“Everolimus, an inhibitor of the mammalian target of rapam


“Everolimus, an inhibitor of the mammalian target of rapamycin (mTOR), is an effective antitumor drug for renal cell carcinomas (RCCs), with its use increasing for management of other neoplasms such as breast cancer [1], neuroendocrine tumors [2], and angiomyolipoma [3]. Because of the high incidence of pulmonary adverse effects

caused by the drug, this increased use of everolimus is expected to result in find more an increased number of patients with drug-induced interstitial lung disease (ILD). In fact, drug-induced ILD was reported to occur in 13.5% patients receiving everolimus in a phase III clinical trial for RCC [4]. In addition to its antitumor effects, everolimus has been used as an immunosuppressant to prevent the rejection of heart and kidney transplants [5]. Therefore,

scrupulous care must be taken against opportunistic infections whenever everolimus is used; however, to our knowledge, there is only limited information regarding pulmonary infectious complications associated with everolimus therapy. In this paper we describe a case of pneumocystis pneumonia (PCP), which was clinically similar to everolimus-induced ILD and was initially managed with a corticosteroid. The patient was successfully treated with trimethoprim-sulfamethoxazole immediately after being diagnosed with PCP on the basis of a PCR assay for Pneumocystis jirovecii and elevated β-D-glucan levels. A 66-year-old Japanese Trametinib male with advanced renal cell carcinoma (RCC) visited our respiratory outpatient clinic complaining of progressive exertional dyspnea for 1 month after administration of everolimus. He had suffered from unresectable RCC with multiple bone metastases for 2 years (clear cell carcinoma. cT3cN0M1. stage IV). Previous therapy included sunitinib

for 1 year, followed by axitinib for 2 months. This regimen failed to prevent disease progression. Thereafter, third-line therapy with everolimus was initiated. Rebamipide The patient was an exsmoker and had stopped smoking 35 years back. Annual check-ups had revealed that he was asymptomatic for any breathing problems, with no abnormalities in the pulmonary function tests or chest computed tomography (CT) scans. On his first visit to our clinic, he was afebrile but presented with general malaise and tachypnea accompanied by hypoxemia (SpO2, 96% after inhaling oxygen by mask at 4 L/min). He had slight systemic edema, probably caused by renal insufficiency and/or hypoalbuminemia. Cardiac pulmonary edema was excluded by echocardiography. On chest auscultation, no wheeze or crackle was audible. Chest radiograph revealed bilateral infiltration on both lungs, while chest CT revealed diffuse ground glass opacities in both lung fields (Fig. 1A and B). The laboratory findings on admission are presented in Table 1. In brief, we observed mild lymphocytosis, mild anemia, thrombocytopenia, slight liver dysfunction, and renal insufficiency.

AT1 receptors are widely distributed throughout the body, includi

AT1 receptors are widely distributed throughout the body, including vascular smooth muscle, kidney, heart and brain, which are responsible for mediating vasoconstriction and sodium re-absorption. The AT2 receptors are generally thought to oppose the actions of AT1 [47]. We hypothesized that if these receptors would be expressed in peripheral taste cells, circulating ANG II may act as a suppressive modulator for amiloride-sensitive salt responses. The reciprocal regulation by ANG II and enhancers (e.g. ALDO) on the peripheral salt taste sensitivity would contribute to their opposing actions on sodium intake and play Ruxolitinib an important role in sodium homeostasis. To explore this hypothesis,

we investigated gustatory nerve and behavioral responses to taste stimuli after administration of ANG II in mice and the expression of ANG II receptors in taste tissues [48]. Salty taste responses are composed of amiloride-sensitive and -insensitive components as mentioned above [17], [18] and [19]. Thus, the CT nerve responses in B6 mice were examined, because both amiloride-sensitive and -insensitive responses were involved. The CT nerve responses of B6 mice to NaCl started to decrease approximately 5 min after an intraperitoneal (i.p.) injection of ANG II, then reached near maximum suppression click here (∼70% of control

before ANG II) approximately 30 min after the injection. Recovery of the responses to near control levels took more than an hour after the injection. In contrast, ANG II had no such effect on responses to NaCl in the presence of 30 μM amiloride. Thus, most of the effect of ANG II was on amiloride-sensitive salt responses. Verteporfin The effect of ANG II on the taste responses was dose dependent and saturated at ∼1000 ng/kg bodyweight ANG II. Surprisingly, ANG II also enhanced nerve responses to sweeteners (natural sugars; glucose, sucrose, artificial sweetener; saccharin, SC45647),

but not to KCl, sour (HCl), bitter (quinine hydrochloride: QHCl) or umami (monosodium glutamate: MSG) tastants. These effects of ANG II on nerve responses were blocked by pretreatment of a specific antagonist of AT1, CV11974 [49]. These results indicate that ANG II acts on the peripheral taste organs via AT1, and modulates the CT nerve responses to sodium (amiloride-sensitive) and sweeteners selectively in mice [48]. Interestingly, significant increases of amiloride-sensitive CT nerve responses to NaCl were observed at 90–120 min after the ANG II administration. ALDO is stimulated by ANG II, and has been proposed as an enhancer of amiloride-sensitive salt taste responses in a time course of hours [25], [34], [35], [36], [37] and [38], illustrating that the increased amiloride-sensitive salt responses at 90–120 min may be mediated by endogenous ALDO stimulated by the exogenous ANG II infusion.

rebaudiana ( Jackson et al 2009), where preliminary results were

rebaudiana ( Jackson et al. 2009), where preliminary results were obtained using desorption electrospray ionisation mass spectrometry (DESI-MS). We now describe an isolation procedure and structural analysis of fructooligosaccharides (FOS) from aqueous extracts of roots and leaves of S. rebaudiana, including determination of their degree of polymerisation (DP), using matrix-assisted laser desorption/ionisation mass spectrometry (MALDI-TOF) and electrospray ionisation mass spectrometry (ESI-MS). Dried, powdered leaves of Stevia rebaudiana (Bert.) Bertoni were purchased from SteviaFarma, Maringá, Paraná State, Brazil. Roots were collected in the nearby Medicinal

Plant Garden. Voucher specimens of the plant material are deposited in the herbarium of the Department

of Biology at the Maringá State University (identification number 14301-HUEM). All reagents were of analytical Selleckchem LY294002 grade. Dried roots (100.0 g) were powdered and successively extracted with refluxing hexane (1000 mL) for 4 h and methanol (1000 mL) for 4 h. Insoluble material was separated and extracted with boiling water for 4 h (1000 mL). The extract was cooled, stirred for 3 h, and centrifuged mTOR inhibitor (8000g, 30 min). The supernatant was evaporated to a small volume, added to EtOH (3×, v/v), left at 4 °C overnight; insoluble fructooligosaccharides were formed as a precipitate on addition to three volumes of EtOH (v/v). Centrifugation (8000g; 20 min) provided sediment, which was collected, washed twice with EtOH at the same 3:1 concentration and dried to give a product (15.7 g). This was dissolved in water (200 mL),

and the solution then submitted to freezing followed by gentle thawing at 4 °C ( Iacomini, Gorin, & Baron, 1988) until no more precipitate appeared. Centrifugation gave, following freeze-drying, the soluble component containing root fructooligosaccharides (RFOS, 4.6 g). Dried leaves of S. rebaudiana (100 g) were extracted with refluxing acetone (1000 mL) for 2 h (3×). The residue was extracted with refluxing water (1000 mL) for 2 h (3×), which was evaporated to a small volume, and added to EtOH (3×, v/v). The resulting precipitate (4.75 g) was dissolved in water (100 mL), and the solution was treated with 10% aqueous 3-oxoacyl-(acyl-carrier-protein) reductase TCA (100 mL) to precipitate protein. After centrifugation, the supernatant was neutralised with aq. NaOH, dialysed and freeze-dried. The residue was dissolved in H2O (100 mL), and the solution was submitted to freeze–thawing until no more precipitate appeared. Centrifugation gave, following freeze-drying, the soluble component (2.68 g). Afterwards, 1.0 g was submitted to treatment using Sartorius ultrafiltration equipment (Model 16249). Commercial membranes with a molecular mass cut-off (MMCO) of 100 kDa and 30 kDa (Millipore) were used. Each one was cut to size and soaked overnight in deionised H2O, prior to use. Filtration experiments were carried out at a constant pressure of 4 bar.

00 mg/100 g) and Af the ascorbic acid content after 55% degradati

00 mg/100 g) and Af the ascorbic acid content after 55% degradation during storage ( Labuza & Schmidl, 1985). The results obtained were

statistically evaluated using the variance analysis (ANOVA) and the means compared by Tukey’s test using version 7.0 of the Statistica program. Fig. 1 shows the results obtained for moisture content. It can KRX-0401 nmr be seen that there was greater water absorption in the accelerated state (35 °C and 90% RH), increasing by about 4.7 times as compared to the product at zero time, whereas under environmental conditions, this increase was about 2.5 times. According to Arlindo et al. (2007), the hygroscopic characteristics of some foods depend mainly on their chemical composition and storage

conditions (air relative humidity), which explains the greater increase in moisture content under the accelerated conditions. Few papers can be found in the literature concerning the shelf life of dehydrated powdered products stored in controlled environments. Thus, the increase in moisture content of the product at the end of the experiment can be attributed to the permeability of the packaging materials, favouring the absorption of moisture from the environment of the controlled storage system. Powdery products have presented, in general, low moisture contents, in the 4–6% interval. In this

study, in the accelerated condition (35 °C) the product showed 6% of moisture content in 26 days VRT752271 datasheet FAD of storage; under these conditions, the vitamin C retention was 75% of initial value. In environmental conditions (25 °C), the same moisture content was obtained in approximately 49 days and the product showed 45% vitamin C retention (Fig. 1 and Fig. 3). Fig. 2 shows the results obtained for water activity of the powdered guavira pulp, indicating that, as for moisture content, the water activity increased during storage, being greater under accelerated conditions (0.680) than under environmental conditions (0.470). This difference can be attributed to the relative humidity of the air in the storage environment. According to Garcia, Padula, and Sarantopulos (1989) as cited by Gomes et al. (2004), the type of packaging material used for food products constitutes a barrier that impedes or hinders contact between the food and the external environment. Nevertheless the permeability of the packaging materials should be considered. Depending on the permeability rates of water vapour and oxygen, greater absorption of moisture can occur from the environment, consequently influencing the water activity and justifying the greater absorption of water under accelerated conditions.

A , Bolivia for providing the coffee samples The ZHAW Department

A., Bolivia for providing the coffee samples. The ZHAW Department of Life Sciences and Facility Management is acknowledged for funding this research. “
“Rennet and coagulants are proteolytic enzyme preparations which have been used in selleck products the cheese industry for milk clotting, being this the oldest known application of enzymes. By definition, rennet is an extract of ruminant abomasums. From the name rennet, derived the word rennin for the milk clotting enzyme, which today is called chymosin (EC 3.4.23.4) (Andrén, 2002). Rennet extracted from calf abomasum consists of chymosin, as the major component, and of another proteolytic enzyme, pepsin (EC 3.4.23.1); when rennet is

extracted from adult animals this proportion is inverted, and there is predominance of pepsin (Guinee and Wilkinson, 1992 and Sousa et al., 2001). Due to its specificity towards the bond Phe105–Met106 of κ-casein, chymosin is more adequate to clot milk for cheese making than pepsin, which presents general proteolytic

action (Visser, 1993), risking the yield and flavour of cheese. Milk-clotting enzymes other than rennet are called coagulants and are represented by LY2109761 molecular weight fermentation produced chymosin, which is 100% calf chymosin produced by recombinant DNA technology involving Aspergillus niger, Kluyveromyces lactis or Escherichia coli ( Andrén, 2002); by vegetable enzymes such as the aqueous extract of flowers of Cynara cardunculus the most popular and

successful in Portugal ( Sousa & Malcata, 1998); and by different microbial coagulants specially the ones from Rhizomucor miehei, Rhizomucor pusillus and Cryphonectria parasitica ( Andrén, 2002, Nelson, 1975 and Sardinas, 1968). Approximately a third of the world’s milk production is used for cheese manufacture and the use of cheese for direct consumption and as an ingredient has increased tremendously (Farkye, 2004). For example, there was a 17% worldwide increase in cheese production from 2000 to 2008, and 43% in Brazil (Embrapa, 2010). Prato cheese, a Brazilian semi-hard cow variety, is of Danish origin, similar to Gouda and Danbo, with characteristic taste and texture; it is widely distributed in Brazil and NADPH-cytochrome-c2 reductase is one of the most consumed cheeses in the country (Cichoscki, Valduga, Valduga, Tornadijo, & Fresno, 2002). It is a ripened cheese made by enzymatic curdling with a smooth, thin rind and an elastic, compact consistency and rectangular in shape (Cichoscki et al., 2002 and Gorostiza et al., 2004). It is clear that cheeses have a very important economical role worldwide and also that the production of cheeses obtained through enzymatic coagulation, such as Prato cheese, tends to keep rising, meaning that the demand for coagulants is growing. Another trend in the cheese industry is that calf slaughter has decreased causing lack of calf rennet and a raise in its cost (Andrén, 2002).

Future model sensitivity and uncertainty analyses can help identi

Future model sensitivity and uncertainty analyses can help identify key factors and research needs to inform exposure measurement researchers and environmental health decision-makers. Collecting data for key inputs will reduce uncertainty for enhancing SHEDS-Multimedia model predictions in future applications. This data will also be relevant and applicable to other model research groups. The United States Environmental Protection Agency, through its Office of Research and Development, funded and managed the

research described here. It has been subjected to agency administrative review and approved for publication. Mention of trade names or commercial products does not constitute endorsement or recommendation for use. The authors declare no conflict of interest. In the U.S. EPA’s Office selleck inhibitor of Research and Development we thank Andrew Geller, Brad Schultz, Roy Fortmann, selleck chemicals llc Halûk Özkaynak, and Kristin Isaacs for their support of the SHEDS-Multimedia model. We gratefully acknowledge David Miller, Steve Nako, Matthew Crowley, Charles Smith, Kelly Lowe, and Victor Miller in the U.S. EPA’s

Office of Pesticide Programs for assisting with pyrethroid inputs and reviewing an early draft of this paper. We also acknowledge Alion Science and Technology for their contribution to the SHEDS-Residential model. “
“Chemicals such as phthalates, parabens, bisphenol A (BPA) and triclosan (TCS), used in a wide variety of consumer products, are suspected endocrine disrupters although their level of toxicity is thought to be low. Combined exposure may occur through ingestion, inhalation and dermal exposure, and their toxic as well as combined effects are

poorly understood. Phthalates are industrial chemicals which are used for a wide range of applications. They are primarily used as plasticizers in PVC found in consumer products such as shoes, gloves and packing materials as well as in building materials, floorings and wall coverings. Some Tolmetin phthalates are also used in non-plastic products such as pharmaceuticals, personal care products, paints and adhesives (Frederiksen et al., 2007 and Wittassek et al., 2011). Phthalates can be released from products and exposure may occur in humans through food, dust, air and direct use of personal care products (Janjua et al., 2008, Wittassek and Angerer, 2008 and Wormuth et al., 2006). After absorption, the parent phthalates are metabolized into respective monoesters, which can be further hydroxylated, oxidized and/or glucuronidated before excretion in urine as free or conjugated monoesters (Frederiksen et al., 2007). The presence of phthalate metabolites in urine indicates recent exposure to respective parent compound (Townsend et al., 2013). Some phthalates, such as di-(2-ethylhexyl) phthalate (DEHP), butylbenzyl phthalate (BBzP) and di-n-butyl phthalate (DnBP) are endocrine disrupters.

g , Allport and Wylie, 2000, Altman, 2007, Gopher et al , 2000 an

g., Allport and Wylie, 2000, Altman, 2007, Gopher et al., 2000 and Lien and Ruthruff, 2004). Based on our account,

these costs arise because the need for a restart enforces an updating process, Carfilzomib cost including costly re-retrieval of the current task set. There are probably many factors that can elicit such updating operations, such as forced breaks (Gopher et al., 2000), high probability of task switches (e.g., Mayr, 2007), or errors and the experience of conflict (e.g., Botvinick et al., 2001). We do not want to preclude the possibility that trial-to-trial transitions between task/control settings have unique characteristics that are not present for LTM retrieval effects. In fact, when also considering stimulus–response repetition effects across task repetitions vs. changes, usually a characteristic cost-benefit pattern arises. Specifically, costs are largest when there is partial overlap (e.g., cost for task changes with stimulus or response repetitions is larger than when everything changes). Hommel (2004) has suggested that this partial-mismatch pattern reflects aftereffects of integrated “event files” that bring all relevant codes for a specific selection instance together into an executable

state and that have to be “unpacked” if specific codes need to be reused on the next trial. Using a rule-switching paradigm, Mayr and Bryck (2005) looked for such a partial-mismatch pattern both for trial-to-trial transitions and for the effect of long-term memory traces on current Cobimetinib processing. Interestingly, while the first yielded the non-monotonic, partial-mismatch pattern, LTM effects were characterized by monotonic, similarity-based effects Everolimus ic50 (the greater the match between

past and current traces the larger the effects). Thus, there seem to be qualitative differences in the way in which the most recent and the less recent past influence processing. The exact cognitive/neural basis for these differences are currently not well understood. Clearly, this is a theoretically important issue that deserves further investigation. According to our results, presence of conflict modulates the cost asymmetry at two points. First, and not surprisingly, across all experiments the cost asymmetry was increased (albeit not quite significantly so in Exp. 5) when stimuli associated with the non-dominant task (i.e., the central cues) were present while performing the dominant task. This result is consistent with findings in the standard task-switching paradigm (e.g., Yeung & Monsell, 2003a) according to which the cost asymmetry is modulated through the presence of stimulus and/or response-related conflict. From the LTM perspective, this can be explained by assuming that the endogenous stimulus serves as a particularly powerful retrieval cue for the currently irrelevant (endogenous) task. Second, and theoretically more interesting is the fact that the presence of the exogenous stimulus (i.e.

, 2005), possibly indicating differences between the shelterwood

, 2005), possibly indicating differences between the shelterwood examined by Harmer et al. (2005) and the more extensive clearfells that we considered. The determination of any relationship between vascular plant cover and regeneration density was complicated by the constantly changing nature of ground flora – the current vegetation structure does not necessarily reflect that present when the seedlings first started growing. Indeed, the

only significant correlation between regeneration density and vascular plant cover was the negative correlation found for birch seedlings (shorter BGB324 chemical structure than 0.5 m). The small size of a birch seed means that its food reserve is only sufficient to grow to 2 cm in height (Miles and Kinnaird, 1979), before it must be able to support itself through photosynthesis. This results selleck compound in birch’s difficulty in establishing itself

in thick vegetation. Scarification (exposure of mineral soil) can increase seedling density in birch spp. (Kinnaird, 1974 and Karlsson, 1996). The ground disturbance and lack of ground vegetation after clear felling provides opportunities for seedlings to become established in bare ground before it is covered with vegetation. In contrast, the lack of regeneration seen on the unplanted upland moorland and unplanted improved farmland sites is likely due to the dense flora coverage (120% and 142% respectively) in Exoribonuclease combination with the lack of any ground disturbance. The rate of tree growth was slow, with regenerating trees achieving a median height of 104 cm

after 10 years of growth post-felling. These growth rates are markedly poorer than those recorded by Harmer and Morgan (2009) in lowland England or by Worrell et al. (2000) in upland NE Scotland. We found that the height distribution of the regenerating trees changed with time since clearfelling (Fig. 3), with large numbers of small trees 4 years post-felling changing to a more even distribution of heights 10 years post-felling. This indicates that the recruitment of new trees is most prolific in the first few years following felling, with fewer seedlings 10 years post-felling indicating a slowdown in this process. This decline is likely to be driven by the increase in herbaceous cover following clearfelling combined with the negative correlation between birch regeneration and herbaceous cover. The weighting of seedling recruitment to the years immediately following clearfelling may also contribute to the observed site to site variability in regenerating tree number since any temporal fluctuations in the ability of trees to regenerate will have substantial effects on the resulting density.

01, 0 10, 1, and 10 EU/mL One hundred microliters of the blank w

01, 0.10, 1, and 10 EU/mL. One hundred microliters of the blank was used according to standard endotoxin concentrations (ie, 0.01, 0.10, 1, and 10 EU/mL), and 100 μL of the samples was added in a 96-well microplate with respective PPC. All reactions were achieved in duplicate to validate the test. The test procedure and calculation of the endotoxin

level were performed following the manufacturer’s instructions. The absorbencies of endotoxin were individually measured IPI-145 by using an enzyme-linked immunosorbent assay plate-reader (Ultramark, Bio-Rad Laboratories) at 340 nm. The spike procedure was performed according to the manufacturer’s instructions by the addition of a known concentration value of endotoxin for each LAL method in order to detect any click here possible inhibition or enhancement from the samples in relation to the LAL substrate. To verify

the lack of product inhibition, an aliquot of test sample (or a dilution of test sample) is spiked with a known amount of endotoxin (0.4 EU/mL). The spiked solution is assayed along with the unspiked samples, and their respective endotoxin concentrations are determined. The difference between these two calculated endotoxin values should be equal to the known concentration of the spike ±25%. For the kinetic tests (chromogenic kinetic assay and turbidimetric assay), the WinkQCL Software (LONZA, Walkersville, MD) was used to calculate the amount of endotoxin recovered in the positive product control (PPC) in the comparison with the known amount of endotoxin spiked. The endotoxin recovered should be equal to the known concentration of the spike or within 50% to 200% as determined by the pharmacopeia. If positive, CHIR-99021 purchase the test was considered validated because a good interaction between the samples and LAL substrate was shown without interfering with the recovery of endotoxin. The linearity of the standard curve within the concentration range used

to determine the endotoxin values were verified for all tests according to the manufacturer’s instructions. The absolute value of the correlation coefficient (r value) of the calculated standard curve had to be ≥0.980. Replicates were run in order to assess the technique and coefficient of variation. The percentage of the coefficient of variation for replicates of a sample had to be less than 10%. Reproducibility between 3% and 4% was considered the best as indicated by the manufacturer’s instructions. After the measurement of endotoxin, if the levels of endotoxin were out of the standard curve or if any possible interference with LAL method by the root canal samples was detected, serial dilutions were considered and reassayed. The endotoxin values were statistically analyzed by using SPSS for WINDOWS, version 12.0 (SPSS Inc, Chicago, IL). The comparison between the chromogenic endpoint and chromogenic and turbidimetric kinetic methods was performed by using the Friedman test (p < 0.05).

In untreated cells, CTGV formed smaller comet tails compared to V

In untreated cells, CTGV formed smaller comet tails compared to VACV-WR (Fig. 4A). In the presence of increasing concentrations of ST-246, comet tails were reduced for both viruses, demonstrating the clear effect of ST-246 on extracellular virus production. Nevertheless, in CTGV-infected Fulvestrant in vitro cells, comet tails were barely detected at 0.015 μM ST-246 whereas VACV-WR still generated small comets and primary plaques at 0.05 μM. This result suggested

that the production of extracellular particles in CTGV-infected cells was more susceptible to the effect of ST-246 than in cells infected with VACV-WR. It is important to note that comet tails were visualized in CTGV-infected cells after 4 days of infection, whereas VACV-WR comets were better visualized after 3 days because of the difference in the sizes of virus plaques. Therefore, to measure the effect of ST-246 after similar period of treatment and infection, BSC-40 cells were infected in the presence of different concentrations of ST-246, and cell medium was harvested after 48 h. Medium samples were first depleted of contaminating IMV released from lysed cells by incubation with anti-A28 PI3K inhibitor neutralizing antibody and were subsequently

titrated on BSC-40 cells. As shown in Fig. 4B, ST-246 inhibited the production of infectious extracellular CTGV in a dose–response way. Extracellular yield was inhibited by nearly 64% at 0.01 μM ST-246, whereas a decrease of BCKDHA approximately 4% was detected for VACV-WR at this dose (p < 0.001). At 1 μM, the yield of extracellular CTGV dropped 3 logs when compared

with a 2-log reduction for VACV-WR (p < 0.001). We next investigated the antiviral effect of ST-246 on the replication of CTGV in vivo. To determine the best route of infection for producing measurable disease in mice, we tested intravenous injection into the tail vein, intranasal inoculation and scarification on the tail. Intravenous inoculations of BALB/c mice with up 5 × 104 PFU of CTGV by the tail vein did not generate lesions on the tail in contrast to inoculation with 5 × 103 PFU of VACV-WR, which produced visible lesions by day 13 post-infection (data not shown). Similarly, intranasal inoculation of mice with 105 or 5 × 107 PFU of CTGV did not produce clinical signs of disease in mice such as weight loss (weight was measured daily for 21 days), ruffled fur or lethargy (Reis, Moussatche and Damaso, unpublished data) whereas intranasal inoculation of mice with 105 PFU of VACV-WR produced measurable clinical disease with symptoms that have been used by others to describe disease severity ( Alcami and Smith, 1996 and Bray et al., 2000).