However, we had decided a priori to include studies of asymptomatic individuals because of the information on reliability they may provide. Seven of our included studies used healthy volunteers as participants. We note that the Libraries majority of included studies calculated Carfilzomib ICC for expressing reliability of measurement of range of motion between raters. ICC are the most appropriate parameter of reliability for continuous data reflecting the ability of raters

to discriminate between individuals (De Vet et al 2006). For effect of intervention, however, insight into absolute measurement error is required and other parameters, such as the limits of agreement, are preferable for expressing agreement within raters on measurements across multiple occasions over time (Bland and Altman 1986, De Vet et al 2006). To date, such data with respect to measurement of passive movements BI 2536 of upper extremity joints are rarely available. Since reliable measures of passive movement do not necessarily also have low absolute measurement errors, they cannot necessarily be used to evaluate the effect of intervention. Finally, with regard to physiological range of motion in the shoulder, we found large variation in reliability of measurement of external rotation and abduction range. Cyriax (1982) first described patterns of joint restrictions to distinguish

between capsular and other causes, eg, external rotation being most limited followed by abduction followed by internal rotation indicates a capsular cause. This pattern, however, was not corroborated in patients with idiopathic

loss of shoulder range of motion (Rundquist and Ludewig 2004). In addition, almost complete loss of external rotation is the pathognomic sign of frozen shoulder (Dias et al 2005). Valid diagnosis of shoulder disorders based on pattern of passive external rotation and abduction loss of range requires further research. This review has limitations with respect to its search strategy, quality assessment, and analysis. Only 11 included studies originated from our electronic search. A reason for this low electronic yield may be the inconsistent click here terminology used in reliability research. In our experience, reliability studies were poorly indexed in databases. In addition, our search strategy may have been too specific. Although much effort was put into reference tracing and hand searching, it is possible that eligible studies were missed. Furthermore, unpublished studies were not included. Publication bias can form a real threat to internal validity of systematic reviews of reliability studies because they are more likely to report low reliability. Additionally, quality assessment was performed by using criteria derived mainly from the quality assessment of diagnostic accuracy studies. No evidence is available on whether these items can be applied to reliability studies.

At each sampling time-point, 5 mL culture sample was withdrawn

from the fermentation vessel and immediately applied to a 0.8 µm Supor 800 filter (Pall) placed on a magnetic filtration funnel (Pall) attached to a vacuum filtration manifold. On the filter disc, the cells were subsequently washed twice with one volume 2.63% (w/v) NaCl solution each, and immediately after the second washing step, the Inhibitors,research,lifescience,medical filter was transferred to a 50 mL tube containing 25 mL 60% methanol solution pre-chilled on an ethanol bath at −23 °C. The whole procedure from sampling to quenching of metabolism was completed within 10–15 s. The samples of each sampling point were collected on the ethanol bath at Inhibitors,research,lifescience,medical −23 °C, subsequently snap-frozen in liquid nitrogen and

stored at −80 °C until metabolite extraction. 3.3. Metabolite Extraction Samples stored at −80 °C were completely thawed on an ethanol bath at −23 °C. An internal standard mix was added to each 25 mL sample (biomass from 5 mL sample on filter in 25 mL 60% methanol solution) yielding final concentrations of 3.34 mM D3-alanine, 312.5 µM D4-succinate, 1.67 µM D8-valine, 62.5 µM 13C6-glucose, 0.416 µM 13C10, 15N5-adenosine monophosphate and 1.04 µM 13C1-α-ketoisocaproic acid). This standard mix included compounds to be used as Inhibitors,research,lifescience,medical internal standards in different analytical methods for metabolites with different chemical properties (organic acids, phosphometabolites, sugars). Samples were then subjected to three cycles of freezing on liquid Inhibitors,research,lifescience,medical nitrogen and thawing at −23 °C on the ethanol bath, found to be sufficient for reaching a maximum of compound extraction into the 60% methanol, and thereafter centrifuged for 5 min at −9 °C and 6000 × g. Supernatants were transferred to new tubes pre-chilled at −23 °C and then divided into aliquots á 6 mL in 15 mL screw cap tubes for analysis using different metabolite profiling methods. Samples were frozen at −80 °C and subsequently subjected to solvent

evaporation on a freeze-dryer for 24 h. The freeze-dried samples were stored at −80 °C Inhibitors,research,lifescience,medical until MS analysis. 3.4. Metabolite Derivatization with Methyl Chloroformate (MCF) and GC-MS Analysis Dried extract samples were dissolved in a solvent mixture consisting of 380 µL 1 M NaOH, 333 µL 100% MeOH, and 67 µL pyridine following a modified protocol of Villas-Boas et al. [40]. 20 µL 1 mM D5-glutamate Non-specific serine/threonine protein kinase was added to each sample as an analytical internal standard, and the dissolved sample was then transferred to a silanized 5 mL glass tube. While vortex PCI-32765 mw mixing, the following steps were performed for derivatization with MCF, extraction with chloroform, and stopping the reaction with sodium hydrogencarbonate: 40 µL MCF added, 30 s vortex mixing, 40 µL MCF added, 30 s vortex mixing, 400 µL chloroform added, 10 s vortex mixing, 400 µL 50 mM NaHCO3 added, 10 s vortex mixing. The chloroform phase was dried with anhydrous Na2SO4 prior to GC-MS analysis.

5 Clinical education is a prerequisite for program accreditation;6 however, the rising student numbers is challenging the capacity of health service organisations to deliver this fundamental component of physiotherapy education.4 Assigning multiple students to one educator in physiotherapy clinical placements is one strategy being adopted to cope with this increase CHIR-99021 chemical structure in demand, and the popularity

of the 2:1 or ‘paired’ model — where two students are supervised by one clinical educator — is growing. In theory, the paired model offers an immediate increase in capacity, compared to the 1:1 model traditionally used in physiotherapy placements. However, a search of four databases ON-01910 ic50 (Medline, CINAHL, SCOPUS and ERIC) up to June 2011, using key search terms synonymous with peer-assisted learning and physiotherapy, yielded no randomised trials and little evidence of the actual effects of paired student models on student, educator or patient outcomes.7, 8, 9, 10 and 11 Physiotherapy clinical educators consider peer-assisted learning models to be feasible8, 9 and 12 and some prefer this to the 1:1 model.12 Those authors recommend inhibitors implementation of the paired student model in physiotherapy and reference the need for clinical educators to be prepared to facilitate peer engagement. Despite the recommendation for the

paired model, no studies have provided a reproducible framework, set of activities or specific tools to assist educators and learners in applying the model. Topping and Ehly13 defined peer-assisted learning as ‘the acquisition of knowledge and skill through active helping and supporting among status equals or matched companions’. Implementation of paired student placements might vary for several reasons, such as student and clinical educator preparation, placement environment and the cohesion of the student-peer relationship.8, 9, 12, 14, 15 and 16 Peer interactions

may take place in a number of ways – from purely social support to formalised Dichloromethane dehalogenase peer-assisted learning tasks. There is little knowledge of how particular aspects of the peer interaction contribute to learning and how to maximise the impact on learning outcomes. Qualitative investigations into physiotherapy education models have reported that the company of another student on placement reduces student anxiety and aids learning.12, 15, 16 and 17 No study provided a description or evaluation of the amount or type of peer interaction occurring within the paired placements. A model of paired student clinical education that specifically aims to facilitate peer-assisted learning may present immediate benefits within the placement and help to develop more sustainable and productive learner behaviours.18 The ability to collaborate with peers is highly valued by workplaces19 and is particularly important in the provision of effective healthcare.

In addition, preventing recurrent cerebrovascular disease and maintaining sufficient cerebral blood perfusion by adequately managing heart failure and avoiding very low blood pressure may help postpone clinical expression of the dementia syndrome, especially among very old people. The second strategy is to maintain the more active and socially integrated Inhibitors,research,lifescience,medical lifestyles by establishing extensive social networks and frequently participating in social, physical, and intellectually stimulating activities, which may reduce the risk or delay the onset of AD.38,132 Taken together, the most effective strategy may be to encourage, people implementing

Inhibitors,research,lifescience,medical multiple preventive measures throughout the life course, including

high selleck chemical educational attainment in childhood and early adulthood, active control of vascular factors and disorders over adulthood, and maintenance of mentally, physically, and socially active lifestyles during middle age and later in life. Intervention trials toward primary prevention The main clinical and intervention trials toward primary prevention by targeting the possible risk and protective Inhibitors,research,lifescience,medical factors for AD and dementia are summarized in Table II. 160,161,176-182 Antihypertensive treatments in reducing the risk of dementia and AD have been tested in a Inhibitors,research,lifescience,medical few clinical trials. The pooling analysis of the 2007 Cochrane review, based essentially on three clinical trials (SHEP,183 Syst-Eur,184 and SCOPE185),

found no convincing evidence that blood pressure-lowering therapy among elderly individuals with hypertension could prevent dementia. However, in this review the SCOPE trial, which did not show any effect of blood pressure-lowering treatment by candesartan on the risk of dementia, was Inhibitors,research,lifescience,medical actually not a placebo-controlled trial due to ethical considerations. By contrast, the placebo-controlled PROGRESS trial among individuals with cerebrovascular disease, (transient ischemic attacks and stroke), which did find a beneficial effect of antihypertensive therapy on cognitive function related to recurrent stroke, was not included.186 The cognition substudy of the double-blind placebo-controlled Hypertension in the Very the Elderly Trial (HYVET-COG) among people 80+ years found a nonsignificant reduction in the risk of dementia related to antihypertensive treatment. Encouragingly, when data from this clinical trial were pooled together with those from three other doubleblind placebo-controlled trials (SHEP, Syst-Eur, and PROGRESS), antihypertensive treatment could reduce the risk of dementia by 13 % (hazard ratio, 0.87; 95 % CI, 0.76-1.00; P=0.045).

In an open-label study, Becker et al29 also found that treatment with modafinil resulted in significantly decreased total mood disturbance. It should be pointed

out that several Selleck Y 27632 preliminary reports show the utility of modafinil as an adjunctive treatment for depressed patients with complaints of significant fatigue and/or excessive sleepiness.30-35 Inhibitors,research,lifescience,medical However, despite significant improvements compared with pretreatment, the majority of scores did not return to normal. Some authors have indeed suggested that depression may be endogenous to narcolepsy,7,36 as abnormalities in REM sleep, such as reduced REM sleep latency, are common to depression37 and narcolepsy. Finally, it is worth mentioning that narcolepsy cases in which the hallucinatory component is unusually prominent may lead to the diagnosis of schizophrenia. Douglass et al38 described five narcoleptic cases in which “psychotic symptoms” dominate the symptomatology. Conventional Inhibitors,research,lifescience,medical antipsychotic drugs were ineffective, and led the investigators to reconsider the diagnosis. The diagnosis of narcolepsy was ultimately confirmed and treatment with stimulants produced substantial improvement. It seems

clear that the hypnagogic and other hallucinations of narcolepsy could cause difficulties with the differential diagnosis from schizophrenia Inhibitors,research,lifescience,medical and, vice versa, narcolepsy should be considered in the differential diagnosis of hallucinations of possible psychotic origin. The hallucinations in narcolepsy are in general visual; sleep paralysis can Inhibitors,research,lifescience,medical be associated; and these usually occur when the patient

is half-asleep. Idiopathic hypersomnia Idiopathic hypersomnia is a rare condition. Its prevalence is about 10 times less than narcolepsy and it usually develops before the age of 30. In its polysymptomatic form, idiopathic hypersomnia is characterized by the following: excessive daytime sleepiness (not as irresistible as in narcolepsy, but usually lasting much longer); nocturnal sleep of abnormally long duration; signs of “sleep drunkenness” (difficulties in coming to complete wakefulness accompanied by confusion, disorientation, Inhibitors,research,lifescience,medical poor motor coordination, and slowness); and long and unrefreshing naps. The poorly defined monosymptomatic form manifests itself only by excessive daytime sleepiness.39 Complications are mostly social and professional, including poor work performance, reduced earning capacity, poor results at school, impaired ability to enjoy recreational activities, frequent click here accidents, and deteriorated memory for recent events.40 Due to these effects, it is possible to infer the possible psychological impact of the condition in the affected subjects, though no definitive conclusions can be made considering its frequency and the small series of published cases. In their survey, Bassetti and Aldrich41 reported a lifetime prevalence of psychiatric symptoms (anxiety and depressive symptoms) in 57% of patients.

FEAR-ESB leads animals to flee, whereas much weaker stimulation elicits a freezing response. Humans stimulated in these same brain regions report being engulfed by an intense free-floating anxiety that appears to have no environmental cause. Key chemistries that regulate this system are Neuropeptide Y and corticotrophin releasing factor (CRF); anti-anxiety agents such as the benzodiazepines Inhibitors,research,lifescience,medical inhibit this system by facilitating GABA transmission. The LUST/sexual systems Sexual LUST,28 mediated by specific brain circuits and chemistries, distinct

for males and females, is aroused by male and female sex hormones, which control many brain chemistries including two “social neuropeptides” – oxytocin transmission is promoted by estrogen in females and vasopressin transmission by check details testosterone in males. These brain chemistries help create gender-specific sexual tendencies. Oxytocin promotes sexual readiness Inhibitors,research,lifescience,medical in females, as well as trust and confidence, and vasopressin promotes assertiveness, and perhaps jealous behaviors, in males. Distinct male and female sexual tendencies are promoted by these steroid hormones early in

life, with sexual activation by gonadal hormones at puberty. Because brain and bodily sex characteristics Inhibitors,research,lifescience,medical are independently organized, it is possible for animals that are externally male to have female-typical sexual urges and, others with female external characteristics to have maletypical sexual urges. The dopamine-driven SEEKING system participates in the search for sexual rewards just as for all other types of rewards, including those relevant for the other social-emotional systems described below. The CARE/maternal Inhibitors,research,lifescience,medical nurturance system Brain evolution has provided safeguards to assure that parents (usually the mother) take care of offspring. Some of the chemistries of sexuality, for instance oxytocin, have been evolutionarily redeployed to Inhibitors,research,lifescience,medical mediate maternal care – nurturance and social bonding – suggesting there is an intimate evolutionary relationship between female sexual rewards and maternal motivations.29 The shifting hormonal tides at the end of pregnancy (declining progesterone,

and increasing estrogen, prolactin, and oxytocin) invigorate maternal urges days before the young are born. 17-DMAG (Alvespimycin) HCl This collection of hormonal and associated neurochemical changes also help assure strong maternal bonds with offspring. The GRIEF/separation distress system system was initially called the PANIC system, but few understood the intent of that primary-process terminology, so we shifted to the more comprehensible tertiary-process term of GRIEF30 (highlighting once more terminological problems in emotion research: what are the differences between the tertiary-level emotions of bereavement, grief, and mourning, for instance?). In any event, young socially dependent animals have powerful emotional systems to solicit nurturance.

whipplei. For isolated CNS WD, it has been suggested that a combination of neuroimaging and T. whipplei polymerase chain reaction (PCR) evaluation on the CSF be used as the standard for diagnosis (Panegyres et al. 2006). Given our report here of isolated CNS WD with normal MRI, we would propose the use of CSF PCR for T. whipplei as the primary confirmatory diagnostic test for isolated CNS WD. It has been suggested that CSF oligoclonal bands may be useful in monitoring response to treatment (Panegyres et al. 2006). The current treatment recommendation for WD is intravenous ceftriaxone, 2 g every 12 h for 2 weeks followed by oral double

strength trimethoprim–sulfamethoxazole Inhibitors,research,lifescience,medical twice daily for 1–2 years (Feurle and Marth 1994; Marth 2001, 2009). In general WD, the gastrointestinal symptoms respond first, but response of neurologic symptoms, particularly Inhibitors,research,lifescience,medical in CNS WD and isolated CNS WD, may require weeks to months for a response, with some patients experiencing relapse and/or death despite treatment (Feurle and Marth 1994; Famularo et al. 2005; Panegyres et al. 2006). In summary, a high index of Antidiabetic Compound Library Suspicion for isolated CNS WD should be maintained for patients presenting with rapidly progressive cognitive decline with supranuclear gaze palsy or other neurologic

signs and negative workup for more common Inhibitors,research,lifescience,medical etiologies. This suspicion should remain high even in the absence of gastrointestinal Inhibitors,research,lifescience,medical symptoms and unexplained MRI lesions, and in the presence of a positive CSF 14-3-3 protein. Suspicion for any form of CNS WD should prompt careful evaluation for oculomasticatory myorhythmia and CSF PCR for T. whipplei. Timely diagnosis and treatment of isolated CNS WD (and WD in general) is critical to prevent a potentially fatal outcome. Conflict of Interest None declared.
Fundamental for visual perception is the segregation of a scene into figure and background. In the process of

figure–ground Inhibitors,research,lifescience,medical segregation, different stages can be discerned: an early stage in which figure borders are detected and a later stage when processes Sitaxentan such as surface segregation and border ownership coding emerge (Lamme 1995; Zhou et al. 2000). For a long time, figure–ground segregation was thought to operate in a strictly hierarchical fashion. In the first stages of visual processing, small receptive fields in the primary visual cortex process elementary features (such as local contrasts, orientation, direction of motion [Livingstone and Hubel 1988; Zipser et al. 1996]), which serves as input for higher tier cortical regions. As information progresses upstream through the cortical hierarchy, receptive fields increase in size and their characteristics become more complex (Maunsell and Newsome 1987), allowing initially distributed information to become integrated (often referred to as “binding”).

11 in Kinnell (2014) BIBF 1120 mw was incorrect. They suggested that it should be equation(12) b1(QR30EI)c1=b1(Ve30EIPe−1)c1b1QREI30c1=b1VeEI30Pe−1c1where

b1 and c1 are the empirical coefficients, QR is the runoff ratio, E is the storm kinetic energy, I30 is the maximum 30-minute intensity, Ve is the runoff amount, and Pe is the rainfall amount. While their Eq. (12) was mathematically correct, Eq. 11 in Kinnell (2014) was presented in the context of modelling soil loss in terms of runoff and sediment concentration with the expression for sediment concentration enclosed in square brackets. Modulators Consequently, Eq. 11 in Kinnell (2014) should have been written as equation(13) b1(QR30EI)c1=Ve[b1Vec1–1(30EIPe−1)c1].b1QREI30c1=Veb1Vec1–1EI30Pe−1c1. The term Vec1–1Vec1–1 was inadvertently omitted from Eq. 11 in Kinnell (2014). Eq. (13) is a mathematically correct rearrangement of Eq. (12). Eq. (13) indicates that sediment concentration varies nonlinearly with both the runoff amount and the product of the kinetic energy per unit quantity of rain (E Pe− 1) and I30. The relevance of the discussion about the effect of runoff on sediment concentration that followed Eq. 11 in Kinnell (2014) is more obvious from Eq. (13) than Eq. (12). However, the discussion in Kinnell (2014) about Ae Pe (EI30)− 1 increasing with Ve to a

power of 1.48 on 22 m long plots at Sparacia followed the observation in Bagarello et al. (2011) that nonlinear relationships between sediment concentration and the product of the kinetic energy per unit quantity of rain and learn more I30 did not ALOX15 definitely exist in experimental data obtained from runoff and soil loss plots at Masse and Sparacia when both runoff and the product of the kinetic energy per unit quantity of rain and I30 were used as independent variables in the prediction of sediment concentration. Although not stated explicitly, the discussion in Kinnell (2014) about Ae Pe (EI30)− 1 increasing with Ve to a power of 1.48 on 22 m long plots at Sparacia focussed on equation(14) b1(QR30EI)c1=Ve[b1Vec2(30EIPe−1)]b1QREI30c1=Veb1Vec2EI30Pe−1where c2 = 0.48

on 22 m long plots at Sparacia, being an alternative to Eq. (13). Given that c2 was greater than c1 − 1 at Sparacia, the conclusion by Kinnell (2014) that runoff had a significant effect on sediment concentration at Sparacia followed more from Eq. (14) than Eq. (13). “
“The authors regret that there were errors in the units for total carbon and total nitrogen in Fig. 5. The corrected version of the figure is shown below. The authors would like to apologise for any inconvenience caused. Figure options Download full-size image Download as PowerPoint slide Fig. 5. Concentrations of carbon, nitrogen, and phosphorus in the organic horizon and the upper mineral soil (0–20 cm) along the Haast dune sequence, New Zealand. Values are the mean ± standard error of three replicate plots located along the dune crest at each site.

Endophenotypes in BPD BPD has been formulated as an emergent personality disorder grounded in the interaction of underlying genetically based dimensions including impulsive aggression, affective instability, and altered emotional information processing. Identifying endophenotypes for these partially discriminable dimensions may thus represent a more achievable goal than identifying endophenotypes for the more complex parent disorder. For each dimension, diagnostic interview criteria, psychometric variables from self-report measures, laboratory behavioral tests, neurochemical variables and neuroimaging paradigms, postmortem neurochemistry and molecular

biology techniques, Inhibitors,research,lifescience,medical as well as brain structural techniques, also represent potential endophenotypes that may identify promising genotypes (Figure Inhibitors,research,lifescience,medical 1 and

2). Figure 1. Identifying promising genotypes from a diagnostic category. Figure 2. Identifying promising genotypes in borderline personality disorder. PSAP, Point Subtraction Aggression Paradigm; CPT, Continuous Performance Inhibitors,research,lifescience,medical Task; IMT, Immediate Memory Task; fMRI, functional magnetic resonance imaging; PET, positron emission tomography; … Impulsivity Impulsivity is a central characteristic of many of the cluster B personality disorders and, as noted above, most aggressive acts committed by personality-disordered patients represent impulsive rather than planned aggression. Impulsive aggression may also be learn more directed toward the subject himself or herself as in self -injurious behavior. Other forms of impulsive behavior, such as binge eating, reckless driving, or gambling, may also be observed in personality-disordered patients. Impulsivity is thus defined as a propensity or readiness to act without reflection or appropriate Inhibitors,research,lifescience,medical constraint, Inhibitors,research,lifescience,medical often resulting in behaviors that bring on negative consequences such as aggression; it is a critical

dimension of BPD12 and, as discussed above, appears to be heritable, relatively stable in longitudinal studies, and a potential target for both pharmacological and psychosocial treatment. While impulsivity is often expressed in the domain of aggression in BPD, the two dimensions may be partially discriminable and will be treated separately. Psychometric measures that might be used for assessments of impulsive tendencies include the Barrett Impulsivity Scale (BIS-11)22,23 and interviews that evaluate life history of actual impulsive behaviors, such during as the Life History of Impulsive Behavior.24 These psychometric measures may be complemented by laboratory assessments that identify critical components of impulsivity. For example, the Immediate Memory Task (IMT) reflects “attentional impulsivity,” while go/stop tasks or go/no go Continuous Performance Tasks (CPTs) reflect a disinhibition or “motor impulsivity.” The Single Key Impulsivity Paradigm (SKIP) reflects “nonplanning impulsivity.

Undoubtedly the implementation

of population-based systems and trauma registry systems is a part of this evolutionary process, the results of which are then utilised #Epigenetic inhibitor randurls[1|1|,|CHEM1|]# to further refine health policy and patient care. In this context the studies conducted to date and examined by this Review could be viewed as precursors of injury surveillance and/or comprehensive trauma registry systems in China. These studies demonstrate both the operational feasibility of these systems and their value as a means of informing public health policy and practice. Inhibitors,research,lifescience,medical It is worth noting that the establishment of trauma registry systems is a relatively recent phenomenon globally; for example, the trauma registry system that captures Inhibitors,research,lifescience,medical major trauma in Victoria, Australia, was established only a decade ago in 2001

[43]. While China has developed into a leading economic power, this has also occurred only recently [6,50]. While a number of barriers could be suggested for reasons as to why a trauma registry has yet to be established in China – such Inhibitors,research,lifescience,medical as language and limited opportunities for training in locations that have established registry systems, it must also be recognised that there is a need to demonstrate the value of such systems which then enables, or ‘unlocks’ the financial resources required for their initial establishment and on-going operation. This latter point is a particularly important consideration in the context of competing development Inhibitors,research,lifescience,medical needs, which remains a feature of China at this point in time – and this is equally applicable in other low and middle

income countries. The development of the NISS [36] introduced in 2005 goes some way in addressing the need for a national injury surveillance and registry system. Notably, four of the studies reviewed here used the NISS Reporting Card as the basis for data collection. That the NISS commenced in a limited number of hospitals supports the contention that the development of population-based health Inhibitors,research,lifescience,medical data systems is progressive. The NISS now collects information on injuries from 129 hospital emergency departments from 43 counties (20 urban centres, 23 rural centres). Information collected on the Reporting Card includes simple demographics (age, occupation), injury cause information such as time and place of occurrence, causes, intention and activity when injured, as well as time of admission. The Reporting Card also collects information on severity, second outcome, clinical diagnosis, and nature and site of injury although internationally recognised scoring systems such as the ICD, ISS, RTS, and TRISS are not currently used. The inclusion of these clinical indicators and severity indices would increase NISS’ value immensely, however it is recognized that the necessary training for the use of these indicators is likely to be costly until a point where a collective of local ‘train-the-trainers’ is established.