(C) 2011 American Institute of Physics [doi:10 1063/1 3626749]“<

(C) 2011 American Institute of Physics. [doi:10.1063/1.3626749]“
“A CAL 101 finite piece method is proposed to simulate three-dimensional slit flows in extrusion sheet dies in this paper. The simulations concern incompressible fluids obeying different constitutive

equations: generalized Newtonian (Carreau-Yasuda law), and viscoelastic Phan-Thien Tanner (PTT) models. Numerical simulations are carried out for the isothermal and nonisothermal flows of polymer melt through sheet dies. The Picard iteration method is utilized to solve nonlinear equations. The results of the finite piece method are compared with the three-dimensional (3D) finite element method (FEM) simulation and experiments. At

the die exit, the relative error of the volumetric flow between the finite piece method and the 3D FEM is below 1.2%. The discrepancy of the pressure distributions does not exceed 6%. The Maximum error of the uniformity index between the simulations and experiments is about 2.3%. It shows that the solution accuracy of the finite piece method is excellent, and a substantial amount of computing time and memory requirement can be saved. (C) 2011 Wiley Periodicals, Inc. J Appl Polym Sci 123: 3189-3198, 2012″

Neural stem cells are currently being investigated as potential therapies for neuro-degenerative diseases, stroke, and trauma. However, LY3039478 solubility dmso concerns have been raised over the safety of this experimental therapeutic

approach, including, for example, whether there is the potential for tumors to develop from transplanted stem cells.

Methods see more and Findings

A boy with ataxia telangiectasia (AT) was treated with intracerebellar and intrathecal injection of human fetal neural stem cells. Four years after the first treatment he was diagnosed with a multifocal brain tumor. The biopsied tumor was diagnosed as a glioneuronal neoplasm. We compared the tumor cells and the patient’s peripheral blood cells by fluorescent in situ hybridization using X and Y chromosome probes, by PCR for the amelogenin gene X- and Y-specific alleles, by MassArray for the ATM patient specific mutation and for several SNPs, by PCR for polymorphic microsatellites, and by human leukocyte antigen (HLA) typing. Molecular and cytogenetic studies showed that the tumor was of nonhost origin suggesting it was derived from the transplanted neural stem cells. Microsatellite and HLA analysis demonstrated that the tumor is derived from at least two donors.


This is the first report of a human brain tumor complicating neural stem cell therapy. The findings here suggest that neuronal stem/progenitor cells may be involved in gliomagenesis and provide the first example of a donor-derived brain tumor. Further work is urgently needed to assess the safety of these therapies.

An age matched 68 non-diabetic

mothers and their infants,

An age matched 68 non-diabetic

mothers and their infants, residing in the same locality, were selected as referents. For a comparative study, the biological samples of non-diabetic and diabetic pregnant and non pregnant of same age group and socio-economics status were also analysed.

The biological samples Screening Library nmr (scalp hair, blood and urine) were collected from study and referent groups. The Cr, Mn and Zn concentrations in all three biological samples were determined by a flame/electrothermal atomic absorption spectrometer, prior to microwave assisted acid digestion. The validity and accuracy of the methodology was checked by certified reference materials (CRMs) and using conventional wet acid digestion method on same CRMs.

The mean values of Cr, Mn and Zn in scalp hair and blood samples of diabetic mothers and their infants were significantly lower as compared to the referent mothers-infants pairs (p < 0.01), while urinary excretion of all these elements were high in diabetic mother-infant pair samples.

The deficiencies of essential trace elements, Cr, Mn and Zn in biological samples of diabetic women, may play role in the pathogenesis

of diabetes mellitus and impacts on their neonates.”
“A subset of neurologically normal females void by efficient Valsalva, not detrusor contraction. We determined the incidence of urinary retention following midurethral sling (MUS) placement in women that void by detrusor contraction versus Valsalva.


of patients Selleck Proteasome inhibitor undergoing MUS insertion between 2002 and 2009 for urodynamic stress incontinence was performed. Women with Crenolanib in vitro concomitant pelvic surgery, previous incontinence surgery, or preoperative incomplete bladder emptying were excluded. Patients were divided into two cohorts based on preoperative urodynamic findings-those that voided with a detrusor contraction > 10 cm of water and those that voided by Valsalva.

One hundred seven patients were available for analysis. The postoperative urinary retention rate was 22% and 5% in the Valsalva and non-Valsalva groups, respectively (p < 0.05). Mean retention duration was 3 weeks for each cohort (range 1-6).

Women voiding by Valsalva are at increased risk of urinary retention following MUS placement.”
“Introduction and objectives. Stenting of coronary bifurcation lesions carries an increased risk of stent deformation and malapposition. Anatomical and pathological observations indicate that the high stent thrombosis rate in bifurcations is due to malapposition of stent struts.

Methods. Strut apposition was assessed with optical coherence tomography (OCT) in bifurcation lesions treated either using the simple technique of stent implantation in the main vessel only or a complex technique (i.e. Culottes). A strut was regarded as malapposed if the gap between its endoluminal surface and the vessel wall was greater than its thickness plus an OCT resolution error margin of 15 mu m.

Results. Simple and complex (i.e.

This study retrospectively reviewed the case histories of 120 pat

This study retrospectively reviewed the case histories of 120 patients that underwent surgical

treatment for 3- or 4-level CSM from July 2003 to June 2008. One hundred and twenty patients (81 male and 39 female) of mean age 58.3 +/- A 9.8 years (37-78) were included. The study compared perioperative parameters (blood loss, operation times), complications [surgery-related complications (CSF, hoarseness, epidural hematoma, C5-palsy, dysphagia), instrumentation and graft related complications (dislodgement, subsidence)], clinical parameters [Japanese Orthopedic Association (JOA) scores, Neck Dysfunciton Index (NDI) scores], and radiologic parameters (segmental lordosis, fusion rate).

At a minimum of 2-year follow-up, learn more INCB28060 mw both ACDF and ACCF groups demonstrated a significant increase in the JOA scores (preoperatively 9.25 +/- A 1.9 and 8.86 +/- A 1.9, postoperatively 13.86 +/- A 1.6 and 13.27 +/- A 1.8, respectively), segmental lordosis (preoperatively 9.79 +/- A 3.4 and 9.54

+/- A 3.0, postoperatively 17.75 +/- A 2.6 and 14.49 +/- A 2.5, respectively) and NDI scores (preoperatively 12.56 +/- A 3.0 and 12.21 +/- A 3.4, postoperatively 3.44 +/- A 1.7 and 5.68 +/- A 2.6, respectively). Six patients (2 dislodgement, 4 subsidence) in ACCF group had instrumentation and graft related-complications and they had no obvious neurological symptoms without a second operation. Blood loss (102.81 +/- A 51.3 and 149.05 +/- A 74, respectively, P = 0.000), NDI scores (P = 0.000), and instrumentation and graft related-complications (P = 0.032) were significantly click here lower in the ACDF group, whereas operation time (138.07 +/- A 30.9 and 125.08 +/- A 26.4, respectively, P = 0.021) and segmental lordosis (P = 0.000) were significantly greater in the ACDF group. Other parameters were not significantly different in the two groups.

Surgical managements of 3- or 4-level CSM by ACDF or ACCF showed no significant differences in terms of achieved clinical symptom improvements,

with the exception of better postoperative NDI scores in ACDF. In addition, ACDF is better than ACCF in terms of blood loss, lordotic curvature improvement and instrumentation and graft related-complication rates, with the exception of operation times.”
“Introduction: Chronic kidney diseases are of growing importance for our health system. With regard to the high number of undetected cases, screening programs provide opportunities for an early to detect and treat patients.

Methods: With the support of local newspapers, we performed a mass screening of the citizens of Wurzburg, Germany. One hundred thousand dipsticks for proteinuria were distributed. Citizens were invited to self-test their urine and to report the results to the organizing centre.

Results: We received information for approximately 22% of the distributed dipsticks.

A ternary experimental design

A ternary experimental design click here was employed to elucidate the influence the three thiols on the thermomechanical and coatings properties of thiol-ene photopolymerizable materials. Tensile strength, tensile modulus, elongation-to-break, glass transition temperature (T(g)), and crosslink density (XLD) were investigated. Coating properties including pencil hardness, pull-off adhesion, MEK double rubs, and gloss were also investigated. Relative reaction conversion was determined by photo differential scanning calorimeter (PDSC). Thiol-ene photopolymerizable materials containing

HBPA-SH resulted in improving tensile strength, tensile modulus, T(g), and pencil hardness but lowering of crosslink density and relative conversion. This was attributed to steric and rigidity

of the double cycloaliphatic structure. The inclusion of CHDM-SH into the systems resulted in the synergistic effect on elongation-to-break and pull-off adhesion. The HD-SH generally resulted in a diminution of thermomechanical and coating properties, but improved the crosslink density. (C) 2009 Wiley Periodicals, Inc. J Appl Poly in Sci 113:2173-2185, 2009″
“Background: Previous studies have demonstrated that sclerostin blockade is anabolic for bone. This study examined whether systemic Vorinostat chemical structure administration of sclerostin antibody would increase implant fixation and pen-implant bone volume in a rat model.

Methods: Titanium cylinders were placed in the femoral medullary canal of ninety male Sprague-Dawley rats. One-half of the rats (n = 45) received murine sclerostin antibody (Scl-Ab, 25 mg/kg, twice weekly) and the other one-half (n = 45) received saline Caspase inhibitor solution. Equal numbers of rats from both groups were sacrificed at two, four, or eight weeks after the implant surgery and the femora were examined by microcomputed tomography, mechanical pull-out testing, and histology.

Results: Fixation strength in the two groups was similar at two weeks but was 1.9-fold greater at four weeks (p = 0.024)

and 2.2-fold greater at eight weeks (p < 0.001) in the rats treated with sclerostin antibody. At two weeks, antibody treatment led to increased cortical area, with later increases in cortical thickness and total cross-sectional area. Significant differences in pen-implant trabecular bone were not evident until eight weeks but included increased bone volume per total volume, bone structure that was more plate-like, and increased trabecular thickness and number. Changes in bone architecture in the intact contralateral femur tended to precede the pen-implant changes. The pen-implant bone properties accounted for 61% of the variance in implant fixation strength, 32% of the variance in stiffness, and 63% of the variance in energy to failure. The implant fixation strength at four weeks was approximately equivalent to the strength in the control group at eight weeks.

No side effects were observed during

No side effects were observed during Selleck BEZ235 a follow-up of more than 2 years. To the best of our knowledge, this is the first report on the anti-tic effect of Clerodendrum inerme.”
“Ba0.6Sr0.4TiO3 (BST) thin films were deposited on La0.7Sr0.3CoO3 (LSCO) buffered and unbuffered Pt (111)/Ti/SiO2/Si substrates by pulsed laser deposition. The former exhibits a (100) preferred orientation and the latter a random orientation, respectively. Grazing incident x-ray diffraction study revealed that the tensile residual stress observed in the latter is markedly reduced in the former. As a result, the dielectric property of the LSCO buffered BST thin film is greatly improved,

which shows a larger dielectric constant and tunability, smaller loss tangent, and lower leakage current than those of the unbuffered BST thin film. The relaxation of the larger tensile residual stress is attributed to the larger grain size in the Geneticin purchase buffered BST thin film and to a closer match of thermal expansion coefficient between the BST and the LSCO buffer layer. (C) 2009 American Institute of Physics. [doi:10.1063/1.3223325]“
“Cerebral artery occlusion in childhood, particularly in the posterior circulation, is a rare neurological complication of Mycoplasma pneumoniae infection. A genetic defect in the methylenetetrahydrofolate

reductase gene could result in hyperhomocysteinemia and increased risk of stroke. We report a patient with posterior cerebral artery occlusion after Mycoplasma

pneumoniae infection associated with a homozygous, methylenetetrahydrofolate reductase click here gene mutant type.”
“We report on the effects of different multifilamentary geometries on the dynamic current and field distributions in YBa2Cu3O7-delta thin films. Finite-element model simulations are presented that allow a direct comparison of the calculated magnetic flux and current profiles with experimental data obtained by time-resolved magneto-optical imaging. We find that increasing the distance between filaments reduces the magnetic coupling and decreases the ac losses. Screening and transport currents also redistribute more evenly between all filaments. The measured transport current density profiles are in good agreement with the modified critical state model. (C) 2009 American Institute of Physics. [doi: 10.1063/1.3212976]“
“Congenital myasthenic syndromes are a genetically and, phenotypically heterogeneous group of hereditary disorders affecting neuromuscular junction. Mutations in the gene encoding choline acetyltransferase cause presynaptic defects. The missense mutation 1336T has been identified in Turkish population, and most of the cases carrying this mutation present with exercise-induced fatigability and ptosis.

After 5 treatments, revised expectation of success was predictive

After 5 treatments, revised expectation of success was predictive of both symptoms and function at 8 and 52 weeks.

Conclusion. Pretreatment expectations and preferences for acupuncture were not found predictive of treatment outcomes for patients with chronic back pain. These results differ from previous studies evaluating acupuncture for chronic back pain. These inconsistent results suggest that the relationship between expectations

and outcomes may be more complex than previously believed.”
“Objective: The goal of the Study described here was to determine mothers’ knowledge and perceptions of electroencephalogram (EEG), to assess mothers’ understanding of the main aspects of electroencephalography (EEG), and to determine the effect

of an informational leaflet on increasing knowledge and perception.

Methods: A 20-item Dihydrotestosterone mouse questionnaire was developed to assess mothers’ knowledge and perceptions of EEG. The questionnaire comprised 20 simple statements on aspects of the procedure, to which the mothers answered “”yes”" or “”no.”" Mothers were interviewed in person by an EEG technician at the beginning of the Study. On completion of the questionnaire, the same technician provided the mothers with an informational leaflet. One month later, the mothers were telephoned and administered the same questionnaire over the phone.

Results: The response 4EGI-1 solubility dmso rate was 86%. Before reading the informational leaflet, 89.5% of the mothers stated that they knew why their child was undergoing electroencephalography, and 67.6% knew what electroencephalography

was. Furthermore, 78.1% of them believed that their child’s brain was mapped by electroencephalography. In addition, nearly I in 10 believed that EEG is a hazardous procedure and 6% believed it was addictive. Knowledge and perceptions changed after distribution of the informational leaflet. Comparison of mothers with different income levels, educational status, and numbers of electroencephalograms their child underwent revealed statistically significant differences with respect to knowledge and perceptions of electroencephalography.

Conclusion: Momelotinib mw Written information is a simple, inexpensive, easy-to-implement, yet effective method of improving parental understanding of EEG. The present Study has significant implications for informing individuals regarding medical procedures. (C) 2009 Elsevier Inc. All rights reserved.”
“The constitutive expression of the rice Osmyb4 gene in Arabidopsis plants gives rise to enhanced abiotic and biotic stress tolerance, probably by activating several stress-inducible pathways. However, the effect of Osmyb4 on stress tolerance likely depends on the genetic background of the transformed species.

The polymers with drug pendent were characterized using FTIR, NMR

The polymers with drug pendent were characterized using FTIR, NMR, and GPC spectroscopy. Following hydrolysis of polymeric drug-saccharide conjugates at 37 degrees C, the cumulative released of naproxen, ibuprofen, and ketoprofen were 70, 55, and 30% after 10 days, respectively. Half-lives (t(1/2)) of the copolymers were calculated through the first 12 h and these were found to be 4.2, 5.3, and 7.8 h, suggesting a slow and sustained drug release mechanism. The drug release profiles were also carried out at different Selleck NVP-BSK805 pH, temperature, and ionic strength and solution varieties. It was concluded that different release profiles occurred and were dependent on temperature and pH. It was apparent that the polymeric drug-saccharide

conjugate had the potential to be developed as a system that enhances drug delivery. (C) 2011 Wiley Periodicals, Inc. J Appl Polym Sci 121: 1654-1660, 2011″
“Production of poly(gamma-glutamic acid) (gamma-PGA) by Bacillus subtilis CGMCC 0833 was investigated. It was influenced by the utilization of extracellular substrate glutamate, which was a relatively low-efficiency procedure in gamma-PGA fermentation. Then it was discovered that the glutamate utilization was greatly dependent on the medium pH. However, selleck chemical the optimal pH for glutamate utilization was not consistent with that for the cell growth. Therefore, in order to obtain the optimal production of gamma-PGA, a two-stage pH-shift

control strategy was buy VX-661 proposed. At first 24h, pH was controlled at 7.0 to obtain the maximum biomass, and then shifted to 6.5 to obtain high level of glutamate utilization and gamma-PGA production. By applying such a pH-shift control strategy, the glutamate utilization increased from 24.3 to 29.5 g/l the intracellular glutamate, which was the direct substrate, also increased, and consequently the yield of gamma-PGA increased from 22.2 to 27.7 g/l, increased by 24.8%. This was the first report of using a two-stage pH-shift control strategy in gamma-PGA production, and it

was proved to be an effective way for the optimization of gamma-PGA production in this strain. (C) 2010 Published by Elsevier B.V.”
“Study Design. A retrospective review.

Objective. To obtain an assessment of complication incidence using the largest known database of adult scoliosis and to determine whether the rate of complication depends on various clinical parameters.

Summary of Background Data. The Scoliosis Research Society (SRS) morbidity and mortality database has previously been used to assess complication rates in adolescents undergoing scoliosis correction. To better understand complications in adults, degenerative and idiopathic adult scoliosis (AS) cases were studied.

Methods. The SRS morbidity and mortality database was queried to identify cases of AS from 2004 to 2007. Complications were identified and analyzed on the basis of patient type of scoliosis (degenerative vs.

In contrast to what is known, it is observed that nanobubbles are

In contrast to what is known, it is observed that nanobubbles are formed ATM/ATR inhibitor on an ultrathin dewetted layer of 0.5 nm thickness and exhibit unusual stability at ultrahigh vacuum conditions. Further, nanobubble rings are observed at atmospheric pressure. The results provide direct experimental evidence of the interaction between MWCNTs and nanobubbles at air-liquid-solid triple contact line and at lower step edge of the FLG, which together lead to the alignment of MWCNTs. Due to the balance between the surface tension forces and the strain forces arising from tube bending, MWCNTs attained

straight rod-like shape. This enabled us to evaluate the elastic modulus of the MWCNT as E = 0.9 TPa. (C) 2011 American Institute of Physics. [doi:10.1063/1.3626456]“
“In 1997, Taiwan made highly active antiretroviral therapy (HAART) available without cost to HIV-infected persons; in 2001, a national web-based surveillance system was implemented. Healthcare workers use the system to monitor patients’ conditions and can intervene when necessary. Free HAART, coupled with the surveillance system, appears to have increased survival rates

of HIV-infected persons with tuberculosis in Taiwan.”
“The aim of this work is to compare disabilities of the upper limb before and after hand allograft transplantation (HAT), and to describe the side effects of immunosuppressive (IS) agents given to recipients of hand allografts. Clinical cases of HAT published between 1999 and 2011 in English,

French, or German were reviewed systematically, SNS-032 mw with emphasis on comparing disabilities of the arm, shoulder and hand (DASH) scores before and after transplantation. Duration of ischemia, extent of amputation, and time since amputation were evaluated for their effect on intrinsic musculature function. Infectious, metabolic, and oncological complications because of IS therapy were recorded. Twenty-eight patients were MLN4924 reported in 56 clinical manuscripts. Among these patients, disabilities of the upper limb dropped by a mean of 27.6 (+/- 19.04) points on the DASH score after HAT (P = 0.005). Lower DASH scores (P = 0.036) were recorded after secondary surgery on hand allografts. The presence of intrinsic muscle function was observed in 57% of the recipients. Duration of ischemia, extent of transplantation, and time since amputation were not associated statistically with the return of intrinsic musculature function. Three grafts were lost to follow-up because of noncompliance with immunosuppression, rejection, and arterial thrombosis, respectively. Fifty-two complications caused by IS agents were reported, and they were successfully managed medically or surgically. HAT recipients showed notable functional gains, but most complications resulted from the IS protocols.

4 nm, is an inert, water-soluble protein that is midway along the

4 nm, is an inert, water-soluble protein that is midway along the size range of endogenous xylem sap proteins. Solutions of ovalbumin conjugated to a fluorescent marker and supplied to transpiring shoot explants of tobacco (Nicotiana tabacum L.) and olive (Olea europaea L.) were shown by confocal laser scanning

microscopy to accumulate specifically at wall-based pit membranes that connect neighbouring xylem conduits. In addition, pressure-induced perfusion of micro-filtered ovalbumin solutions, at concentrations similar to those of endogenous xylem sap proteins, through the xylem of tobacco stem or olive twig segments resulted in the retention of c. 40% of the ovalbumin and reductions in the axial hydraulic Copanlisib price conductance of the PARP activity xylem. Smaller molecules such as Texas Red 3000 (MW 3 kDa) and Alexafluor 488-cadaverin conjugates (MW 0.64 kDa) did not show similar characteristics. The partial reduction in xylem hydraulic conductance appeared to be related to the accumulation of ovalbumin at xylem pit membranes and the consequent fouling of trans-membrane water-conducting pores with smaller diameters than those of the ovalbumin molecules. Potential implications of these novel findings for whole-plant water relations are considered.”

We examined whether registered and unregistered

donors’ perceptions about transplant recipients’ previous behavior (e.g., substance use) and responsibility for illness differed based on their deceased organ donor registration decisions.


Students and community members from Queensland, Australia, were surveyed about their perceptions of transplant recipients.


Respondents (n = 465) were grouped based on their organ donor registration status

to determine whether their perceptions about transplant recipients differed. Compared to registered respondents, a higher proportion of unregistered respondents held more negative and less favorable perceptions of recipients. Multivariate analysis of variance confirmed statistically that unregistered respondents evaluated recipients more negatively MK-1775 concentration than registered respondents, F(6, 449) = 5.33, p < 0.001. Unregistered respondents were more likely to view recipients as a smoker, substance user, or alcohol dependent and as undeserving of a transplant, blameworthy, and responsible for their illness.


Potential donors’ perceptions of transplant recipients’ behavior and responsibility for illness differ according to their registration status. Future interventions should challenge negative perceptions about recipients’ deservingness and responsibility and promote the perspective that people from all walks of life need transplants in the aim of ultimately encouraging an increase in donor registration.

Thirty-five patients were retrospectively recruited from 5 medica

Thirty-five patients were retrospectively recruited from 5 medical centers in Korea. Patients received either weekly or 3 weekly with docetaxel +/- cisplatin.


Thirty-one out of 35 patients were evaluated for treatment response. A total of 94 cycles of chemotherapy (median, 2; range, 1 to 7) were TPX-0005 administered. The overall response rate was 14.3%, and the disease control rate was 45.7%. The median progression-free survival (PFS) was 1.9 months (95% confidence interval

[Cl], 1.1 to 2.7 months). The median overall survival (OS) was 3.6 months (95% Cl, 2.8 to 4.4 months). PFS and OS were significantly prolonged in patients of the Eastern Cooperative Oncology Group, with performance status of 0 or 1 in multivariate analysis (PFS: hazard ratio[HR], 0.411; 95% Cl, 0.195 to 0.868; p=0.020 and OS: HR, 0.390; 95% Cl, 0.184 to 0.826; p=0.014, respectively). Four of the 35 patients enrolled in the study died due to infection associated with neutropenia.


Our findings suggest that salvage docetaxel-based chemotherapy is a feasible treatment option for AGC patients with good performance status (PS),

whereas chemotherapy for patients with poor PS (PS <= 2) should be undertaken with caution for those who previously failed oxaliplatin- and irinotecan-based regimens.”

The current study was conducted in order to evaluate the clinical outcome of radical radiotherapy (RI) with or without chemotherapy for elderly patients with stage III check details non-small cell lung cancer (NSCLC).

Materials and Methods

Between 1990 and 2010, 125 patients, aged 70 years or more,

received radical RT with or without chemotherapy for treatment of stage III NSCLC. We reviewed the patients’ prognostic factors, including comorbidities. Comorbidity status was evaluated using a simplified comorbidity score (SCS). Of the patients reviewed, 82 received radical RT alone, whereas the other 43 patients underwent chemoradiotherapy (CRT). A platinum-based chemotherapy regimen was most commonly used (42/43).


The two-year overall-survival (OS) and progression-free survival (PFS) rates were 32.2% and 21.8%, respectively. SCS was the independent prognostic factor for OS. In the frail elderly subgroup with a SCS of >= 10, CRT demonstrated a significant difference HSP990 solubility dmso in PFS, but not in OS. In contrast, OS and PFS following CRT were significantly superior to RT in the fit elderly subgroup with a SCS of <10. The incidence of severe pulmonary toxicities in the frail elderly subgroup was significantly higher than that in the fit elderly subgroup.


Multiple comorbidities evaluated according to the SCS are related to poor OS in elderly patients with stage III NSCLC. CRT improved clinical outcome when compared to RI in the fit elderly subgroup, however, the gain from this treatment was negated in the frail elderly subgroup with multiple comorbidities.