There is evidence that sensorimotor function

There is evidence that sensorimotor function BMS-777607 cell line in people with LBP is altered. This study evaluates the sensorimotor function in the lumbopelvic region, as measured by postural sway, response to sudden load and repositioning accuracy, following SM to the lumbar and pelvic region when compared to a sham treatment.\n\nMethods/Design: A total of 219 participants with acute, subacute or chronic low back pain are being recruited from the Quad Cities area located

in Iowa and Illinois. They are allocated through a minimization algorithm in a 1: 1: 1 ratio to receive either 13 HVLA-SM treatments over 6 weeks, 13 LVVA-SM treatments over 6 weeks or 2 weeks of a sham treatment followed by 4 weeks of

full spine “doctor’s choice” SM. Sensorimotor function tests are performed before and immediately after treatment at baseline, week 2 and week 6. Self-report outcome assessments are also collected. The primary aims of this study are to 1) determine immediate pre to post changes in sensorimotor function as measured by postural sway following delivery of a single HVLA-SM or LVVA-SM treatment when compared to a sham treatment and 2) to determine changes from baseline to 2 weeks (4 treatments) of HVLA-SM or LVVA-SM compared to a sham treatment. Secondary aims include changes in response to sudden loads and lumbar repositioning accuracy at these endpoints, estimating

Nepicastat sensorimotor function in the SM groups after 6 weeks of treatment, and exploring if changes in sensorimotor function are associated with changes in self-report outcome assessments.\n\nDiscussion: This study may provide clues to the sensorimotor mechanisms that explain observed functional deficits associated with LBP, as well as the mechanism of action of SM.”
“OBJECTIVE To evaluate the effect of the demographic/clinical characteristics of patients and testicular histologic findings on the in vitro colonization of human spermatogonial stem cells (SSCs). In vitro isolation and proliferation of human SSCs has emerged as a suitable method for the enrichment of spermatogonia germ cells.\n\nMETHODS SSCs were isolated from the testicular biopsies of 47 infertile men with nonobstructive azoospermia and CA4P co-cultured with a Sertoli cell monolayer. Age, infertility duration, medical/surgical history, testicular size, and testicular histologic findings were recorded. The patients were divided into 2 groups according to the growth/no growth of human SSC colonies in culture. As the main outcome measure, the number and diameter of germ cell-derived colonies were compared between 2 groups in days 8, 13, and 18 after cultivation with respect to the recorded parameters.\n\nRESULTS No difference was found between the 2 groups regarding the demographic/clinical parameters.


“Background Patients with a history of previous malignanc


“Background. Patients with a history of previous malignancy are often encountered in a discussion of buy Tubastatin A surgical resection of non-small-cell lung cancer (NSCLC). The outcome of patients with 2 or more previous cancers remains unknown.\n\nMethods. We performed a retrospective study including all patients undergoing resection for NSCLC from January 1980 to December

2009 at 2 French centers. We then compared the survival of patients without a history of another cancer (group 1), those with a history of a single malignancy (group 2), and those with a history of 2 or more previous malignancies (group 3).\n\nResults. There were 5,846 patients: 4,603 (78%) in group 1, 1,147 (20%) in group 2, and 96 (2%) in group 3. The proportion of patients included in group 3 increased from 0.3% to 3% over 3 decades. Compared with groups 1 and 2, group 3 was associated with older age, a larger proportion of women, earlier tumor stage, less induction therapy, and fewer pneumonectomies. Despite this, postoperative complications and mortality were similar in groups 2 and 3, and higher than in group 1. Five-year survival rates were 44.6%, 35.1%, and 23.6% in groups 1, 2, and 3, respectively (p < 0.000001 for comparison between 3 groups; p = 0.18 for comparison between groups 2 and 3). In multivariate analysis, male sex, higher T stage,

higher N stage, incomplete resection, and study group were significant predictors of adverse prognosis.\n\nConclusions. Despite earlier diagnosis and acceptable long-term survival, patients operated on for NSCLC after 2 or 3 previous malignancies selleck chemical carried a worse prognosis than did those undergoing operation after 1 malignancy or if there was no previous diagnosis of cancer. (Ann Thorac Surg 2013;95:1000-5) (C) 2013 by The Society of Thoracic Surgeons”
“The success of helminth parasites is partly related to their ability to modulate host immune responses towards an anti-inflammatory/regulatory phenotype. This ability resides with the molecules contained in the secretome of various helminths that have been shown to interact with host immune

cells and influence their function. Consequently, there exists a unique opportunity to exploit these molecules for the prophylactic and LBH589 inhibitor therapeutic treatment of human pro- and auto-inflammatory disorders (for example septic shock, transplant rejection and autoimmune disease). In this review, we describe the mechanisms used by the trematode parasite, Fasciola hepatica, to modulate the immune responses of its host and discuss the potent immune-modulatory effects of three individual molecules within the secretome; namely cathepsin L1, peroxiredoxin and helminth defence molecule. With a focus on the requirements from industry, we discuss the strategies by which these molecules may be clinically developed to control human immune responses in a way that is conducive to the prevention of immune-mediated diseases. Crown Copyright (C) 2012 Published by Elsevier Ltd.

We demonstrated that 18F-FDG PET-CT visualizes the active focus o

We demonstrated that 18F-FDG PET-CT visualizes the active focus of glucose metabolism of PNET of the chest wall and is effective for the preoperative PARP signaling evaluation of patients with this tumor.”
“Sequencing and analyses of 16S rRNA gene amplicons were performed to estimate the composition of the rumen methanogen community in 252 samples from eight cohorts of sheep and cattle, separated into 16 different sample groups by diet, and to determine which methanogens are most prominent in the rumens of farmed New Zealand ruminants. Methanobacteriales (relative abundance +/- standard deviation,

89.6% +/- 9.8%) and Methanomassiliicoccales (10.4% +/- 9.8%) were the two major orders and contributed 99.98% (+/- 0.1%) to the rumen methanogen communities in the samples. Sequences from Methanobacteriales were almost entirely from only

four different species (or clades of very closely related species). Each was detectable in at least 89% of the samples. These four species or clades were the Methanobrevibacter gottschalkii clade and Methanobrevibacter ruminantium clade with a mean abundance of AC220 in vivo 42.4% (+/- 19.5% standard deviation) and 32.9% (+/- 18.8%), respectively, and Methanosphaera sp. ISO3-F5 (8.2% +/- 6.7%) and Methanosphaera sp. group5 (5.6% +/- 5.7%). These four species or clades appeared to be primarily represented by only one or, in one case, two dominant sequence types per species or clade when the sequences were grouped into operational taxonomic units (OTUs) at 99% sequence identity. The mean relative abundance of Methanomassiliicoccales in the samples was relatively low but exceeded 40% in some of the treatment groups. Animal feed affected the apparent methanogen community structure of both orders, as evident from differences in relative abundances of the major OTUs in animals

under different feeding regimens.”
“Metformin is widely used in the treatment of diabetes mellitus type 2 where it reduces insulin resistance and diabetes-related morbidity and mortality. Population-based studies show that metformin treatment is associated with a dose-dependent reduction in cancer risk. The metformin treatment also increases complete pathological tumour response rates following neoadjuvant Flavopiridol molecular weight chemotherapy for breast cancer, suggesting a potential role as an anti-cancer drug. Diabetes mellitus type 2 is associated with insulin resistance, elevated insulin levels and an increased risk of cancer and cancer-related mortality. This increased risk may be explained by activation of the insulin- and insulin-like growth factor (IGF) signalling pathways and increased signalling through the oestrogen receptor. Reversal of these processes through reduction of insulin resistance by the oral anti-diabetic drug metformin is an attractive anti-cancer strategy. Metformin is an activator of AMP-activated protein kinase (AMPK) which inhibits protein synthesis and gluconeogenesis during cellular stress.

All samples were analyzed for PTEN mutations using PCR and direct

All samples were analyzed for PTEN mutations using PCR and direct DNA sequencing methods. Demographic data collected, were analyzed using SPSS version 19.0 software and a P value of smaller than 0.05 was considered statistically significant. Results: Of the 55 patients examined, tumor stage was T1,

T2 (T2a, T2b) in 34 (61.8%) and 21 (38.2%) and tumor grade was high, low in 34 (61.8%) and 21 (38.2%), respectively. No mutations in the PTEN gene were found in patients with bladder cancer and control. Among the risk factors studied, only the occupation and history of urinary tract stones, were significantly associated with bladder cancer (P value smaller than 0.05). However, other risk factors did not show such a relationship. Conclusion: No mutation selleckchem was found in PTEN gene of patients with bladder cancer. Therefore, mutations in this gene cannot predict the prognosis and progression of urothelial bladder cancer. On the other hand, significant relationship was found between occupation and urinary stones with bladder cancer. This communication reflects click here the impact of these factors on the risk of bladder cancer.”
“Curcumin has attracted increasing interest as an anti-cancer drug for decades. The mechanisms of action involve multiple cancer-related signaling pathways. Recent studies highlighted

curcumin has epigenetic regulatory effects on miRNA in cancers. In the present study, we demonstrated the proapoptotic effects of curcumin in vitro and in vivo. miRNA microarray and qPCR indicated that miR-192-5p and miR-215 were the most responsive miRNAs upon curcumin treatment in H460 and A427 cells. Functional studies showed miR-192-5p/215 were putative tumor suppressors in non-small cell lung cancer. Curcumin also promoted miR-192-5p/215 expressions

in A549 cells (p53 wild type) but not in H1299 cells (p53-null). Conditional knockdown of p53 by tetracycline inducible expression system significantly abrogated curcumin-induced YAP-TEAD Inhibitor 1 inhibitor miR-192-5p/215 upregulation in the p53 wild-type H460, A427 and A549 cells. Conversely, ectopic expression of exogenous wild-type but not R273H mutant p53 in the p53-null H1299 cells enabled miR192-5p/215 response to curcumin treatment. The proapoptotic effects of curcumin also depended on miR-192-5p/215 induction, and antagonizing miR-192-5p/215 expression attenuated curcumin-induced apoptosis in H460, A427 and A549 cells, but not in H1299 cells. Finally, X-linked inhibitor of apoptosis (XIAP) is proved to be a novel transcriptional target of miR-192-5p/215. Taken together, this study highlights that the proapoptotic effects of curcumin depend on miR-192-5p/215 induction and the p53-miR-192-5p/215-XIAP pathway is an important therapeutic target for non-small cell lung cancer. (c) 2014 Elsevier Ireland Ltd. All rights reserved.


“The treatment of upper urinary tract stone with flexible


“The treatment of upper urinary tract stone with flexible ureteroscopy is safe and efficient. According to the size and the localization of stone, it is the first-line treatment. The patient must be informed about modalities and risks of this treatment. Urines must be sterile. The fragmentation of stone is made with the energy of Laser Holmium. The knowledge of material and technique allows to obtain a complete treatment in about 80% of cases. (C) 2011 Published by Elsevier Masson SAS.”
“Isoniazid (INH) is a key drug ingredient in the fixed dose combination for the treatment of tuberculosis (TB). INH is highly soluble in aqueous medium and also stable in pure form,

but it undergoes degradation when it is part of the FDC due to cross reactions. In continuation of our studies to GSK461364 concentration Cediranib concentration improve the physiochemical properties of INH, we performed a cocrystal screen with pharmaceutically acceptable molecules

selected from the generally regarded as safe (GRAS). Cocrystals with acidic conformers, such as vanillic acid (VLA), ferulic acid (FRA), caffeic acid (CFA), as well as with hydroxyl coformer resorcinol (RES), are reported. INHVLA and INHFRA are dimorphic, and INHCFA is trimorphic. Form-1 of INHFRA and INHVLA are two-dimensional isostructural. All cocrystal structures are sustained by the expected acidpyridine synthon, except the isostructural cocrystals which have the hydroxylpyridine synthon. The cocrystal forms were tested in accelerated ICH conditions of 40 degrees C and 75% RH for stability, and it was found that all the solid forms are stable for a test period of six months, except the INHRES cocrystal. Slurry conditions and grinding experiments suggest that Form-2 of INHFRA and INHVLA have good stability, and Form-1 of INHCFA is the most stable crystalline form of INH.”
“Objective:

To assess the quality of informed consent for patients undergoing invasive procedures and to reveal patient preferences for being informed about the potential risks of treatment and alternatives to treatment. Design: This studywas planned as a pilot Cyclosporin A clinical trial study. Hospitalized patients’ perceptions and expectations about the informed-consent process were explored in a general surgery department. The prepared questionnaire was completed by patients via interview. Setting: Inpatient services of the general surgery department of a large academic hospital in Istanbul, Turkey. Participants: The study population consisted of hospitalized patients in a general surgery department who underwent invasive procedures in March 2013. Main outcome measures: Recognition of consent forms by the patients, rate of patients’ recall of risks, rate of patients who were willing to be involved in decision making, and rate of patients who were satisfied with the whole decision-making process were measured. Results: All patients signed consent forms.

Results: The model that was built can be used for any level of dr

Results: The model that was built can be used for any level of drug effect and can generate classical isobolograms to determine the nature of drug interactions (additivity, subadditivity or synergy), which is of particular importance in the case of novel compounds endowed with a high biological activity for which the mechanism of Rigosertib in vitro action is unknown. In addition, this method is an interesting alternative allowing for a meaningful reduction in the number of animals used for in vivo studies. Conclusions: In a mouse model of toxic

peripheral neuropathy induced by a single intraperitoneal dose of oxaliplatin, the usefulness of this SVR method for modeling dose-effect relationships was confirmed. This method may also be applicable during preliminary investigations regarding the mechanism of action selleck screening library of novel compounds. (C) 2014 Elsevier Inc. All rights reserved.”
“Background-Heart failure (HF) is the leading cause of hospitalization among older Americans. Subsequent discharge to skilled nursing facilities (SNF) is not well described.\n\nMethods and Results-We performed an observational analysis of Medicare beneficiaries >= 65 years of age, discharged alive to SNF or home after >= 3-day

hospitalization for HF in 2005 and 2006 within the Get With The Guidelines-HF Program. Among 15 459 patients from 149 hospitals, 24.1% were discharged to an SNF, 22.3% to home with home health service, and 53.6% to home with self-care. SNF use varied significantly among hospitals

(median, 10.2% versus 33.9% in low versus high tertiles), with rates highest in the Northeast. Patient factors associated with discharge to SNF included longer length of stay, advanced age, female sex, hypotension, Rigosertib in vivo higher ejection fraction, absence of ischemic heart disease, and a variety of comorbidities. Performance measures were modestly lower for patients discharged to SNF. Unadjusted absolute event rates were higher at 30 days (death, 14.4% versus 4.1%; rehospitalization, 27.0% versus 23.5%) and 1 year (death, 53.5% versus 29.1%; rehospitalization, 76.1% versus 72.2%) after discharge to SNF versus home, respectively (P<0.0001 for all). After adjustment for measured patient characteristics, discharge to SNF remained associated with increased death (hazard ratio, 1.76; 95% confidence interval, 1.66 to 1.87) and rehospitalization (hazard ratio, 1.08; 95% confidence interval, 1.03 to 1.14).\n\nConclusions-Discharge to SNF is common among Medicare patients hospitalized for HF, and these patients face substantial risk for adverse events, with more than half dead within 1 year. These findings highlight the need to better characterize this unique patient population and understand the SNF care they receive. (Circ Heart Fail. 2011;4:293-300.)”
“Surveys with questionnaires play a vital role in decision and policy making in society.

Our method is

Our method is MLN2238 mouse also robust for the image with a much higher level of speckle noise. For clinical images, the results show that MR-GND-PCA can reduce speckle and preserve resolvable details.”
“It has been validated that sentinel lymph node biopsy (SLNB) shows whether a patient’s breast cancer or melanoma has spread to regional lymph nodes. As

a result, management of patients with these cancers has been revolutionized. SLNB has replaced axillary lymph node dissection (ALND) as the staging modality of choice for early breast cancer and has replaced complete lymph node dissection as the staging modality of choice for melanoma in patients whose SLNBs indicate no metastases. Recently concluded multicenter, randomized trials for breast cancer with 5-

to 10-y outcome data have shown no significant differences in disease-free survival rates or overall survival rates between SLNB and ALND groups but have shown significantly lower morbidity with SLNB than with ALND. The lowest false-negative rates ( 5.5%-6.7%) were seen in studies that used preoperative lymphoscintigraphy and dual mapping during surgery. To assess the survival impact of SLNB in melanoma, the Multicenter Selective Lymphadenectomy www.selleckchem.com/products/gsk923295.html Trial I was performed. Melanoma-specific survival rates were not different between subjects randomized to SLNB with lymphadenectomy for nodal metastasis on biopsy and subjects randomized to observation with lymphadenectomy for nodal relapse. However, the 10-y disease-free survival rates were better for the SLNB group than for the observation group, specifically among patients with intermediate-thickness melanomas or thick melanomas.”
“PURPOSE: To correlate aqueous vasoactive protein changes with macular edema after dexamethasone implant in retinal vein occlusion (RVO). DESIGN: Prospective, interventional case series. METHODS: Twenty-three central RVO (CRVO) and 17 branch RVO (BRVO) subjects with edema despite prior anti vascular endothelial growth factor (VEGF)

treatment had aqueous taps at baseline and 4 and 16 weeks after dexamethasone implant. Best-corrected visual acuity (BCVA) and center subfield thickness were measured every 4 weeks. Aqueous vasoactive protein levels were measured by protein array or enzyme-linked immunosorbent assay. RESULTS: Thirty-two FK228 concentration vasoactive proteins were detected in aqueous in untreated eyes with macular edema due to RVO. Reduction in excess foveal thickness after dexamethasone implant correlated with reduction in persephin and pentraxin 3 (Pearson correlation coefficients = 0.682 and 0.638, P = .014 and P = -.003). Other protein changes differed among RVO patients as edema decreased, but bigger than = 50% of patients showed reductions in hepatocyte growth factor, endocrine gland VEGF, insulin-like growth factor binding proteins, or endostatin by bigger than = 30%.

By the end of the study period, 1003 (68%) patients

were

By the end of the study period, 1003 (68%) patients

were alive and in care, one (<1%) had died, eight Selumetinib manufacturer (0.5%) had transferred out and 453 (31%) were lost to follow-up.\n\nConclusionGood management of HT and DM can be achieved in a primary care setting within an informal settlement. This model of intervention appears feasible to address the growing burden of non-communicable diseases in developing countries.”
“Purpose: To report a patient with a ruptured diverticulum of Kommerell and to discuss treatment options and complications.\n\nCase Report: An 82-year-old woman with no prior medical history was diagnosed with a ruptured aneurysmal proximal aberrant right subclavian artery (diverticulum of Kommerell). She was treated with a carotid-subclavian bypass, a thoracic aortic stent-graft covering both subclavian orifices, and a vascular plug in the proximal right subclavian artery. After an initially uneventful recovery, the patient developed delayed ischemic esophageal ulcerations and subsequent perforation at 6 weeks postoperatively, leading to mediastinitis and stent-graft infection.\n\nConclusion: A hybrid approach may be of value in cases of ruptured Screening Library cell line diverticulum of Kommerell. However, despite the anticipated reduction in perioperative mortality,

this technique still yields a considerable risk of postoperative complications and mortality. J Endovasc Ther. 2010;17:762-766″
“The efficacy of standard air quality model evaluation techniques is becoming compromised as the simulation periods continue to lengthen in response to ever increasing computing capacity. Accordingly, the purpose of this paper is to demonstrate a statistical approach called

Principal Component Analysis (PCA) with the intent of motivating its use by the evaluation community. One of the main objectives of PCA is to identify, through data reduction, the recurring and ML323 independent modes of variations (or signals) within a very large dataset, thereby summarizing the essential information of that dataset so that meaningful and descriptive conclusions can be made. In this demonstration, PCA is applied to a simple evaluation metric – the model bias associated with EPA’s Community Multi-scale Air Quality (CMAQ) model when compared to weekly observations of sulfate (SO42-) and ammonium (NH4+) ambient air concentrations measured by the Clean Air Status and Trends Network (CASTNet). The advantages of using this technique are demonstrated as it identifies strong and systematic patterns of CMAQ model bias across a myriad of spatial and temporal scales that are neither constrained to geopolitical boundaries nor monthly/seasonal time periods (a limitation of many current studies).

This reaction can be used for the preparation of cyclopropane-sub

This reaction can be used for the preparation of cyclopropane-substituted tetrahydropyrans. The protocol was used as a key step in the total synthesis of the sponge-derived macrolide clavosolide A.”
“Purpose: The aim of this study was to evaluate stress distribution on peri-implant bone simulating the influence of implants with different XMU-MP-1 purchase lengths on regular and switching platforms in the anterior maxilla by means of three-dimensional finite element analysis.\n\nMaterials

and Methods: Four mathematical models of a central incisor supported by an external hexagon implant (diameter, 5.0 mm) were created, varying the length (15.0 mm for long implants [L] and 7.0 mm for short implants [S]) and the diameter of the abutment platform (5.0 mm for regular models [R] and 4.1 mm for switching models [S]). The models were created

using the Mimics 11.11 (Materialise) and SolidWorks 2010 (Inovart) software. Numerical analysis was performed using ANSYS Workbench 10.0 (Swanson Analysis System). Oblique forces (100 N) were applied to the palatine surface of the central incisor. The bone/implant interface was considered perfectly integrated. Maximum (sigma(max)) and minimum (sigma(min)) principal stress Alvocidib manufacturer values were obtained.\n\nResults: For the cortical bone, the highest stress values (sigma(max)) were observed in the SR (73.7 MPa) followed by LR (65.1 MPa), SS (63.6 MPa), and LS (54.2 MPa). For the trabecular bone, the highest stress values (sigma(max)) were observed in the SS (8.87 MPa) followed by the SR (8.32 MPa), LR (7.49 MPa), learn more and LS (7.08 MPa).\n\nConclusions: The influence of switching platform was more evident for the cortical bone in comparison with the trabecular bone for the short and long implants. The long implants showed lower stress values in comparison to the short implants, mainly when the switching platform was used.”
“Objective To develop, apply and evaluate a new research method to establish relationships between structural and process elements of the provision of cognitive services. In-depth knowledge about how local organisational

structural elements of community pharmacies shape the implementation process of cognitive services is needed to develop targeted quality assurance systems to ensure that the services are continuously provided to the patients who need them. The first publicly reimbursed cognitive service in Denmark, the Inhaler Technique Assessment Service (ITAS) is used as the case. Setting The research method was developed at the Faculty of Pharmaceutical Sciences at the University of Copenhagen and later applied to seven community pharmacies geographically spread around Denmark. Methods A pilot study as well as a subsequent literature review was conducted to determine which structure-process elements to focus on in the research method as well as to select appropriate theories and methods.


“Objective:

To evaluate the prevalence of incident


“Objective:

To evaluate the prevalence of incidentally found unruptured intracranial aneurysms (UIAs) on the brain MR angiography (MRA) from a community-based general hospital.\n\nMaterials and Methods: This was a prospectively collected retrospective study, carried out from January 2004 to December 2004. The subjects included 3049 persons from a community-based hospital in whom MRA was performed according to a standardized protocol in an outpatient setting. Age- and sex-specific prevalence of UIAs was calculated. The results by MRA were compared with intra-arterial digital subtraction angiography (DSA) findings.\n\nResults: Unruptured intracranial aneurysms were found in 137 (5%) of the 3049 patients (M:F = 43:94; mean age, 60.2 years). The prevalence of UIAs was 5% (n = 94) this website in women and 4% (n = 43) in men, respectively (p = 0.2046) and showed no age-related

increase. The most common site of aneurysm was at the distal internal carotid artery (n = 64, 39%), followed by the middle cerebral artery (n = 40, 24%). In total, 99% of aneurysms measured less than 12 mm, and 93% of aneurysms measured Less than 7 mm. Direct comparisons between MRA and DSA were available selleck compound in 70 patients with 83 UIAs; the results revealed two false positive and two false negative results.\n\nConclusion: This community-hospital based study suggested a higher prevalence of UIAs observed by MRA than previously reported. These findings should be anticipated in the design and use of neuroimaging in clinical practice.”
“As health care improves and life expectancy increases, Wnt inhibitor dentists and dental students are treating a growing

number of elderly and medically compromised patients, increasing the likelihood of a medical emergency during treatment. Previous studies examining emergencies in a dental setting have relied upon self-reports and are therefore subject to biases in reporting. The purpose of this study was to examine data generated from documentation of CODE-5 medical emergency events at the University at Buffalo School of Dental Medicine over an eight-and-a-half-year period. The incidence of emergencies was found to be 164 events per million patient visits, which is lower than reported in previous studies. Most emergencies involved suspected cardiovascular events, syncope, complications related to local anesthesia, and hypoglycemia. Twenty percent of emergencies involved people who were in the building for reasons other than to receive dental care, underscoring the need for an operational CODE-5 system whenever a building is occupied. We suggest strategies to reduce the incidence of medical emergencies and increase ability to manage those that do occur.