is Critical For Cyst Wall Integrity And Promotes Bradyzoite Persistence, Tadakimi Tomita, David J. Bzik, Yan Fen Ma, Barbara A. Fox

Dartmouth Scholarship

Toxoplasma gondii infects up to one third of the world's population. A key to the success of T. gondii as a parasite is its ability to persist for the life of its host as bradyzoites within tissue cysts. The glycosylated cyst wall is the key structural feature that facilitates persistence and oral transmission of this parasite. Because most of the antibodies and reagents that recognize the cyst wall recognize carbohydrates, identification of the components of the cyst wall has been technically challenging. We have identified CST1 (TGME49_064660) as a 250 kDa SRS (SAG1 related sequence) domain protein with a large …

A Mechanism Linking Id2-Tgfβ Crosstalk To Reversible Adaptive Plasticity In Neuroblastoma, Lina Chakrabarti, Bi-Dar Wang, Norman H. Lee, Anthony D. Sandler

Pharmacology and Physiology Faculty Publications

The ability of high-risk neuroblastoma to survive unfavorable growth conditions and multimodal therapy has produced an elusive childhood cancer with remarkably poor prognosis. A novel phenomenon enabling neuroblastoma to survive selection pressure is its capacity for reversible adaptive plasticity. This plasticity allows cells to transition between highly proliferative anchorage dependent (AD) and slow growing, anoikis-resistant anchorage independent (AI) phenotypes. Both phenotypes are present in established mouse and human tumors. The differential gene expression profile of the two cellular phenotypes in the mouse Neuro2a cell line delineated pathways of proliferation in AD cells or tyrosine kinase activation/ apoptosis inhibition in AI …

Divergent Antibody Subclass And Specificity Profiles But Not Protective Hla-B Alleles Are Associated With Variable Antibody Effector Function Among Hiv-1 Controllers, Jennifer I. Lai, Anna F. Licht, Anne-Sophie Dugast, Todd Suscovich, Ickwon Choi, Chris Bailey-Kellogg, Galit Alter, Margaret E. Ackerman

Dartmouth Scholarship

Understanding the coordination between humoral and cellular immune responses may be the key to developing protective vaccines, and because genetic studies of long-term HIV-1 nonprogressors have associated specific HLA-B alleles with spontaneous control of viral replication, this subject group presents an opportunity to investigate relationships between arms of the adaptive immune system. Given evidence suggesting that cellular immunity may play a role in viral suppression, we sought to determine whether and how the humoral immune response might vary among controllers. Significantly, Fc-mediated antibody effector functions have likewise been associated with durable viral control. In this study, we compared the effector …

Impact Of Oxidative Stress On Female Fertility., Tasha Harris

Undergraduate Honors Theses

This study examined nutritional status and fecundity of women and was approved for patient enrollment by the ETSU Institutional Review Board (IRB). Once enrolled, participants filled out two food frequency questionnaires (FFQ, fruit/vegetable intake, fat intake), self-reported anthropometric data, and had one 5 mL vacutainer of whole blood (EDTA) collected for measures of oxidative stress (OS), coenzyme Q10 level, and fatty acid profile of the red blood cell (RBC) membrane. Participants were either designated to the case group (13 women experiencing fertility problems and an anti-mullerian hormone level of 1 ng/ml or less (AMH, <1 ng/mL)) or the control group (13 women experiencing normal ovulation cycles and no evidence of polycystic disease). This study hypothesized that the case group would have poorer plasma antioxidant status, consume more dietary saturated fat and have lower levels of omega-3 and higher levels of omega-6 fatty acids in the RBC membrane. Results showed that case participants had significantly higher body mass index (BMI) when graduating from high school, BMI upon enrollment in the study, and trended to gain more weight since high school. Antioxidant status of the plasma tended to be higher for the case group. This result was surprising as case participants consumed significantly fewer servings of fruits and vegetables (sources of antioxidants) than control subjects. FFQ results indicated that case participants consumed significantly higher amounts of total fat (g), saturated fat (g), unsaturated fat (g), and their diets had a higher dietary fat percent. No significant differences were noted in the individual fatty acids isolated from the RBC membrane or in calculated ratios of fatty acid between case and control groups. The fatty acid profile from RBC membranes are in agreement with self-reported fat intake from FFQ data and may provide a rationale for no differences observed between the two groups.

Biochemical Assay Optimization And Computational Screening Efforts To Identify Potential Luxs Inhibitors, Keeshia Q. Wang

Master's Theses

Quorum sensing (QS) is a process of coordination of bacterial gene expression in response to cell population. System two QS is regulated by the small signaling molecule autoinducer-2 (AI-2) and is implicated in the infectious behaviors of various bacterial species. AI-2 is biosynthesized from S-ribosylhomocysteine (SRH) by the enzyme LuxS and induces interspecies cell-to-cell communication. Inhibition of LuxS would therefore inhibit interspecies QS. Herein, a search for novel molecular species that will competitively bind with SRH in the LuxS binding site is performed in silico. Computational screening results are then validated in vitro using an optimized LuxS inhibition …

Impact Of Noise On Molecular Network Inference, Radhakrishnan Nagarajan, Marco Scutari

Biostatistics Faculty Publications

Molecular entities work in concert as a system and mediate phenotypic outcomes and disease states. There has been recent interest in modelling the associations between molecular entities from their observed expression profiles as networks using a battery of algorithms. These networks have proven to be useful abstractions of the underlying pathways and signalling mechanisms. Noise is ubiquitous in molecular data and can have a pronounced effect on the inferred network. Noise can be an outcome of several factors including: inherent stochastic mechanisms at the molecular level, variation in the abundance of molecules, heterogeneity, sensitivity of the biological assay or measurement …

Surface-Enhanced Raman Spectroscopy (Sers) Tracking Of Chelerythrine, A Na+ K+ Pump Inhibitor, Into Cytosol And Plasma Membrane Fractions Of Human Lens Epithelial Cell Cultures, Kevin M. Dorney, Ioana E.P. Sizemore, Tariq Alqahtani, Norma C. Adragna, Peter K. Lauf

Pharmacology and Toxicology Faculty Publications

Background/aims: The quaternary benzo-phenanthridine alkaloid (QBA) chelerythrine (CET) is a pro-apoptotic drug and Na(+)/K(+) pump (NKP) inhibitor in human lens epithelial cells (HLECs). In order to obtain further insight into the mechanism of NKP inhibition by CET, its sub-cellular distribution was quantified in cytosolic and membrane fractions of HLEC cultures by surface-enhanced Raman spectroscopy (SERS). Methods: Silver nanoparticles (AgNPs) prepared by the Creighton method were concentrated, and size-selected using a one-step tangential flow filtration approach. HLECs cultures were exposed to 50 μM CET in 300 mOsM phosphate-buffered NaCl for 30 min. A variety of cytosolic extracts, crude and purified membranes, …

Enhanced Pancreatic Beta-Cells Proliferation And Functionality, Hanan Abdulaziz Alismail

Graduate Theses and Dissertations

Biologically functional beta-cells proliferate at an extremely low rate with limited turnover capacity. This cellular property hinders cell-based therapy for clinical applications. Many attempts have been made to develop techniques that allow large quantities of production of clinically relevant islet β-cells in vitro. A line of studies demonstrates that functional beta-cells can proliferate under certain circumstances, providing hope for generating and expanding these cells in vitro and transplanting them into the recipient. In this study, we showed that a membrane substrate offers a better niche for beta cell proliferation and insulin secretion. Mouse beta cells were grown on a tissue …

Intrahypothalamic Pituitary Adenylate Cyclase-Activating Polypeptide Regulates Energy Balance Via Site-Specific Actions On Feeding And Metabolism, Jon Resch, Brian Maunze, Adriana K. Gerhardt, Samuel K. Magnuson, Kailynn A. Phillips, Sujean Choi

Biomedical Sciences Faculty Research and Publications

Numerous studies have demonstrated that both the hypothalamic paraventricular nuclei (PVN) and ventromedial nuclei (VMN) regulate energy homeostasis through behavioral and metabolic mechanisms. Receptors for pituitary adenylate cyclase-activating polypeptide (PACAP) are abundantly expressed in these nuclei suggesting PACAP may be critical for the regulation of feeding behavior and body weight. To characterize the unique behavioral and physiological responses attributed to select hypothalamic cell groups, PACAP was site-specifically injected into the PVN or VMN. Overall food intake was significantly reduced by PACAP at both sites, however meal pattern analysis revealed only injections into the PVN produced significant reductions in meal size, …

Tibial Tubercle Transfer To Correct Bilateral Patellar Tendinopathy In A Collegiate Football Player, Andrew D. Hamstra

Boise State University Theses and Dissertations

Objective: To present a case of a competitive football player with chronic patellar tendinopathy and the associated bilateral tibial tubercle transfer surgeries performed leading to the reduction of pain and return to participation.

Background: A 19 year-old male football athlete (height= 187.96 cm, mass= 112.037 kg) presented with chronic patellar tendinopathy that began in his high school career and continued to worsen with the increased physical demands associated with participation in collegiate sport.

Differential Diagnosis: Chondromalacia patella and Osgood Schlatters disease.

Treatment: After nonsurgical intervention resulted in no decrease of pain, bilateral tibial tubercle transfer surgery was conducted to correct …

Staphylococcus Aureus Sara Regulates Inflammation And Colonization During Central Nervous System Biofilm Formation, Jessica N. Snowden, Matthew K. Beaver, Karen Beenken, Alexander R. Horswill, Tammy L. Kielian

Journal Articles: Pediatrics

Infection is a frequent and serious complication following the treatment of hydrocephalus with CSF shunts, with limited therapeutic options because of biofilm formation along the catheter surface. Here we evaluated the possibility that the sarA regulatory locus engenders S. aureus more resistant to immune recognition in the central nervous system (CNS) based on its reported ability to regulate biofilm formation. We utilized our established model of CNS catheter-associated infection, similar to CSF shunt infections seen in humans, to compare the kinetics of bacterial titers, cytokine production and inflammatory cell influx elicited by wild type S. aureus versus an isogenic sarA …

Retention Strategies For Medical Technologists: Addressing The Shortages And Vacancies In The Clinical Laboratory, Kathy S. Small

Electronic Theses and Dissertations

It is important to have well-trained and qualified laboratory professionals. Seventy percent of patient care is based on decisions made from laboratory results, yet there is a growing shortage of medical technologists. Although some baby boomers are delaying retirement, worsening of the shortage crisis is inevitable. Retention of medical technologists has become more important than recruitment. The purpose of this study was to identify and evaluate innovative retention strategies used by clinical laboratory managers throughout the United States.

A significant finding of this study was the lack of qualified medical technologists entering the ranks of laboratory managers. This study identified …

Scanned Ion Beam Therapy For Thoracic Tumors, John Gordon Eley

Dissertations and Theses (Open Access)

Although frequently cured of Hodgkin lymphoma, adolescents and young adults can develop radiation induced second cancers. These patients could potentially benefit from scanned ion radiotherapy yet likely would require motion mitigation strategies. In theory, four-dimensional (4D) optimization of ion beam fields for individual motion states of respiration can enable superior sparing of healthy tissue near moving targets, compared to other motion mitigation strategies. Furthermore, carbon-ion therapy can sometimes provide greater relative biological effectiveness (RBE) for cell sterilization in a target but nearly equivalent RBE in tissue upstream of the target, compared to proton therapy. Thus, we expected that for some …

Attenuation Of Parenteral Nutritionassociated Liver Disease By Omega-3 Long-Chain Polyunsaturated Fatty Acids, Emma Monique Tillman

Theses and Dissertations (ETD)

No abstract provided.

Erg11-Mediated Azole Resistance In Candida Albicans, Stephanie Ann Flowers

Theses and Dissertations (ETD)

Although many medically important Candida species are commensal to the gut or colonizers of the skin, these organisms have the propensity to cause disease in the event of a waning immune system. Clinical manifestations of infections with Candida species can range from superficial mucosal infections to deep organ involvement usually resulting from haematogenous spread of infection. Despite significant progress made in the management of patients with fungal infections, the emergence of antifungal resistant clinical isolates creates significant problem in regards to antifungal prophylaxis and empirical treatment strategies. Antifungal resistance is associated with high mortality rates and hefty medical costs. The …