Data were recorded using MP100, Biopac digital acquisition system

Data were recorded using MP100, Biopac digital acquisition system, www.selleckchem.com/products/ABT-263.html and analyzed using Acknowledge 3.5.7 software (Biopac). Synthesis procedures Flash chromatography was performed on a CombiFlash Companion chromatography system (Teledyne Isco, Lincoln, NE). 1H and 13C NMR images were obtained on a Bruker 300 MHz instrument (Bruker Corp., Billerica, MA, USA). High-resolution mass spectrometry was done at a core facility at the University of California (Riverside, CA, USA). Elemental analyses were done at the Micro-Mass Facility (University of California, Berkeley, CA, USA). N-(2-methoxyethyl)-4-phenyl-2-thiazolamine (compound 1) A solution of 2-bromoacetylphenone (1.59 g, 7.99 mmol) and 1-(2-methoxyethyl)-2-thiourea (1.02 g, 7.61 mmol) in ethanol (30 ml) was refluxed under argon for 4 h.

After the reaction mixture was cooled to room temperature, saturated aqueous NaHCO3 was slowly added. Ethanol was removed under reduced pressure. The resulting suspension was extracted twice with CH2Cl2. The combined organic phase was washed with water, dried (Na2SO4), and concentrated. Chromatography [silica, hexanes:ethyl acetate (9:1 to 4:1)] yielded a white crystalline solid (1.62 g, 91%), melting point 57�C60��C. 1H NMR (300 MHz, CDCl3) �� 3.39 (s, 3H), 3.53 (m, 2H), 3.64 (m, 2H), 5.46 (br, 1H), 6.70 (s, 1H), 7.27 (m, 1H), 7.37 (m, 2H), and 7.80 (m, 2H). 13C NMR (75 mHz, CDCl3) �� 45.2, 58.8, 70.7, 101.0, 126.0, 127.6, and 128.5. ESI-MS calculated for C12H15N2OS 235.0900; found 235.0902. N-(2-methoxyethyl)-N-(4-phenyl-2-thiazolyl)-2,3,4-trimethoxybenzeneacetamide (Eact) A solution of compound 1 (1.

00 g, 4.27 mmol) and anhydrous pyridine (690 ml, 8.54 mmol) in anhydrous toluene (40 ml) was stirred for 5 min. To the reaction mixture was added a solution of 3,4,5-trimethoxybenzoyl chloride (1.47 g, 6.41 mmol) in anhydrous toluene (20 ml). The mixture was refluxed under argon for 4.5 h, cooled to room temperature, and poured into water and ethyl acetate. The organic phase was collected, dried (Na2SO4) and concentrated. Chromatography [silica, hexanes:ethyl acetate (4:1 to 3:1)] yielded a crystalline solid (1.33 g, 73%), melting point 97�C100��C. 1H NMR (300 MHz, CDCl3) �� 3.28 (s, 3H), 3.86 (t, J = 5.4, 2H), 3.88 (s, 6H), 3.90 (s, 6H), 4.48 (t, J = 5.4, 2H), 6.92 (s, 2H), 7.26 (s, 1H), 7.33 (m, 1H), 7.43 (m, 2H), and 7.90 (m, 2H). 13C NMR (75 mHz, CDCl3) �� 49.

6, 56.2, 58.9, 61.0, 69.7, 105.4, 109.4, 126.0, 127.9, and 128.7. ESI-MS is calculated for C22H25N2O5S 429.1479; found 429.1477. Synthesis of Fact analogs, exemplified with N-(4-bromophenyl)-3-(1H-tetrazol-1-yl)benzamide (Fact) Thionyl chloride (477 ml, 6.58 mmol) and 3-(1H-tetrazol-1-yl)benzoic acid (50 mg, 0.263 Dacomitinib mmol) was heated to 80��C in a screw-cap vial. After a clear solution was observed, the residue solid on the wall was washed by gentle shaking. After 1.5 h, the reaction was cooled to room temperature.

Before specific interventions for college student smokers can be

Before specific interventions for college student smokers can be developed and tested, research needs to characterize patterns of smoking in this population and examine whether evidence exists for a classification of smokers that goes beyond the traditional ��current smoker�� or ��daily versus nondaily�� taxonomy. In this study, we used latent class analysis Belnacasan (VX-765) (LCA) to identify subgroups (classes) of college smokers with similar smoking patterns (Lazarsfeld & Henry, 1968; McCutcheon, 1987). LCA is an empirically based statistical method for explaining heterogeneity in response patterns in terms of underlying classes.

We aimed to (a) use LCA to characterize patterns of smoking in a sample of college students; (b) estimate the prevalence of these patterns of smoking; and (c) better understand the variation in smoking patterns by examining the associations with demographic variables, health risk variables, and other aspects of smoking behavior, including efficacy to quit, nicotine dependence, and perceived health effects. Methods Population and sample In fall 2006, a random sample of undergraduate students attending 10 universities (eight public and two private) in North Carolina were invited to complete a Web-based survey as part of a randomized group trial of an intervention to prevent high-risk drinking behaviors and their consequences (Wolfson et al., 2007). Students from each campus were selected randomly from undergraduate enrollment lists provided by each school. The goal was to have 416 students (104 each of freshmen, sophomores, juniors, and seniors) from each university to complete the survey (n=4,160).

The number of students selected to participate was based on the expectation from previous studies and previous waves of the survey that approximately 30%�C35% of the students would complete the survey within the allowed time period (Reed, Wang, Shillington, Clapp, & Lange, 2006). The Web site was shut down shortly after the target numbers from the 10 schools were achieved. The response rate across all 10 schools was 21.0% and varied quite a bit across campuses (9.3%�C34.0%). Variation in the response rates across schools may reflect varying levels of technological capabilities (Mitra, Jain-Shukla, Robbins, Champion, & DuRant, 2007). The response rate was likely affected by the survey link being deactivated after the quota (4,160 students) was reached (i.

e., a higher response rate would have been achieved if a quota system had not been used). All the students selected to participate were sent an E-mail inviting them to participate in a Web-based survey, which provided a link to a secured Web site where the survey could be completed. The E-mail notification protocol, GSK-3 including multiple, frequent reminders for the Web-based survey, was based on the Dillman (2000) approach (Mitra et al., 2007).

It was administered in English, Spanish, Mandarin, and Cantonese

It was administered in English, Spanish, Mandarin, and Cantonese and contained closed-ended questions http://www.selleckchem.com/products/nutlin-3a.html that took approximately 25 min to complete. The cooperation rate for the NYSES was 54%, which is typical for random-digit�Cdialed telephone studies in large, densely populated urban areas (Galea et al., 2003). Comparisons of the NYSES sample to the U.S. census revealed that the sample was representative of New York City residents on age, gender, and race/ethnicity (data not shown). The institutional review board at the University of Michigan approved the study’s protocol. Current smokers (N=835) answered additional survey questions (requiring about five more minutes). These questions were designed to assess the perceived social unacceptability of smoking and possible behavioral correlates of this social unacceptability.

The dependent variable in the present study was the response to the following question: ��Have you ever kept your smoking status a secret from a doctor or other health care provider?�� We also assessed potential demographic correlates (age, race/ethnicity, education, income, and marital status) and other potential covariates of keeping one’s smoking status a secret. Specifically, we asked respondents if they were the parent or primary caretaker of any children under the age of 21 and asked them to characterize their general health status (excellent, very good, good, fair, or poor). Parents may be more reluctant to admit to a health care provider that they smoke because of fear of embarrassment or shame for exposing family members to the harms posed by second-hand smoke or because they do not want to be perceived as a poor role model to their children because of their smoking.

People in fair or poor health also may keep their smoking status a secret from health care providers due to embarrassment that, instead of taking steps to improve health, they are further harming their health by continuing to smoke. The measures of tobacco use, including the average number of cigarettes smoked per day in the past 12 months (categorized as ��5, 6�C10, 11�C20, or >20), and tobacco dependence were assessed using the World Mental Health Composite International Diagnostic Interview (Kessler & Ustun, 2004; Kessler et al., 2004). The measure of tobacco dependence asks about problems respondents may have had because of smoking tobacco (e.g.

, emotional symptoms after cutting down or stopping smoking). Current smoking status was Anacetrapib assessed with the question ��Are you a current smoker, ex-smoker, or have you never smoked?�� Several items were used to assess the perceived social unacceptability of smoking, including variables that tap into respondents�� normative environment and new items designed for the present study to assess the extent to which smokers perceive stigma and differential treatment because of their smoking status.

Several genetic and biochemical studies indicate that the FoxO fa

Several genetic and biochemical studies indicate that the FoxO family is a key downstream target of the PI3K-Akt pathway in development and longevity (Lin et al, Tofacitinib Citrate buy 1997; Brunet et al, 1999). Thus, phosphorylation of FoxO factors in specific serine and/or threonine sites modulates their subcellular localisation (Rena et al, 2002; Barthel et al, 2005; Anton et al, 2007). Once placed in the nucleus, they play tumour suppressor roles through enhanced transcription of proapoptotic genes, such as BCL6, a Bcl-2-interacting mediator of cell death (Bim), and Fas ligand (Dijkers et al, 2000; Yang et al, 2006). Bim is a proapoptotic member of the Bcl-2 family, and is one of the main downstream targets of FoxO3a. After transcription, Bim mRNA undergoes an alternate splicing, giving three isoforms (BimS, BimL and BimEL) with different length (Ewings et al, 2007).

Interestingly, there are in vivo and in vitro evidence demonstrating an essential role of Bim proteins in Bax activation (Ren et al, 2010). Based on this information, we focused this study on the FoxO3a regulation of Bim expression after treatment with pharmacological concentrations of melatonin, in an attempt to gain further mechanistic insights on the molecular pathways leading to melatonin-induced apoptosis in HepG2 liver cancer cells. Materials and methods Cell culture HepG2 cells were obtained from the American Type Culture Collection (Manassas, VA, USA) and grown in Dulbecco’s modified Eagle’s medium (DMEM). Primary human hepatocytes were isolated from healthy liver tissue of patients undergoing partial hepatectomy by two-step collagenase perfusion.

Cells were seeded on collagen-coated culture dishes in Williams medium supplemented with 10% fetal bovine serum, 15mmoll?1 HEPES (pH 7.4), 2mmoll?1 glutamine, 100Uml?1 penicillin and 100��gml?1 streptomycin. LY294002 was from Tocris (Bristol, UK). Melatonin and epidermal growth factor (EGF) were obtained from Sigma-Aldrich (St Louis, MO, USA). Viability assays HepG2 cells or primary human hepatocyte were seeded in 96-well plates. Melatonin dissolved in dimethyl sulphoxide (DMSO) was added to the cells at the concentrations as indicated in the figures. Apoptosis was induced in HepG2 cells with 200ngml?1 of the monoclonal antibody (Ab) to human (APO-1/Fas) anti-APO-1, kindly provided by Peter H Krammer.

Cell viability was determined using the CellTiter-Glo (Promega, Fitchburg, WI, USA) and 3-(4,5-Dimethythiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assays (Sigma-Aldrich). CellTiter-Glo assay was performed according to Batimastat the manufacturer’s instructions (Promega). Luminescence was determined in a Saphire luminometer (Tecan Austria, Gr?dig, Austria). The MTT assay was carried out as described by Denizot and Lang (1986). Briefly, after exposure of cells to melatonin, culture media were changed by serum-free culture media.

, 2009) The observed imbalance of ST use studies among the servi

, 2009). The observed imbalance of ST use studies among the service branches may be attributable, at least in part, to varying institutional review board (IRB) requirements across Ganetespib OSA the service branches. Because each branch has its own set of procedures in place for obtaining IRB and other military approvals, the obstacles to engaging in data collection across the service branches can be formidable. A standardized or centralized IRB approval process would help to reduce this limiting factor. Clinical Implications The results of this literature review have a number of important clinical implications. Broadly, the findings indicate that ST use represents an important target for intervention in the U.S. military population because it impairs ��military readiness�� and hurts the health of the military.

Prevalence estimates of ST use across all studies were high, even when compared with demographically similar nonmilitary populations, suggesting that military personnel carry a disproportionate burden of ST use and its associated risks. Targeted interventions are needed to reduce ST use in this population. In addition to a high overall prevalence of ST use, the review found that many military personnel use both cigarettes and ST concurrently. Concurrent use was reported in nearly half of the studies (n = 19). From an intervention perspective, concurrent use presents a unique challenge for intervening with ST use in population. Dual users are exposed to higher levels of nicotine (Wetter et al., 2002), may be less likely to make a quit attempt (Hatsukami & Severson, 1999; Tomar, Alpert, & Connolly, 2010; Walsh et al.

, 2010), and more likely to relapse (Wetter et al., 2002). The extent to which existing cessation approaches are effective in addressing concurrent use patterns of tobacco use is largely unknown. New strategies may be needed to effectively address the problem of concurrent use in this population. It is noteworthy that the current review identified only a handful of ST intervention studies involving military personnel (n = 5). Three of these studies were conducted in the Air Force, one in the Army, and one with participants from multiple branches. Only one intervention study had both a behavioral and a pharmacological component (Shipley et al., 2002). The results of these studies suggest that it is possible to effectively intervene with ST use in this population.

However, more intervention studies are clearly needed. Future Directions To address significant gaps in research on ST use in the military, we offer the following recommendations. First, more longitudinal and cohort studies of ST use are needed in this population. Such studies would provide a better understanding GSK-3 of important critical periods for intervening with ST use. In particular, more research is needed that examines the developmental trajectories of tobacco use among military personnel.

Resection of the abnormally innervated bowel is essential to avoi

Resection of the abnormally innervated bowel is essential to avoid life threatening complications. Previous data showed despite successful surgical treatment, there was a large proportion of patients in whom constipation, soiling and abdominal pain persisted. After an average of 9 years, 53% of patients continued to suffer from fecal incontinence and 22% were still Ganetespib cancer constipated 2-4. The reasons for these persistent symptoms were not clear, although data were emerging to suggest that those with constipation have a neuropathy proximal to the aganglionic segment 5. Aganglionosis is attributed to a failure in the time-specific migration of enteric neural crest-derived cells into the intestinal tract.

Most studies on the pathogensis of HSCR were concerned on the autologous abnormity of migrating enteric neural precursors (ENPs), and the results showed that mutations of the RET, GDNF, EDNRB, SOX10, NRG1, NKX2-1 and EDN3 genes appeared to give dominant, recessive, or polygenic patterns of inheritance 6-9. However, research on target cells such as smooth muscle was rather limited. Smooth muscle thickening and intestinal wall remodeling existed in aganglionic and ganglionic segment of HSCR. But the influence of intestinal wall remodeling on prognosis of Hirschsprung disease, and the molecular pathways triggering the thickening and remodeling process are still poorly understood. Previous studies indicated that smooth muscle had a major impact on determining the number of innervating neurons. Jacob CL found that smooth muscle of the aganglionic colon was less favourable for neuronal development than that of normal colon and the mechanism was not clear [10].

Many proteins with abnormal function or expression level in the smooth muscle cells of the aganglionic part of the colon in HSCR have been identified, such as cholinoreceptors, alpha-smooth muscle isoactin, Semaphorin 3A, sarcoglycan subcomplex and Connexin43 etc 11- 17. These proteins participate in the pathogenesis through impairing intercellular communication between interstitial cells of Cajal and smooth muscle cells or altering the cytoskeleton in smooth muscle cells or disturbing the microenvironment around the targets of migrating neural crest cells in autocrine or paracrine manner during colon development. But the mechanism of the proteins in smooth muscle participated in intestinal dysfunction in HSCR patients has not been clarified. The FHL1 gene, located on chromosome Xq27.2, encodes four-and-a-half Carfilzomib LIM protein-1 (FHL1) and its spliced isoform, SLIMMER or FHL1C.

Louis, MO) (15, 34, 59) The fluorescence of the released 4-methy

Louis, MO) (15, 34, 59). The fluorescence of the released 4-methylumbelliferone was measured in a Fluoroskan II spectrophotometer (Labsystems, Helsinki, Finland) using excitation and emission wavelengths of 355 and 460 nm, respectively. The enzymatic activity of NA protein was selleck chemical 17-AAG standardized to 0.1 mg total protein by using a bicinchoninic acid assay (Sigma, St. Louis, MO) and was expressed as the quantity of substrate (in picomoles) converted during a 30-min incubation at 37��C. The NA inhibitor oseltamivir carboxylate ([3R,4R,5S]-4-acetamido-5-amino-3-[1-ethylpropoxy]-1-cyclohexene-1-carboxylic acid) was provided by Hoffmann-La Roche, Ltd. (Basel, Switzerland). The compound was dissolved in distilled water, and aliquots were stored at ?20��C until use.

NA activity was inhibited by using a 4 ��M concentration of oseltamivir carboxylate added immediately posttransfection or 1 h before the assay. The effect of an NA protein inhibitor on the pH of fusion was determined by performing a syncytium formation assay in parallel. RESULTS The HA protein mutations have little effect on the in vitro replication kinetics of recombinant H5N1 influenza viruses. In a previous study, we identified four mutant H5 HA proteins whose pH values of membrane fusion differed from that of wild-type HA protein when expressed from transiently transfected plasmid DNA (36). Here we determined whether the HA protein mutations affected the in vitro replication kinetics of recombinant H5N1 influenza viruses by generating single-step and multiple-step growth curves.

Single-step growth curves showed that mutant and wild-type viruses grew at similar rates over the 10-h time course (Fig. (Fig.1A).1A). In multiple-step growth curves, viruses containing the HA protein mutations Y231H, H241Q, and K582I had replication rates similar to that of wild-type virus (Fig. (Fig.1B).1B). Titers of the virus containing an N1142K mutation in the HA protein were similar to those of wild-type virus at the 12-h time point but were later reduced by 1 to 3 log10 units. FIG. 1. Replication kinetics of recombinant A/chicken/Vietnam/C58/04 (H5N1) influenza viruses in MDCK cells. (A) For single-step growth curves, cells were infected at an MOI of 3 PFU/cell with wild-type virus or viruses containing HA protein mutation Y231H, H24 … The HA protein mutations alter the pH of membrane fusion in vitro. The cell surface expression, cleavage, receptor binding affinities, and membrane fusion efficiencies of the mutant HA proteins in Vero cells were previously found to be similar to those of wild-type virus (36). Moreover, infection of DF-1 primary chicken embryonic fibroblasts with the viruses resulted in HA protein properties similar to those Entinostat found when Vero cells were infected with the viruses.

Eight patients were not eligible for IFN treatment because of LC,

Eight patients were not eligible for IFN treatment because of LC, complication (depression), or advanced age. Seven patients had received IFN therapy in the past. Six patients were non-responders to IFN and 1 discontinued therapy because of Erlotinib HCl side effect (depression). All patients assessed the tolerability as excellent. Table 1 Characteristics of patients During fucoidan treatment, 11 patients received a glycyrrhizin preparation. Fucoidan (provided by Kanehide Bio Co., Okinawa, Japan) was given orally as capsules containing 166 mg of dry extract from C. okamuranus Tokida per capsule in a dose of five capsules daily for 12 mo. Informed consent was obtained from all patients enrolled in the study, after a thorough explanation of the aims, risks, and benefits of this therapy.

Test parameters The outcome parameters included the course of alanine aminotransferase (ALT), aspartate aminotransferase (AST), quantitative HCV RNA levels, subjective symptoms associated with CHC, LC, and HCC (such as fatigue, abdominal discomfort, depression, and dyspepsia), safety, and compliance. Data on all clinical parameters were documented at each visit. HCV RNA levels were determined using the AMPLICOR GT HCV Monitor test (Roche Diagnostics, Basel, Switzerland), which has a lower limit of quantitation of 0.5 kIU/mL at a linear range up to 850 kIU/mL. Statistical analysis Data are expressed as mean �� SD. The results of biochemical tests and HCV RNA levels were compared by the Student��s t test. A P < 0.05 was considered significant.

RESULTS Fucoidan suppresses HCV replication To assess the effects of fucoidan on intracellular replication of the HCV genome, HCV subgenomic replicon cells FLR3-1 were cultured in the presence of various concentrations of fucoidan in the medium. The luciferase activities of the FLR3-1 cells showed a concentration-dependent suppression of replication of HCV replicon by fucoidan. The WST-8 assay showed that fucoidan had negligible effect on cell viability (Figure (Figure1).1). These results suggest that fucoidan inhibits HCV replication but does not have cytotoxic effects. Figure 1 Anti-hepatitis C virus effects of fucoidan in hepatitis C virus replicon cells. Luciferase (LUC) activity (a marker of replication level) and cell viability of FLR3-1 cells, which constitutively express hepatitis C virus replicon, were measured in the …

Effect of fucoidan therapy on HCV RNA and alanine aminotransferase levels Changes in HCV RNA and serum ALT levels in patients treated with fucoidan GSK-3 are shown in Figure Figure2.2. The mean HCV RNA for the 15 patients was 736 �� 118 kIU/mL (range, 100-850 kIU/mL) before fucoidan therapy. As shown in Figure Figure2A,2A, fucoidan tended to reduce the mean HCV RNA level with time relative to the baseline, with significant falls registered at 8-10 mo of treatment. However, HCV RNA increased after 11 and 12 mo.

The Cochrane Collaboration offers

The Cochrane Collaboration offers selleck kinase inhibitor a guide for inclusion of nonrandomized studies [59] and it has developed a tool for assessing the risk of bias in both RCT and controlled nonrandomized studies[60]. Conclusions Different study designs addressing the same question yielded varying results, with differences in about half of all examples. The risk of presenting uncertain results without knowing for sure the direction and magnitude of the effect holds true for both nonrandomized and randomized controlled trials, though, the risk of bias and confounding is probably higher in the nonrandomized ones. The integration of multiple study designs in systematic reviews is required if patients should be informed on the many facets of patient relevant issues of health care interventions.

Supporting Information Table S1 PRISMA Checklist. (DOC) Click here for additional data file.(70K, doc) Table S2 Qualitative summary of key messages. Type of review. Systematic review (first 8 papers): Cochrane Systematic Review (Archampong 2012), Health Technology Assessment of National Health Service in UK (Britton 1998), other systematic reviews not issued by Cochrane or HTA (Chambers 2009, Chambers 2010, Chou 2010, Lewsey 2000, Linde 2002, Norris 2005). Non-systematic review (rest of 34 papers): narrative review or editorial or comment or letter. Message. We extracted messages with respect to the question whether nonrandomized studies should be conducted or integrated in systematic reviews to complement available RCTs or replace lacking RCTs. We did not extract data on differences between those two study design on size or direction of effect.

NRS also: We perceived a tendency in Cilengitide the message that nonrandomized studies should also be considered in addition to RCTs in general or to answer specific research questions. RCT only: We perceived a tendency in the message that RCTs are sufficient to answer research questions in clinical trials and in systematic reviews and that nonrandomized studies cannot complement or replace them. Field.

The occurrence of AEs documented by our study contrasts with the

The occurrence of AEs documented by our study contrasts with the absence of any event reported in Egypt [23] even though both the treatment regimen and the manufacturer of triclabendazole were the same. While comparison might not be fully appropriate, as in Egypt no active search of events was carried out, such discrepancy selleckchem Ceritinib might be attributable to the lower mean intensity of infection observed in this country (12.2 epg at baseline). Frequency and severity of AEs are however expected to be less important at subsequent rounds of treatment in reason of the progressively decreasing intensity of infection, as shown by experiences from different helminth control interventions implemented across the world [1], [21], [33]. The parasitological cure rate achieved after a single administration of triclabendazole at 10 mg/kg was high (77.

8%) and consistent with previous reports in the scientific literature for this treatment course [27]�C[29]. ERRs were also considerable, even though lower rates were observed among individuals with a higher intensity of infection at baseline (Table 4). The negative relationship between ERR and baseline intensity of infection has been described in the case of other helminth infections, such as those by Trichuris trichiura: both density-dependent fecundity and reduced bioavailability of triclabendazole per adult worm have been proposed as possible explanatory hypotheses [34], [35]. Finally, only 1.1% of the 90 treated children still had high-intensity infections (��400 epg) at the first parasitological follow-up, compared to 7.8% at baseline.

If we apply to fascioliasis the model described in other helminth infections, that intensity of infection is proportionate to morbidity [1], [2], it can be inferred that morbidity was under control in a very high proportion of children three months after a single administration of triclabendazole 10 mg/kg. Based on the results of the pilot intervention, we conclude that triclabendazole is a safe and efficacious drug when administered to a paediatric population living in a fascioliasis endemic area. These considerations suggest that a population-based drug distribution approach, without individual diagnosis and without direct medical supervision, in a manner comparable with the preventive chemotherapy interventions implemented worldwide against the four major helminth infections, is appropriate and feasible. Notably, triclabendazole was well tolerated across the population examined, including individuals with a high intensity of infection: AEs elicited Anacetrapib were self-limiting, did not require any specialist medical attention and could be managed by the local health staff.