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Using fine-scale panel data and an econometric model, we predict land use change in the Midwestern United States if a new bioenergy crop, Miscanthus × Giganteus (miscanthus), is introduced. To explain farmers' current crop choices, we use a local, limited dependent variable regression based on soil and weather characteristics. To this model, we add miscanthus as a new crop, based on its place dependent BioCro model-predicted yield. We find that the vast majority of land used to grow miscanthus will come from land now used for non-major crops, pasture, woodland, and other uses. This implies that miscanthus can help mitigate climate change by displacing oil usage without causing food conflict.

Shaken Bahy Syndrome is a serious form of child abuse, involving infants under the age of six months. Dcliherately shaking an infant is often associated with frustration or anger, particularly when an infant will not stop crying. The shaking results in numerous initial and long-term consequences for the developing infant. In its most severe form Shaken Bahy Syndrome results in the death of the infant. A case study detailing the clinical findings and treatment of a six-month-old infant with Shaken Bahy Syndrome who received inpatient occupational therapy services is presented. [ABSTRACT FROM AUTHOR]

Background: Several studies have demonstrated improved outcomes poststroke when higher intensity rehabilitation is provided. Canadian Stroke Best Practice Recommendations advise patients receive 180 min of therapy time per day; however, the exact amount required to reach benefit is unknown., Aims: The primary aim of this study was to determine the association between rehabilitation intensity (RI) and total Functional Independence Measure (FIM) Instrument change. Secondary aims included determining the association between RI and discharge location, 90-day home time, rehabilitation effectiveness, and motor and cognitive FIM change., Methods: A retrospective cohort study was conducted using available administrative databases of acute stroke patients discharged to inpatient rehabilitation facilities in Ontario, Canada, from January 2017 to December 2021. RI was defined as number of minutes per day of direct therapy by all providers divided by rehabilitation length of stay. The association between RI and the outcomes of interest were analyzed using regression models with restricted cubic splines., Results: A total of 12,770 individuals were included. Mean age of the sample was 72.6 years, 46.0% of individuals were female, and 87.6% had an ischemic stroke. Mean RI was 74.7 min (range: 5-162 min) per day. Increased RI was associated with an increase in mean FIM change. However, there was diminishing incremental increase after reaching 95 min/day. Increased RI was positively associated with motor and cognitive FIM change, rehabilitation effectiveness, 90-day home time, and discharge to preadmission setting. Higher RI was associated with a lower likelihood of discharge to long-term care., Conclusions: None of the patients met the recommended RI of 180 min/day based on the Canadian Stroke Best Practice Recommendations. Despite this, higher intensity was associated with better outcomes. Given that most positive associations were observed with a RI ⩾95 min/day, this may be a more feasible target., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This document used data adapted from the Statistics Canada Postal CodeOM Conversion File, which is based on data licensed from Canada Post Corporation, and/or data adapted from the Ontario Ministry of Health (MOH) Postal Code Conversion File, which contains data copied under license from ©Canada Post Corporation and Statistics Canada. Parts of this material are based on data and/or information compiled and provided by CIHI and the Ontario MOH. The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. Parts of this material are adapted from Statistics Canada, Census, 2016. This does not constitute an endorsement by Statistics Canada of this product.

L-DOPA is deficient in the developing albino eye, resulting in abnormalities of retinal development and visual impairment. Ongoing retinal development after birth has also been demonstrated in the developing albino eye offering a potential therapeutic window in humans. To study whether human equivalent doses of L-DOPA/Carbidopa administered during the crucial postnatal period of neuroplasticity can rescue visual function, OCA C57BL/6 J-c2J OCA1 mice were treated with a 28-day course of oral L-DOPA/Carbidopa at 3 different doses from 15 to 43 days postnatal age (PNA) and for 3 different lengths of treatment, to identify optimum dosage and treatment length. Visual electrophysiology, acuity, and retinal morphology were measured at 4, 5, 6, 12 and 16 weeks PNA and compared to untreated C57BL/6 J (WT) and OCA1 mice. Quantification of PEDF, βIII-tubulin and syntaxin-3 expression was also performed. Our data showed impaired retinal morphology, decreased retinal function and lower visual acuity in untreated OCA1 mice compared to WT mice. These changes were diminished or eliminated when treated with higher doses of L-DOPA/Carbidopa. Our results demonstrate that oral L-DOPA/Carbidopa supplementation at human equivalent doses during the postnatal critical period of retinal neuroplasticity can rescue visual retinal morphology and retinal function, via PEDF upregulation and modulation of retinal synaptogenesis, providing a further step towards developing an effective treatment for albinism patients., (© 2023. Springer Nature Limited.)

Objective: To retrospectively examine sex-differences and predictors of completion in consecutively-referred patients to a 6-month exercise-based cardiac rehabilitation program (CRP) from 2006 to 2017., Materials/methods: People with hemiplegic gait participated in stroke-adapted-CRP; otherwise, traditional-CRP. Reasons for non-completion were ascertained by interview. Regression-analyses were conducted to determine non-completion in all patients and women and men separately., Results: There were 1536 patients (30.3% women), mean age 64.5 ± 12.5 with 23% initiating the stroke-adapted-CRP. Overall, 75.1% completed the CRP (87.3% stroke-adapted-CRP vs 71.5% traditional-CRP; p < .001). There was no difference in completion between women and men (74.5% vs 75.4%; p=0.7), or in attendance to pre-scheduled sessions (p=0.6) or reasons for non-completion (p > .05, all). The only sex difference in completion by age (decade) occurred in those <41 years (59% women vs 85% men; p=.02). Baseline predictors of non-completion among all patients included not being enrolled in the stroke-adapted-CRP, lower V̇O 2peak , smoking, diabetes (prescribed insulin) and depression but not sex (p=.5) or age (p=.15). Unique predictors in women vs men were younger age, lower V̇O 2peak , smoking, diabetes (prescribed insulin), depression, and cancer diagnoses. Unique to men was having >1 stroke and diabetes (any anti-diabetes medication). The strongest predictor of non-completion among all models was not being enrolled in stroke-adapted-CRP., Conclusions: While there were no sex-differences in adherence to the CRP, women and men have mostly unique predictors of non-completion. Younger women are at greatest risk for non-completion. Practitioners should provide sex-specific, tailored strategies for enhancing completion with a focus on younger women and offering a stroke-adapted-CRP with close attention to those with diabetes., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Cyathostomins are the most common and highly prevalent parasites of horses worldwide. Historically, the control of cyathostomins has mainly relied on the routine use of anthelmintic products. Increasing reports on anthelmintic resistance (AR) in cyathostomins are concerning. A potential method proposed for detecting emerging AR in cyathostomins has been estimating the egg reappearance period (ERP). This paper reviews the data available for the ERP of cyathostomins against the three major classes of anthelmintics, macrocyclic lactones, tetrahydropyrimidines, and benzimidazoles. Published peer-reviewed original research articles were obtained from three databases (PubMed, CAB Direct and Web of Science) and were evaluated for their inclusion in a systematic review. Subsets of articles were then subjected to a review of ERP data. A total of 54 (of 134) studies published between 1972 and 2022 met the criteria for inclusion in the systematic review. Until the beginning of 2022, there was no agreed definition of the ERP; eight definitions of ERP were identified in the literature, complicating the comparison between studies. Additionally, potential risk factors for the shortening of the ERP, including previous anthelmintic use and climate, were frequently not described. Reports of shortened ERP for moxidectin and ivermectin are frequent: 20 studies that used comparable ERP definitions reported shortened moxidectin and ivermectin ERPs of 35 and 28 days, respectively. It is unclear whether the ERPs of these anthelmintics reduced to such levels are due to the development of AR or some biological factors related to horses, cyathostomin species, and/or the environment. The ERPs for other anthelmintics, such as fenbendazole and pyrantel, were frequently not reported due to established resistance against these drugs. Future research in horses is required to understand the mechanism(s) behind the shortening of ERP for cyathostomins. Based on this systematic review, we propose recommendations for future ERP studies., Competing Interests: Declaration of competing interest The authors are members of the Australian Equine Parasitology Advisory Panel supported by AgriFutures Australia and Boehringer Ingelheim Animal Health Australia. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Abstract: With improving stroke mortality rates, more individuals are living with the consequences of stroke. Obesity is a known risk factor for stroke, but its effect on functional outcomes poststroke is less clear. The aim of this study was to determine the association between body mass index classification (underweight, normal weight, overweight, and obese) and functional outcomes, as measured by Functional Independence Measure change, Functional Independence Measure efficiency, and rehabilitation length of stay after inpatient stroke rehabilitation. A retrospective cohort study of individuals with a diagnosis of stroke admitted to a high-intensity inpatient rehabilitation program was performed. Patients were divided into 4 groups based on body mass index category using normal body mass index as the reference. Overall, 34 individuals (4.5%) were classified as underweight, 303 (40.1%) had body mass indices within the normal range, 269 (35.6%) were overweight, and 149 (19.7%) were obese. Ischemic stroke was the most common stroke type across all body mass index categories. Patients in the overweight and obese groups tended to be younger. There were no statistically significant differences in rehabilitation length of stay, Functional Independence Measure change, or Functional Independence Measure efficiency with all groups demonstrating significant functional improvements. Based on these findings, patients admitted for inpatient rehabilitation after stroke can be expected to make similar functional improvements regardless of BMI class., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Several differences have been reported between male and female patients with stroke in clinical and sociodemographic features, treatment, and outcomes. Potential effects in the inpatient rehabilitation population are unclear., Objective: To evaluate the differences between male and female patients in discharge functional status, length of stay, and discharge home after inpatient rehabilitation for stroke., Design: Retrospective, population-based cohort study., Setting: Inpatient rehabilitation centers in Ontario, Canada., Participants: Male (N = 10,684) and female (N = 9459) patients discharged from acute care between September 1, 2012 and August 31, 2017, with a diagnosis of stroke and subsequently admitted to inpatient rehabilitation., Exposure Variable: Female sex., Main Outcome Measures: Discharge Functional Independence Measure (FIM) score, length of stay, and discharge home., Results: Female patients had a lower functional status at discharge (mean FIM score 94.1 vs. 97.8, p < .001) and a lower proportion were discharged home (81.1% vs. 82.9%, p = .001). Female and male patients had similar rehabilitation length of stay (mean 31.8 vs. 31.7 days, p = .90). In the adjusted analyses, there was no difference in discharge functional status between male and female patients (FIM score β -.20 [95% confidence interval [CI] -0.64 to 0.25]). Female patients had a mean length of stay 2% shorter (0.98 [95% CI 0.96-0.99]) and a higher odds of discharge home (odds ratio [OR] 1.14 [95% CI 1.05-1.24])., Conclusions: There were no clinically significant sex differences in outcomes after inpatient rehabilitation for stroke. Observed sex disparities in the general stroke population may not be directly applicable to individuals undergoing inpatient rehabilitation., (© 2021 American Academy of Physical Medicine and Rehabilitation.)

Background: Low socioeconomic status is associated with increased risk of stroke and worse poststroke functional status. The aim of this study was to determine whether socioeconomic status, as measured by material deprivation, is associated with direct discharge to long-term care or length of stay after inpatient stroke rehabilitation., Methods: We performed a retrospective, population-based cohort study of people admitted to inpatient rehabilitation in Ontario, Canada, after stroke. Community-dwelling adults (aged 19-100 yr) discharged from acute care with a most responsible diagnosis of stroke between Sept. 1, 2012, and Aug. 31, 2017, and subsequently admitted to an inpatient rehabilitation bed were included. We used a multivariable logistic regression model to examine the association between material deprivation quintile (from the Ontario Marginalization Index) and discharge to long-term care, and a multivariable negative binomial regression model to examine the association between material deprivation quintile and rehabilitation length of stay., Results: A total of 18 736 people were included. There was no association between material deprivation and direct discharge to long-term care (most v. least deprived: odds ratio [OR] 1.07, 95% confidence interval [CI] 0.89-1.28); however, people living in the most deprived areas had a mean length of stay 1.7 days longer than that of people in the least deprived areas ( p = 0.004). This difference was not significant after adjustment for other baseline differences (relative change in mean 1.02, 95% CI 0.99-1.04)., Interpretation: People admitted to inpatient stroke rehabilitation in Ontario had similar discharge destinations and lengths of stay regardless of their socioeconomic status. In future studies, investigators should consider further examining the associations of material deprivation with upstream factors as well as potential mitigation strategies., Competing Interests: Competing interests: Shannon MacDonald is chair or cochair of Toronto Stroke Network committees, a surveyor for Accreditation Canada’s Stroke Distinction program (paid position) and a member of the Heart and Stroke Foundation of Canada Health Systems Quality Committee. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Grapevine leafroll disease is a significant concern in the wine grape industry, as it spreads rapidly and contributes to economically significant reductions in yield and grape quality. Our objective was to utilize 5 yr of grower-sourced data from Napa (California, USA) to improve local and regional disease management efforts. Specifically, we applied a spatially integrated multivariate clustering technique to improve understanding of spatiotemporal trends in Pseudococcus maritimus (Ehrhorn) male populations-the primary vector in the region. We also implemented generalized linear mixed models to evaluate the effects of two key practices, insecticide sprays and roguing, on disease incidence. Results show P. maritimus has a biannual flight pattern in the study area, with the first flight peaking in early May and the second between early August and early September. Clusters of P. maritimus flight data fall largely within the vineyard footprints of individual growers, but also showed clear neighborhood effects. We found that when disease incidence within a block is <1%, consistent monitoring and removal of diseased vines is required to contain within-block spread. As within-block disease incidence grows to 1-20%, both insecticide applications and roguing are effective practices to reduce spread. At incidence levels >20%, roguing is a critical practice. Our results emphasize the importance of individual management efforts, but also the value of programs that engage the wider neighboring community and highlight the power of community data collection to guide decision-making., (© The Author(s) 2021. Published by Oxford University Press on behalf of Entomological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The ability to preserve microbial communities in faecal samples is essential as increasing numbers of studies seek to use the gut microbiome to identify biomarkers of disease. Here we use shotgun metagenomics to rigorously evaluate the technical and compositional reproducibility of five room temperature (RT) microbial stabilisation methods compared to the best practice of flash-freezing. These methods included RNALater, OMNIGene-GUT, a dry BBL swab, LifeGuard, and a novel method for preserving faecal samples, a Copan FLOQSwab in an active drying tube (FLOQSwab-ADT). Each method was assessed using six replicate faecal samples from five participants, totalling 180 samples. The FLOQSwab-ADT performed best for both technical and compositional reproducibility, followed by RNAlater and OMNIgene-GUT. LifeGuard and the BBL swab had unpredictable outgrowth of Escherichia species in at least one replicate from each participant. We further evaluated the FLOQSwab-ADT in an additional 239 samples across 10 individuals after storage at -20 °C, RT, and 50 °C for four weeks compared to fresh controls. The FLOQSwab-ADT maintained its performance across all temperatures, indicating this method is an excellent alternative to existing RT stabilisation methods., (© 2021. The Author(s).)

Objective: To describe the sociodemographic features, impairments, and functional changes of COVID-19-positive individuals who underwent inpatient rehabilitation at three rehabilitation hospitals in Toronto, Canada., Design: Retrospective chart review of patients admitted to three COVID-19 rehabilitation units between 20 April 2020 and 3 June 2020. Sociodemographic factors, impairments, length of stay, and Functional Independence Measure data were reported., Results: A total of 41 patients were included in this study, including 22 males and 19 females. The median age was 75 years. Thirty-six percent of patients were admitted to the intensive care unit during their acute stay. The most commonly affected body functions were: neuromusculoskeletal (73.2%); combined cardiovascular, haematological, immunological, and respiratory (65.9%); and mental functions (29.3%). Median total Functional Independence Measure score was 85 at admission and 108.5 at discharge., Conclusion: This study represents some of the first data on the characteristics and outcomes of COVID-19-positive individuals admitted to inpatient rehabilitation in Toronto, Canada early in the COVID-19 pandemic., Competing Interests: The authors have no conflicts of interest to declare, (Journal Compilation © 2021 Foundation of Rehabilitation Information.)

Objective: The aims of the study were to describe potential age-related differences in injury type and mechanism, comorbidities, and physical medicine and rehabilitation-relevant complications in patients admitted after major trauma and to examine whether functional outcomes vary by age group after traumatic injury., Design: This is a subanalysis of a pre-post study. Individuals admitted to a level 1 trauma center who sustained major trauma were divided into three age groups (young, middle age, and elderly). The demographic, acute care, and rehabilitation factors for these patients were then compared across the three age groups., Results: Based on an age distribution plot, the age categories were defined as follows: young, 18-39 yrs (n = 120); middle age, 40-64 yrs (n = 124); and elderly, 65 yrs or older (n = 85). Patients 65 yrs or older demonstrated a greater frequency of comorbidities (P < 0.001) and complications (P < 0.001). For individuals admitted to inpatient rehabilitation, admission and discharge functional independence measure scores were lower for the elderly individuals, but functional independence measure change was not significantly different between groups., Conclusions: Although the elderly trauma patient demonstrates important differences from the younger one, capacity for improvement with rehabilitation seems similar.

Australia's 2019-2020 mega-fires were exacerbated by drought, anthropogenic climate change and existing land-use management. Here, using a combination of remotely sensed data and species distribution models, we found these fires burnt ~97,000 km 2 of vegetation across southern and eastern Australia, which is considered habitat for 832 species of native vertebrate fauna. Seventy taxa had a substantial proportion (>30%) of habitat impacted; 21 of these were already listed as threatened with extinction. To avoid further species declines, Australia must urgently reassess the extinction vulnerability of fire-impacted species and assist the recovery of populations in both burnt and unburnt areas. Population recovery requires multipronged strategies aimed at ameliorating current and fire-induced threats, including proactively protecting unburnt habitats.

Objective: The aim of the study was to identify factors associated with exceeding a target inpatient rehabilitation length of stay of 28 days or less for individuals with hip fracture., Design: Retrospective cohort study of hip fracture patients admitted to an urban Canadian inpatient rehabilitation facility between January 1, 2013, and January 1, 2018. Patient characteristics previously shown to be associated with individual outcomes and/or length of stay after hip fracture were extracted from the institution's data warehouse. Regression models were used to examine factors associated with exceeding target length of stay as well as overall length of stay., Results: Four hundred ninety-three subjects were included in the analysis. Three hundred forty-five (70%) met and 148 (30%) exceeded their target length of stay. Patients who exceeded their target were more likely to be elderly (odds ratio, 1.05; 95% confidence interval, 1.02-1.08), to live alone prefracture (odds ratio, 1.72; 95% confidence interval, 1.02-2.91), to have dementia (odds ratio, 2.79; 95% confidence interval, 1.12-6.97), and higher admission pain scores (severe pain odds ratio, 2.51; 95% confidence interval, 1.06-5.93). Higher admission motor Functional Independence Measure scores (odds ratio, 0.95; 95% confidence interval, 0.92-0.98) were protective., Conclusions: Advancing age, having dementia, living alone prefracture, and reporting moderate or severe pain at the time of admission not only increased the odds of an individual exceeding their target length of stay but also was associated with an overall increase in length of stay. Conversely, having a higher admission motor Functional Independence Measure score was protective.

Background: Obesity is a known risk factor for stroke, but its impact on functional recovery is less clear. Understanding the effect of obesity on functional recovery during inpatient rehabilitation will aid clinicians in patient counselling and help administrators with program planning., Objective: To determine if obesity affects the functional outcomes of adults undergoing inpatient stroke rehabilitation., Methods: MEDLINE, Embase, CINAHL, and Cochrane databases were searched using the subject headings and text word terms for stroke, rehabilitation, and obesity. Two independent reviewers screened the articles against pre-defined eligibility criteria and extracted the data. Outcomes of interest included FIM, mRS, Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, and Barthel Index., Results: Seven studies from five countries with a total of 3070 participants were included. There was significant heterogeneity among the studies in the BMI cut-off points and functional outcome measures used. Two studies found a positive association between obesity and functional outcome, two studies found no association, and three studies reported a negative relationship., Conclusions: No conclusions could be drawn regarding whether the functional outcome of adults undergoing inpatient stroke rehabilitation differ between individuals with and without obesity.

We describe a new species of rock-dwelling Gehyra Gray, 1834 (Gekkonidae) from the Einasleigh Uplands of inland north Queensland, Australia. Morphological, ecological, and molecular data clearly support the new species as distinct and place it within the 'australis group'. Gehyra electrum sp. nov. is distinguished from congeners by a combination of medium adult size (SVL 46-50 mm), an orange-brown to pinkish-orange background colouration with a pattern of distinct whitish spots and irregular black to purple-brown blotches or bars, possessing 7-8 undivided subdigital lamellae on the expanded portion of the fourth toe, and a wedge-shaped mental scale that separates the inner-postmental scales along 40% or more of their length. Gehyra electrum sp. nov. is a rock specialist currently known only from granite outcrops of the Mt Surprise region, Queensland. This is the second recently described Gehyra from the Einasleigh Uplands and adds to the growing number of endemic reptiles recognised in the region.

The objective of this study was to describe the incidence of complications in trauma patients that could be prevented, diagnosed, or managed by a consulting acute care physiatrist. Demographic and complication data were extracted by chart review of adult trauma patients admitted to a Canadian academic trauma center. Subjects were included if they had a diagnosis of traumatic brain injury, spinal cord injury, or multiple injuries resulting in an Injury Severity Score greater than 15. Means and standard deviations were calculated for continuous variables and frequencies for categorical data. Secondary analyses involved using Spearman's ρ and χ analysis to examine relationships between the development of complications and various patient factors. A total of 286 individuals were included. The overall incidence of a physical medicine & rehabilitation-relevant complication was 32.9%. The complications with the highest incidence were pneumonia (15.5%), delirium (14.1%), and urinary tract infection (13.4%). Secondary analyses demonstrated associations between the development of complications with older age, the presence of comorbidities, having both a traumatic brain injury and spinal cord injury, and length of stay. This study demonstrated that trauma patients may experience multiple complications that are of relevance to the consulting physiatrist.

Objective: Previous retrospective studies suggest that early physical medicine and rehabilitation (PM&R) consultation for trauma patients improves outcome and reduces acute care length of stay (LOS). There have not been controlled studies to evaluate this impact. This study assesses the impact of PM&R consultations on acute trauma patients., Design: This study compared measured outcomes before and after the introduction of a PM&R consultation service to the trauma program at a large academic hospital. The primary outcome measure was acute care LOS., Results: The 274 historical controls and 76 patients who received a PM&R consultation were not different in injury severity score, age, or sex. Length of stay was not different between the two groups. However, when early (≤8 days after injury) versus late (>8 days) consults were compared, the early group had a markedly lower LOS (12 vs. 30 days, P < 0.001). When adjusted for injury severity score, an early consult was associated with an 11.8-day lower LOS (P < 0.001). The early consult group also had fewer complications and less usage of benzodiazepines and antipsychotics., Conclusions: An acute care PM&R consultation of 8 days or less after admission is associated with a shorter acute care LOS, fewer complications, and less use of benzodiazepines and antipsychotics.

Ontario physicians are legally obligated to report patients who may be medically unfit to drive to the Ministry of Transportation of Ontario (MTO). Currently at Toronto Rehabilitation Institute (TRI), there are no standardised processes for MTO reporting, resulting in inconsistent communication regarding driving with patients and between healthcare providers, redundant assessments and ultimately reduced patient satisfaction. TRI received 10 patient complaints regarding the driving reporting process in the 5 years prior to this project and a large number of patients were not being reported appropriately. The project aim was to use Lean Methods to achieve 100% reporting and optimise communication and education of drivers admitted to a 23-bed inpatient stroke rehabilitation unit. Interventions included process mapping, identification of wasteful steps and implementation of a standard work. Chart audits before and after implementation were performed. Value stream process mapping identified inconsistent reporting procedures and lack of use of the government-issued driver reporting form. Following implementation of standard work processes, use of the MTO Medical Conditions Report Form increased from 0% to 100%. Indication of whether drivers were reported to the MTO in Physical Medicine & Rehabilitation consultation notes increased from 50% to 91%. Identifying reported drivers in the discharge summary, of which patients receive a copy at the time of discharge, increased from 0% to 90%. Physician satisfaction with the new standard work process was qualitatively assessed to be high, with no negative impacts reported. Lean methodology was effective for increasing the usage of the MTO Medical Conditions Report Form, documenting driver status in the initial Physical Medicine & Rehabilitation consultation and indicating MTO reporting status in the discharge summary. Communication between healthcare providers regarding patients' driving status has been successfully standardised, resulting in improved coordination of care and a reduction in patient complaints to zero in the 14 months since implementation., Competing Interests: Competing interests: None declared.

The impact of climate change may be felt most keenly by tropical ectotherms. In these taxa, it is argued, thermal specialization means a given shift in temperature will have a larger effect on fitness. For species with limited dispersal ability, the impact of climate change depends on the capacity for their climate-relevant traits to shift. Such shifts can occur through genetic adaptation, various forms of plasticity, or a combination of these processes. Here we assess the extent and causes of shifts in 7 physiological traits in a tropical lizard, the rainforest sunskink (Lampropholis coggeri). Two populations were sampled that differ from each other in both climate and physiological traits. We compared trait values in each animal soon after field collection versus following acclimation to laboratory conditions. We also compared trait values between populations in: (i) recently field-collected animals; (ii) the same animals following laboratory acclimation; and (iii) the laboratory-reared offspring of these animals. Our results reveal high trait lability, driven primarily by acclimation and local adaptation. By contrast, developmental plasticity, resulting from incubation temperature, had little to no effect on most traits. These results suggest that, while specialized, tropical ectotherms may be capable of rapid shifts in climate-relevant traits., (© 2018 International Society of Zoological Sciences, Institute of Zoology/Chinese Academy of Sciences and John Wiley & Sons Australia, Ltd.)

The objective of this study was to describe the provision of Physical Medicine and Rehabilitation acute care consultations in the United States and Canada. Physical Medicine and Rehabilitation department chairs/division directors at academic centers in Canada and the United States were mailed an 18-item questionnaire. Seven of 13 (54%) Canadian and 26/78 (33%) American surveys were returned. A majority of Canadian and American academic institutions provide acute care consultations; however, there were some national differences. American institutions see larger volumes of patients, and more American respondents indicated using a dedicated acute care consultation service model compared with Canadians.

Understanding the climatic drivers of local adaptation is vital. Such knowledge is not only of theoretical interest but is critical to inform management actions under climate change, such as assisted translocation and targeted gene flow. Unfortunately, there are a vast number of potential trait-environment combinations, and simple relationships between trait and environment are ambiguous: representing either plastic or evolved variation. Here, we show that by incorporating connectivity as an index of gene flow, we can differentiate trait-environment relationships reflecting genetic variation vs. phenotypic plasticity. In this way, we rapidly shorten the list of trait-environment combinations that are of significance. Our analysis of an existing data set on geographic variation in a tropical lizard shows that we can effectively rank climatic variables by the strength of their role in local adaptation. The promise of our method is a rapid and general approach to identifying the environmental drivers of local adaptation., (© 2017 John Wiley & Sons Ltd/CNRS.)

Background and Objective: Legionella longbeachae is a predominant cause of Legionnaires' disease in some parts of the world, particularly in Australasia. Clinical reports of L. longbeachae infection are limited to case reports or small case series, and culture-confirmed cases., Methods: We reviewed the clinical characteristics and outcomes of L. longbeachae pneumonia in a large case series from Christchurch, New Zealand during a 4-year period when both PCR and cultures were used as routine diagnostic tools for Legionnaires' disease. Cases of Legionella pneumophila pneumonia were reviewed for comparison., Results: A total of 107 cases of L. longbeachae infection were identified by PCR and/or culture. The median age was 65 years (range 25-90 years), 63% were male, and most became unwell during spring or summer. Presenting clinical features were similar to those reported for community-acquired pneumonia, with headache, myalgia and diarrhoea being common. Elevated C-reactive protein, hyponatraemia and abnormal liver function tests were also common. History of productive cough, involvement of both lungs, and high bacterial load were independently associated with culture of Legionella from lower respiratory samples. One quarter required intensive care unit admission, and 5% died. Among patients given antimicrobial therapy before admission, those given agents without anti-Legionella activity were more likely to be admitted to the intensive care unit. Limited comparisons were made with the 19 L. pneumophila cases over the same time period., Conclusion: Characteristics of L. longbeachae pneumonia are broadly similar to those reported for community-acquired pneumonia from a variety of other populations, except for the spring/summer seasonality., (© 2016 Asian Pacific Society of Respirology.)

As biomechanical research evolves, a continuing challenge is the standardization of data collection and analysis techniques. In gait analysis, placement of markers to construct an anatomical model has been identified as the single greatest source of error; however, there is currently no standardized approach to quantifying these errors. The current study applies morphometric methods, including a generalized Procrustes analysis (GPA) and a nearest neighbour comparison to quantify discrepancies in marker placement, with the goal of improving reliability in gait analysis. An extensive data-set collected by an Expert (n = 340) was used to evaluate marker placements performed by a Novice (n = 55). Variances identified through principal component analysis were used to create a modified GPA to transform anatomical data, and scaled coordinates from the Novice data-set were then scored against the Expert subset. The results showed quantitative differences in marker placement, suggesting that, although training improved consistency, systematic biases remained.

Introduction: Historically, there has been no objective method of measuring the time required for radiologists to produce reports during normal work. We have created a technique for semi-automated measurement of radiologist reporting time, and through it produced a robust set of absolute time requirements and relative value units for consultant reporting of diagnostic examinations in our hospital., Methods: A large sample of reporting times, recorded automatically by the Radiology Information System (COMRAD, Software Innovations, Christchurch, New Zealand) along with the description of each examination being reported, was placed in a database. Analysis was confined to diagnostic reporting by consultant radiologists. A spreadsheet was produced, listing the total number and the frequency of reporting times of each distinct examination. Outliers with exceptionally long report times (more than 10 min for plain radiography, 30 min for ultrasound, or 60 min for CT or MRI with some exceptions) were culled; this removed 9.5% of the total. Complex CTs requiring separate workstation time were assigned times by consensus. The median time for the remainder of each sample was the assigned absolute reporting time in minutes and seconds. Relative value units were calculated using the reporting time for a single view department chest X-ray of 1 min 38 s including verifying a report made using speech recognition software., Results: A schedule of absolute and relative values, based on over 179 000 reports, forms Table 2 of this paper., Conclusions: The technique provides a schedule of reporting times with reduced subjective input, which is more robust than existing systems for measuring reporting time., (© 2013 The Authors. Journal of Medical Imaging and Radiation Oncology © 2013 The Royal Australian and New Zealand College of Radiologists.)

Introduction: We describe how techniques traditionally used in the manufacturing industry (lean management, the theory of constraints and production planning) can be applied to planning radiology services to reduce the impact of constraints such as limited radiologist hours, and to subsequently reduce delays in accessing imaging and in report turnaround., Methods: Targets for imaging and reporting were set aligned with clinical needs. Capacity was quantified for each modality and for radiologists and recorded in activity lists. Demand was quantified and forecasting commenced based on historical referral rates. To try and mitigate the impact of radiologists as a constraint, lean management processes were applied to radiologist workflows. A production planning process was implemented., Results: Outpatient waiting times to access imaging steadily decreased. Report turnaround times improved with the percentage of overnight/on-call reports completed by a 1030 target time increased from approximately 30% to 80 to 90%. The percentage of emergency and inpatient reports completed within one hour increased from approximately 15% to approximately 50% with 80 to 90% available within 4 hours. The number of unreported cases on the radiologist work-list at the end of the working day reduced. The average weekly accuracy for demand forecasts for emergency and inpatient CT, MRI and plain film imaging was 91%, 83% and 92% respectively. For outpatient CT, MRI and plain film imaging the accuracy was 60%, 55% and 77% respectively. Reliable routine weekly and medium to longer term service planning is now possible., Conclusions: Tools from industry can be successfully applied to diagnostic imaging services to improve performance. They allow an accurate understanding of the demands on a service, capacity, and can reliably predict the impact of changes in demand or capacity on service delivery., (© 2013 The Royal Australian and New Zealand College of Radiologists.)

Introduction: Accurate and transparent measurement and monitoring of radiologist workload is highly desirable for management of daily workflow in a radiology department, and for informing decisions on department staffing needs. It offers the potential for benchmarking between departments and assessing future national workforce and training requirements. We describe a technique for quantifying, with minimum subjectivity, all the work carried out by radiologists in a tertiary department., Methods: Six broad categories of clinical activities contributing to radiologist workload were identified: reporting, procedures, trainee supervision, clinical conferences and teaching, informal case discussions, and administration related to referral forms. Time required for reporting was measured using data from the radiology information system. Other activities were measured by observation and timing by observers, and based on these results and extensive consultation, the time requirements and frequency of each activity was agreed on. An activity list was created to record this information and to calculate the total clinical hours required to meet the demand for radiologist services., Results: Diagnostic reporting accounted for approximately 35% of radiologist clinical time; procedures, 23%; trainee supervision, 15%; conferences and tutorials, 14%; informal case discussions, 10%; and referral-related administration, 3%. The derived data have been proven reliable for workload planning over the past 3 years., Conclusions: A transparent and robust method of measuring radiologists' workload has been developed, with subjective assessments kept to a minimum. The technique has value for daily workload and longer term planning. It could be adapted for widespread use., (© 2013 The Authors. Journal of Medical Imaging and Radiation Oncology © 2013 The Royal Australian and New Zealand College of Radiologists.)

Many drugs have been reported to convert dendritic cells (DCs) into a tolerogenic phenotype in vitro. However, there is evidence that an additional stimulus, such as lipopolysaccharide (LPS), may also be necessary for tolerogenic function in vivo. Little is known concerning the effects of drug modification on LPS-prestimulated DCs. In this study, monocyte-derived immature DCs were stimulated with LPS first and the influence investigated of six different agents on surface antigen expression, cytokine production and lymphocyte proliferation and cytotoxicity. Mycophenolic acid- and rapamycin-exposed DCs had little effect on surface antigen expression or functional activity towards lymphocytes. In contrast, treatment of immature dendritic cells with aspirin, dexamethasone, 1alpha,25-dihydroxyvitamin D3 (VD3) or butyric acid was associated with diminished expression of CD1a, CD1c, CD40, CD80 and CD83. Dendritic cell modification by aspirin, dexamethasone and VD3 were all associated with decreased production of tumour necrosis factor-alpha (TNFalpha). Furthermore, VD3 treatment was associated with a consistent and significant elevation of IL-6 production. Aspirin-, dexamethasone- VD3- and butyric acid-modified DCs suppressed interferon-gamma production, proliferation and cytotoxicity in co-culture with allogeneic mononuclear cells, but inconsistent results were obtained with different allogeneic combinations. Different drugs show varying effects on DC phenotype. No single agent was consistently effective in suppressing the stimulation of allogeneic mononuclear cells and future work is needed to explore drug combinations.

Extranodal natural killer/T-cell lymphoma (ENKTL), nasal type, is a rare form of non-Hodgkin lymphoma. Treatment of ENKTL primarily relies on radiation; thus, proper delineation of target volumes is critical. Currently, the ideal modalities for delineation of gross tumor volume for ENKTL are unknown. We describe three consecutive cases of localized ENKTL that presented to the Nova Scotia Cancer Centre in Halifax, Nova Scotia. All patients had a planning CT and MRI as well as a planning FDG-PET/CT in the radiotherapy treatment position, wearing immobilization masks. All patients received radiation alone. In two patients, PET/CT changed not only the stage, but also the target volume requiring treatment. The third patient was unable to tolerate an MRI, but was able to undergo PET/CT, which improved the accuracy of the target volume. PET/CT aided the staging of and radiotherapy planning for our patients and appears to be a promising tool in the treatment of ENKTL.

Mannan (or mannose)-binding lectin (MBL) can bind to monocytes and dendritic cells, but the significance of such interactions is unknown. We hypothesized that the presence of MBL might prevent the differentiation of monocytes into monocyte-derived dendritic cells or interfere with the development of dendritic cells in some way. We therefore investigated the influence of recombinant human MBL on surface antigen expression and on secretion of selected cytokines. By these means, no direct influence of rhMBL on dendritic cell differentiation or maturation was detected. However, mature dendritic cells prepared in the presence of rhMBL and subsequently co-cultured with allogeneic mononuclear cells, markedly promoted production of interleukin-1β, interleukin-6, and tumor necrosis factor-α in vitro. In most dendritic cell-mononuclear cell combinations, IFN-γ production was also enhanced. This influence required the presence of rhMBL during dendritic cell maturation and was critically dependent on the presence of monocytes. This observation provides evidence that MBL can influence cellular immunity in addition to its established role as an opsonin., (Copyright © 2010 American Society for Histocompatibility and Immunogenetics. Published by Elsevier Inc. All rights reserved.)

Purpose: Well done systematic reviews provide the highest quality evidence for clinical questions of therapeutic effectiveness. We assessed the methodological quality of systematic reviews in the urological literature., Materials and Methods: We systematically investigated all systematic reviews published in 4 major urological journals from 1998 to 2008. Studies were identified using a predefined search strategy in PubMed and confirmed by a hand search of journal tables of contents. A validated 11-point instrument to assess the methodological quality of systematic reviews was applied by 2 independent reviewers after a pilot testing phase. Disagreements were discussed and resolved by consensus., Results: The systematic literature search identified 217 individual systematic reviews, of which 57 ultimately met study eligibility criteria. Ten (17.5%), 20 (35.1%) and 27 (47.4%) systematic reviews were published in 1998 to 2001, 2002 to 2005 and 2006 to 2008, respectively. Using the measurement tool to assess systematic reviews the mean +/- SD score was 4.8 +/- 2.0 points. Fewer than half of all systematic reviews performed a systematic literature search that included at least 2 databases (49.1%) or unpublished studies (31.6%), or provided a list of included and excluded studies (45.6%). Of the systematic reviews 63.2% assessed and documented the methodological quality of included studies. Systematic reviews with The Cochrane Collaboration authorship affiliation had a higher mean score than those with no such reported affiliation (6.5 +/- 1.2 vs 4.4 +/- 1.9 points, p <0.001)., Conclusions: Results suggest that an increasing number of systematic reviews are published in the urological literature. However, many systematic reviews fail to meet established methodological standards, raising concerns about validity. Increased efforts are indicated to promote quality standards for performing systematic reviews among the authors and readership of the urological literature., (Copyright (c) 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe and characterize the potential for malignancy of noncalcified lung nodules adjacent to fissures that are often found in current or former heavy smokers who undergo computed tomography (CT) for lung cancer screening., Materials and Methods: Institutional review board approval and informed consent were obtained. Baseline and follow-up thin-section multidetector CT scans obtained in 146 consecutive subjects at high risk for lung cancer (age range, 50-75 years; > 30 pack-year smoking history) were retrospectively reviewed. Noncalcified nodules (NCNs) were categorized according to location (parenchymal, perifissural), shape, septal connection, manually measured diameter, diameter change, and lung cancer outcome at 7(1/2) years., Results: Retrospective review of images from 146 baseline and 311 follow-up CT examinations revealed 837 NCNs in 128 subjects. Of those 837 nodules, 234 (28%), in 98 subjects, were adjacent to a fissure and thus classified as perifissural nodules (PFNs). Multiple (range, 2-14) PFNs were seen in 47 subjects. Most PFNs were triangular (102/234, 44%) or oval (98/234, 42%), were located inferior to the carina (196/234, 84%), and had a septal connection (171/234, 73%). The mean maximal length was 3.2 mm (range, 1-13 mm). During 2-year follow-up in 71 subjects, seven of 159 PFNs increased in size on one scan but were then stable. The authors searched a lung cancer registry 7(1/2) years after study entry and found 10 lung cancers in 139 of 146 study subjects who underwent complete follow-up; none of these cancers had originated from a PFN., Conclusion: PFNs are frequently seen on screening CT scans obtained in high-risk subjects. Although PFNs may show increased size at follow-up CT, the authors in this study found none that had developed into lung cancer; this suggests that the malignancy potential of PFNs is low. (c) RSNA, 2010.

We previously reported an association between relative L-ficolin deficiency and recurrent respiratory infections co-existing with allergic disorders in children. To confirm and extend this preliminary finding, we performed a prospective study on children of a similar age (mean 8.9 years) designed to establish whether the principal relationship was with infection or allergy. Serum L-ficolin values in healthy children were normally distributed with a mean value of 3838 ng/ml. L-ficolin concentrations were generally lower in patients with asthma and/or allergic rhinitis with (mean 3413 ng/ml; p=0.02) or without (3512 ng/ml; p<0.07) respiratory infections, but not in patients with respiratory infections without allergic disease (3623 ng/ml; p=0.2). The lower average values in the group comprised of children with respiratory allergy and infections were largely due to a high proportion of very low values: 18.3% had values below 2150 ng/ml compared to only 5.5% of healthy controls (OR=3.9; p=0.01). This relationship was not apparent in the groups characterized by allergy without infection or infections without allergy. An association between mannan-binding lectin (MBL) insufficiency and recurrent respiratory infections was also confirmed. One of the patients was MASP-2 deficient, evidenced both by MASP2 genotyping and by lectin pathway activity measurement. In conclusion, L-ficolin may confer some protection from microorganisms that exacerbate allergic inflammation in the lung and its relative deficiency may contribute to enhanced susceptibility to respiratory infections. MBL insufficiency and MASP-2 deficiency are risk factors for recurrence of infections independently of allergic disease.

One collectin (mannan-binding lectin, MBL) and three ficolins (M-ficolin/ficolin-1, L-ficolin/ficolin-2 and H-ficolin/ficolin-3) share the capability to activate complement via the lectin pathway. This property depends on the ability of these lectins to form complexes with MBL-associated serine proteases (MASPs), particularly MASP-2. We report the results of an investigation of cord blood MASP-2 concentrations in a large, ethnically homogeneous cohort (n=1788) of neonates. The median value of MASP-2 in cord sera was determined to be 93 ng/ml (range <25-812). Serum MASP-2 concentrations correlated with gestational age and birthweight and were significantly lower in premature babies and other pre-term babies compared with term babies. Neonates with MASP-2 concentrations below 42 ng/ml were deemed to be MASP-2 deficient. That group had a shorter mean gestational age and a higher incidence of premature and low birthweight babies, but not of perinatal infections when compared with the others. Indeed, there was a trend towards higher MASP-2 concentrations amongst babies with infections. Among 362 samples tested for the D120G single nucleotide polymorphism (SNP) of the MASP2 gene, no homozygote for that mutation was found. Heterozygosity for this allele significantly influenced the protein concentration, but not the lectin pathway of complement activity (MBL-MASP-2 complex activity). Moreover, no association of this SNP was apparent with prematurity, low birthweight or perinatal infections.

Ficolins and one collectin, mannan-binding lectin (MBL), are the only factors known to activate the lectin pathway (LP) of complement. There is considerable circumstantial evidence that MBL insufficiency can increase susceptibility to various infections and influence the course of several non-infectious diseases complicated by infections. Much less information is available concerning l-ficolin. We report the results of a prospective study to investigate any association between either MBL deficiency or l-ficolin deficiency with prematurity, low birthweight or perinatal infections in a large cohort of Polish neonates, representing an ethnically homogenous population (n=1832). Cord blood samples were analysed to determine mbl-2 gene variants, MBL concentrations and MBL-MASP-2 complex activities (MBL-dependent lectin pathway activity) as well as l-ficolin levels. Median concentrations of l-ficolin and MBL were 2500 and 1124 ng/ml, respectively, while median LP activity was 272 mU/ml. After genotyping, 60.6% of babies were mbl-2 A/A, 35.4% were A/O and 4% were O/O genotypes. We found relative l-ficolin deficiency to be associated with prematurity, low birthweight and infections. l-Ficolin concentration correlated with gestational age and with birthweight, independently of gestational age. Preterm deliveries (<38 weeks) occurred more frequently among neonates with low LP activity but not with those having low serum MBL levels. Similarly, no association of serum MBL deficiency with low birthweight was found, but there was a correlation between LP activity and birthweight. Genotypes conferring very low serum MBL concentrations were associated with perinatal infections, and high-MBL-conferring genotypes were associated with prematurity. Our findings suggest that l-ficolin participates in host defence during the perinatal period and constitute the first evidence that relative l-ficolin deficiency may contribute to the adverse consequences of prematurity. Some similar trends were found with facets of MBL deficiency, but the observed relationships were weaker and less consistent.

Circulating mannan (or mannose)-binding lectin (MBL) is genetically determined. Low MBL concentrations are associated with certain point mutations in the human MBL2 gene. Here we report the full MBL2 genotypes of 1800 Polish neonates and relate individual genotypes to serum MBL and MBL-dependent activity of the lectin pathway of complement activation. The seven acknowledged common haplotypes were found, plus the uncommon LYPD haplotype, combining to form 33 genotypes in this population. As expected, a strong correlation existed between genotypes and serum MBL or lectin pathway activity, and the latter two entities correlated strongly with each other. However, serum MBL values varied up to greater than 90-fold within genotypes. Unexpectedly, higher lectin pathway activity was found in association with the P allele relative to the Q allele. These data from a large cohort of neonates, representing an ethnically homogenous population, suggest that the current knowledge of the genetics of MBL2 is inadequate to predict serum MBL concentration and MBL-dependent lectin pathway activity in individual subjects.

Background and Aims: Bronchiectasis is a common chronic respiratory condition with recurrent cough and sputum production and recurrent chest infections. It is characterised by pathological dilatation of the bronchi thought to result from infection and inflammation. It was hypothesised that impaired innate immunity might influence susceptibility to this disease process. The aim of the present study was to look for an association between bronchiectasis and insufficiency of either mannan-binding lectin (MBL) or L-ficolin., Materials and Methods: MBL and L-ficolin were measured by Enzyme-linked Immunosorbent Assay (ELISA) in sera from 119 clinically stable bronchiectasis patients, and compared with 43 age-matched disease controls admitted to hospital with community-acquired pneumonia, as well as healthy blood donors (168 for L-ficolin and 564 for MBL)., Results: Average (mean and median) serum L-ficolin concentrations were lower in the bronchiectasis patients (P < 0.04), but average MBL values did not differ significantly between the three groups. Relative L-ficolin deficiency was more frequent in bronchiectasis patients compared with blood donors (P

MBL (mannan-binding lectin; also called mannose-binding lectin) is a circulating C-type lectin with a collagen-like region synthesized mainly by the liver. MBL may influence susceptibility to infection in recipients of stem cell transplants, and it has even been suggested that the MBL status of a donor can influence the recipient's susceptibility to post-transplant infections. We have previously reported that MBL can be detected on human monocytes and monocyte-derived dendritic cells, based on detection using biotinylated anti-MBL, suggesting that those cells could synthesize MBL. If true, permanent MBL replacement therapy could be achieved by stem cell infusions. However, two other groups independently failed to find mbl-2-derived mRNA in monocytes. Therefore, to confirm or refute our previous observations, we used an alternative experimental strategy. Instead of using biotinylated antibody and labelled streptavidin, detection of surface MBL was attempted using MBL-specific primary antibodies (131-1, 131-10 and 131-11) followed by fluorescein-labelled anti-IgG, and controlled by the use of non-specific IgG as primary antibody. Monocytes were counterstained with anti-CD14-PE before FACS analysis. Adherent monocytes were also cultured for 48 h in serum-free medium or converted into immature dendritic cells by culture with IL-4 (interleukin-4) and GM-CSF (granulocyte/monocyte colony-stimulating factor). During FACS analysis, the dendritic cells were gated after counter-staining with anti-CD1a-PE. MBL was readily detected on the surface of fresh monocytes using all three specific anti-MBL monoclonal antibodies, but specific anti-MBL binding was greatly diminished after monocytes had been cultured for 2 days in serum-free medium. Moreover, we could not detect any MBL present on the surface of monocyte-derived dendritic cells. We therefore conclude that MBL is indeed present on the surface of fresh human monocytes. However, in view of the mRNA findings of others and our own previous observation that no secretion of MBL took place in culture, we presume that the surface-bound MBL is derived from autologous plasma and not synthesized by the cells. This conclusion is consistent with our in vivo findings in stem cell transplant patients which provided evidence against significant extra-hepatic production of serum MBL. It provides no ready explanation for the remarkable observation of Mullighan, Heatley, Doherty, Szabo, Grigg, Hughes, Schwarer, Szer, Tait, Bik To and Bardy [(2002) Blood 99, 3524-3529] that the presence of variant alleles of mbl-2 in stem cell donors can influence susceptibility to serious infections in their recipients.