14 resultados para Downstream

em Brock University, Canada


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The newt, Notopthalmus viridescens is one of the few tet rapod vertebrates capable of extensive regeneration of the central nervous system, however, the factors involved in this process are still unknown. Chemokine signalling through the receptor CXCR4, has been found to be involved in the development of the central nervous system of mammals and more recently in epimorphic fin regeneration in zebrafish. We have hypothesized that the CXCR4 signalling pathway is involved in spinal cord and tail regeneration in the adul t newt , possibly as a downstream target of retinoic acid signalling. We found that CXCR4 mRNA expression was observed in the brain, spinal cord, heart, gut, liver and regenerating tail blastemas. CXCR4 expression increased over the f i rst 12 days of tail regeneration and returned to basal expression levels at day 21 of regeneration. Inhibition of CXCR4 wi th AMD3100, a specific receptor antagonist, led to a decrease in CXCR4 mRNA in the regenerating tail 14 days post amputation. Histological analysis suggests a delay in the early stages of tail and spinal cord regeneration. Spinal cord explants t reated wi th CXCL12, the ligand to CXCR4, displayed enhanced neurite outgrowth in vitro. Explants t reated wi th AMD3100 abolished any retinoic acid enhanced neurite outgrowth effects suggesting a link between these signalling pathways.

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This investigation of geochemistry and mineralogy of heavy metals in fine grained (<63^m) sediment of the Welland River was imdertaken to: 1) describe metal dispersion patterns relative to a source, identify minerals forming and existing at the outfall region and relate sediment particle size to chemistry; 2) to delineate sample handling, preparation and evaluate, modify and develop analytical methods for heavy metal analysis of complex environmental samples. Ajoint project between Brock University and Geoscience Laboratories was initiated to test a contaminated site of the Welland River at the base of Atlas Speciality Steels Co. Methods were developed and utilized for particle size separation and two acid extraction techniques: 1) Partial extraction; 2) Total extraction. The mineralogical assessment identified calcite, dolomite, quartz and clays. These minerals are typical of the carbonate-shale rock basement of the Niagara Peninsula. Minerals such as, mullite and ferrocolumbite were found at the outfall region. These are not typical of the local geology and are generally associated with industrial pollutants. Partial and total extraction techniques were used to characterize the sediments based on chemical distribution, elemental behaviour and analytical differences. The majority of elements were lower in concentration in the partial extraction technique; suggesting these elements are bound in an acid extractable phase (exchangeable, organic and carbonate phases). The total extraction technique yielded higher elemental concentrations taking difficult oxides and silicates into solution. Geochemical analyses of grain size separates revealed that heavy metal (Co, Ni, V, Mn, Fe, Ba) concentrations did not increase with decreasing grain size. This is a function of the anthropogenic mill scale input into the river. The background elements (Sc, Y, Sr, Mg, Al and Ti) showed an increase in concentration to the finest grain size suggesting that it is directly related to the local mineralogy and geology. Dispersion patterns ofmetals fall into two distinct categories: 1) the heavy metals (Co, Cu, Ni, Zn, V and Cr), and 2) the background elements (Be, Sc, Y, Sr, Al and Ti). The heavy metals show a marked increase in the outfall region, while the background elements show a significant decrease at the outfall. This pattern is attributed to a "dilution effect" ofthe natural sediments by the anthropogenic mill scale sediments. Multivariant statistical analysis and correlation coefficient matrix results clearly support these results and conclusions. These results indicate the outfall region ofthe Welland River is highly contaminated with to heavy metals from the industrialized area of Welland. A short distance downstream, the metal concentrations return to baseline geochemical levels. It appears, contaminants rapidly come out of suspension and are deposited in close proximity to the source. Therefore, it is likely that dredging the sediment from the river may cause resuspension of contaminated sediments, but may not distribute the sediment as far as initially anticipated.

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The rate of decrease in mean sediment size and weight per square metre along a 54 km reach of the Credit River was found to depend on variations in the channel geometry. The distribution of a specific sediment size consist of: (1) a transport zone; (2) an accumulation zone; and (3) a depletion zone. These zones shift downstream in response to downcurrent decreases in stream competence. Along a .285 km man-made pond, within the Credit River study area, the sediment is also characterized by downstream shifting accumulation zones for each finer clast size. The discharge required to initiate movement of 8 cm and 6 cm blocks in Cazenovia Creek is closely approximated by Baker and Ritter's equation. Incipient motion of blocks in Twenty Mile Creek is best predicted by Yalin's relation which is more efficient in deeper flows. The transport distance of blocks in both streams depends on channel roughness and geometry. Natural abrasion and distribution of clasts may depend on the size of the surrounding sediment and variations in flow competence. The cumulative percent weight loss with distance of laboratory abraded dolostone is defined by a power function. The decrease in weight of dolostone follows a negative exponential. In the abrasion mill, chipping causes the high initial weight loss of dolostone; crushing and grinding produce most of the subsequent weight loss. Clast size was found to have little effect on the abrasion of dolostone within the diameter range considered. Increasing the speed of the mill increased the initial amount of weight loss but decreased the rate of abrasion. The abrasion mill was found to produce more weight loss than stream action. The maximum percent weight loss determined from laboratory and field abrasion data is approximately 40 percent of the weight loss observed along the Credit River. Selective sorting of sediment explains the remaining percentage, not accounted for by abrasion.

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The water quality and fish populations of the Welland River were observed to decline with distance downstream. This coincided with increased agricultural , domestic and industrial waste loadings. The river upstream of the City of Welland received considerable loadings from agricultural sources. Centrarchids, sciaenids, ictalurids, cyprinids and esocids characterized this upper section of the river. Most of these species were tolerant of low dissolved oxygen concentrations and the high turbidity which prevailed there . The river near Port Robinson receives many industrial and domestic wastes as evidenced by the water quality data. The fish in this section were less abundant and the observed population was comprised almost solely of cyprinids. Further downstream, near Montrose, the Welland River received shock loads of chemical wastes that exceeded a specific conductance of ISiOOO ;umhos/cm. Few fish were captured at this site and those that were captured were considered to be transients. A review of the literature revealed that none of the common indices of water quality in use today could adequately predict the observed distributions. In addition to the above, the long-term trend (l3 yrs) of water quality of the lower Welland River revealed a gradual improvement. The major factor thought to be responsible for this improvement was the operation of the Welland Sewage Treatment Plant. The construction of the New Welland Ship Canal coincided with large fluctuations of the total solids and other parameters downstream. These conditions prevailed for a maximum of three years (1972- 1975)' Furthermore, spawning times and temperatures, geographic distributions, length-weight regressions and many other descriptive aspects of the ecology of some 26 species/ taxa of fish were obtained. Several of these species are rare or new to southern Ontario.

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A regional geochemical reconnaissance by bottom stream sediment sampling, has delineated an area of high metal content in the north central sector of the North Creek Watershed. Development of a geochemical model, relating to the relative chemical concentrations derived from the chemical analyses of bottom sediments, suspended sediments, stream waters and well waters collected from the north central sector, was designed to discover the source of the anomaly. Samples of each type of material were analysed by the A.R.L. Direct Reading Multi-element Emission Spectrograph Q.A. 137 for elements: Na, K, Ca, Sr, Si, As, Pb, Zn, Cd, Ni, Ti, Ag, Mo, Be, Fe, AI, Mn, Cu, Cr, P and Y. Anomalous results led to the discovery of a spring, the waters of which carried high concentrations of Zn, Cd, Pb, As, Ni, Ti, Ag, Sr and Si. In addition, the spring waters had high concentrations of Na, Ca, Mg, 504 , alkalinity, N03' and low concentrations of K, Cl and NH3. Increased specific conductivity (up to 2500 ~mho/cm.) was noted in the spring waters as well as increased calculated total dissolved solids (up to 2047 mg/l) and increased ionic strength (up to 0.06). On the other hand, decreases were noted in water temperature (8°C), pH (pH 7.2) and Eh (+.154 volts). Piezometer nests were installed in the anomalous north central sector of the watershed. In accordance with the slope of the piezometric surface from wells cased down to the till/bedrock interface, groundwater flow is directed from the recharge area (northwest of the anomaly) towards the artesian spring via the highly fractured dolostone aquifer of the Upper Eramosa Member. The bedrock aquifer is confined by the overlying Halton till and the underlying Lower Eramosa Member (Vinemount Shale). The oxidation of sphalerite and galena and the dissolution of gypsum, celestite, calcite, and dolomite within the Eramosa Member, contributed its highly, dissolved constituents to the circulating groundwaters, the age of which is greater than 20 years as determined by tritium dating. Groundwater is assumed to flow along the Vinemount Shale and discharge as an artesian spring where the shale unit becomes discontinuous. The anomaly is located on a topographic low where bedrock is close to the surface. Thermodynamic evaluation of the major ion speciation from the anomalous spring and surface waters, showed gypsum to be supersaturated in these spring waters. Downstream from the spring, the loss of carbon dioxide from the spring waters resulted in the supersaturation with respect to calcite, aragonite, magnesite and dolomite. This corresponded with increases in Eh (+.304 volts) and pH (pH 8.5) in the anomalous surface waters. In conclusion, the interaction of groundwaters within the highly, mineralized carbonate source (Eramosa Member) resulted in the characteristic Ca*Mg*HC03*S04 spring water at the anomalous site, which appeared to be the principle effect upon controlling the anomalous surface water chemistry.

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Background: Ang II plays a major role in cardiovascular regulation. Recently, it has become apparent that vascular superoxide anion may play an important role in hypertension development. Treatment with antisense NAD(P)H oxidase or SOD decreased BP in Ang II-infused rats. Wang et al recently reported mice which lack one of the subunits of NAD(P)H oxidase developed hypertension at a much lower extent when compared to the wild type animals infused with Ang II, indicating that superoxide anion contributes to elevation in BP in the Ang II-infused hypertensive model. In the Ang II-infused hypertensive model, altered reactivity of blood vessels is often associated with the elevation of systolic blood pressure. We have observed abnormal tension development and impaired endothelium-dependent relaxation in the isolated aorta of Ang II-infused and DOCA-salt hypertensive rats. Recently, several other cellular signal molecules, including ERK1I2 and PI3K, have been determined to play important roles in the regulation of smooth muscle contraction and relaxation. ERKl/2 and PI3K pathways are also reported to contribute to Ang II induced cell growth, hypertrophy, remodeling and contraction. Moreover, these signaling pathways have shown ROS-sensitive properties. Therefore, the aim of the present study is to investigate the roles of ERKl12 and PI3K in vascular oxidative stress, spontaneous tone and impaired endothelium relaxation in Ang II-infused hypertensive model. Hypothesis: We hypothesize that the activation of ERKl12 and PI3K are elevated in response to an Ang II infusion for 6 days. The elevated activation of phospho-ERKl/2 and PI3K mediated the increased level of vascular superoxide anion, the abnormal vascular contraction and impaired endothelium-dependent vascular relaxation in Ang II-infused hypertensive rats. Methods: Vascular superoxide anion level is measured by lucigenin chemiluminescence. Spontaneous tone and ACh-induced endothelium-dependent relaxation was measured by isometric tension recording in organ chamber. The activity of ERK pathway will be measured by its Western blot of phosphorylation of ERK. PI3K activity was evaluated indirectly by Western blot of the phosphorylation of PDKl, a downstream protein of PI3K signaling pathway. The role of each pathway was also addressed via comparing the responses to the specific inhibitors. Results: Superoxide anion was markedly increased in the isolated thoracic aorta from Ang II-infused rats. There was spontaneous tone developed in rings from Ang II-induced hypertensive but not sham-operated normotensive rats. ACh-induced endothelium-dependent relaxation function is impaired in Ang II-infused hypertensive rats. Superoxide dismutase and NAD(P)H oxidase inhibitor, apocynin, inhibited the abnormal spontaneous tone and ameliorated impaired endothelium-dependent relaxation. The expression of phopho-ERKII2 was enhanced in Ang II-infused rats, indicating the activity of ERK1I2 could be increased. MEK1I2 inhibitors, PD98059 and U126, but not their inactive analogues, SB203580 and U124, significantly reduced the vascular superoxide anion in aortas from Ang II-infused rats. The MEK1I2 inhibitors reduced the spontaneous tone and improved the impaired endothelium-dependent relaxation in aorta of hypertension. These findings supported the role of ERKII2 signaling pathway in vascular oxidative stress, spontaneous tone and impaired endothelium-dependent relaxation in Ang II-infused hypertensive rats. The amount of phospho-PDK, a downstream protein of PI3K was increased in Ang II rats indicating the activity of PI3K activity was elevated. Strikingly, PI3K significantly inhibited the increase of superoxide anion level, abnormal spontaneous tone and restored endothelium-dependent relaxation in Ang II-infused hypertensive rats. These findings indicated the important role of PI3K in Ang II-infused hypertensive rats. Conclusion: ERKII2 and PI3K signaling pathways are sustained activated in Ang II-infused hypertensive rats. The activated ERKII2 and PI3K mediate the increase of vascular superoxide anion level, vascular abnormal spontaneous tone and impaired endothelium-dependent relaxation.

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In light of the fact that literature on toxicity of heavy metals in non-acidified freshwater systems is sparse, this project was initiated to conduct an environmental assessment of Lake Gibson. Chemistry of soils from adjacent areas and vineyards in the region provide a comparative background database. Water quality determinations were used to identify and highlight areas of environmental concern within the Lake Gibson watershed. A Shelby Corer was used to obtain 66 sediment cores from Lake Gibson. These were sectioned according to lithology and color to yield 298 samples. A suite of 122 soil samples was collected in the region and vicinity of Lake Gibson. All were tested for metals and some for Total Petroleum Hydrocarbons (TPH). Evaluation of the results leads to the following conclusions: 1. Metal concentrations ofAI, Cd, Cu, Cr, Pb, Ni, Fe and Zn in soils from the Niagara Region are well below background limits set by the Ministry of the Environment and Energy (MOEE) for provincial soils. 2. There is a spatial and depth difference for some of the metals within the various soils. The Cr, Ni and Pb contents of soils vary throughout the region (pdownstream from the Old WeIland Canal divergence point and waterfall. Other areas of concern are located just south of Beaverdams Road and just west ofthe Ontario Hydro control pipes; south ofthe Village ofBeaverdams. The fourth area of environmental concern and TPH impact is located between Highway 406 and Merrittville Highway.

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Sediment samples were taken from seven locations in the WeIland River in December 1986 and April 1987. The DMSO extracts of these sediment samples showed a significant (pdownstream portion of the river bounded by an industrialized area were slightly toxic according to -the alkaline phosphatase inhib_ii~ion component of the 50S chromotest analyses. The toxicity of these samples was only evident once they had been activated by the 59 (liver extract) mixture.

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The effec s of relative water level changes in Lake Ontario were detected in the ysical, chemical and biological characteristics of the sediments of the Fifteen, Sixteen and Twenty Mile Creek lagoonal complexes. Regional environmental changes have occurred resulting in the following sequence of sediments in the three lagoons and marsh. From the base up they are; (I) Till,(2) Pink Clay, (3) Bottom Sand, (4) Gyttja, (5) Orange Sandy Silt, (6) Brown Clay and (7) Gray Clay. The till was only encountered in the marsh and channel; however, it is presumed to occur throughout the entire area. The presence of diatoms and sponge spicules, the vertical and ongitudinal uniformity of the sediment and the stratigr ic position of the Pink Clay indicate that it has a glacial or post-glacial lacustrine origin. Overl ng the Pink Clay or Till is a clayey, silty sand to gravel. The downstream fining and unsorted nature of this material indicate that it has a fluvial/deltaic origin. Water levels began rising in the lagoon 3,250 years ago resulting in the deposition of the Gyttja, a brown, organic-rich silty clay probably deposited in a shallow, stagnant environment as shown by the presence of pyrite in the organic material and relatively high proportions of benthic diatoms and grass pollen. Increase in the rate of deposition of the Gyttja on Twenty Mile Creek and a decrease in the same unit on Sixteen Mile Creek is possibly the result of a capture of the Sixteen Mile Creek by the Twenty Mile Creek. The rise in lake level responsible for the onset and transgression of this III unit may have been produced by isostatic rebound; however, the deposition also corresponds closely to a drop in the level of Lake Huron and increased flow through the lower lakes. The o ange Sandy Silt, present only in the marsh, appears to be a buried soil horizon as shown by oxidized roots, and may be the upland equivalant to the Gyttja. Additional deepening resulted in the deposition of Brown Clay, a unit which only occurs at the lakeward end of the three lagoons. The decrease in grass pollen and the relatively high proportion of pelagic diatoms are evidence for this. The deepening may be the result of isostatic rebound; however, the onset of its deposition at 1640 years B.P. is synchronous in the three lagoons and corresponds to the end of the subAtlantic climatic episode. The effects of the climatic change in southern Ontario is uncertain. Average deposition rates of the Brown Clay are similar to those in the upper Gyttja on Sixteen Mile Creek; however, Twenty Mile Creek shows lower rates of the Brown Clay than those in the upper Gyttja. The Gray Clay covers the present bottom of the three lagoons and also occurs in the marsh It is inter1aminated wi sand in the channels. Increases in the rates of deposi ion, high concentrations of Ca and Zn, an Ambrosia rise, and an increase in bioturbation possibly due to the activities of the carp, indicate th this unit is a recent deposit resulting from the activities of man.

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The streams flowing through the Niagara Escarpment are paved by coarse carbonate and sandstone sediments which have originated from the escarpment units and can be traced downstream from their source. Fifty-nine sediment samples were taken from five streams, over distances of 3,000 to 10,000 feet (915 to 3050 m), to determine downstream changes in sediment composition, textural characteristics and sorting. In addition, fluorometric velocity measurements were used in conjunction with measured -discharge and flow records to estimate the frequency of sediment movement. The frequency of sediments of a given lithology changes downstream in direct response to the outcrop position of the formations in the channels. Clasts derived from a single stratigraphic unit usually reach a maximum frequency within the first 1,000 feet (305 m) of transport. Sediments derived from formations at the top of waterfalls reach a modal frequency farther downstream than material originating at the base of waterfalls. Downstream variations in sediment size over the lengths of the study reaches reflect the changes in channel morphology and lithologic composition of the sediment samples. Linear regression analyses indicate that there is a decrease in the axial lengths between the intial and final samples and that the long axis decreases in length more rapidly than the intermediate, while the short axis remains almost constant. Carbonate sediments from coarse-grained, fossiliferous units - iii - are more variable in size than fine-grained dolostones and sandstones. The average sphericity for carbonates and sandstones increases from 0.65 to 0.67, while maximum projection sphericity remains nearly constant with an average value of 0.52. Pebble roundness increases more rapidly than either of the sphericity parameters and the sediments change from subrounded to rounded. The Hjulstrom diagram indicates that the velocities required to initiate transport of sediments with an average intermediate diameter of 10 cm range from 200 cm/s to 300 cm/s (6.6 ft./sec. to 9.8 ft./sec.). From the modal velocitydischarge relations, the flows corresponding to these velocities are greater than 3,500 cfs (99 m3s). These discharges occur less than 0.01 p~r cent (0.4 days) of the time and correspond to a discharge occurring during the spring flood.

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Alexander McLeod was Deputy Sheriff of the Niagara District during the Rebellion of 1837-38 in Upper Canada. On December 24, 1837, he became aware of a scheme by the rebels to use the American steamboat Caroline to provide supplies to William Lyon Mackenzie and his followers on Navy Island in the Niagara River. McLeod notified the authorities in Upper Canada about the situation. A few days later, on December 29, Commodore Andrew Drew led a band of men, including McLeod, to the American side, where the Caroline was moored at Schlosser’s Wharf. A scuffle ensued, in which American Amos Durfee was killed. The Caroline was then released from its moorings, set on fire, and drifted downstream before sinking. Many Americans viewed the incident as a violation of their sovereignty. Tensions between the United States and England were already strained over a boundary dispute between Maine and New Brunswick, and the situation with the Caroline further escalated the tension. McLeod was subsequently arrested in November, 1840 in Lewiston, NY and indicted for arson and murder. The British foreign secretary, Lord Palmerston, insisted that McLeod be released and could not be held personally responsible for the incident, as he was acting on orders from authorities in Canada. Eventually, McLeod was acquitted.

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The Madagascar periwinkle [Catharanthus roseus (L.) G. Don] is a commercially important horticultural flower species and is the only source for several pharmaceutically valuable monoterpenoid indole alkaloids (MIAs), including the powerful antihypertensive ajmalicine and the antineoplastic agents vincristine and vinblastine. While biosynthesis of MIA precursors has been elucidated, conversion of the common MIA precursor strictosidine to MIAs of different families, for example ajmalicine, catharanthine or vindoline, remains uncharacterized. Deglycosylation of strictosidine by the key enzyme Strictosidine beta-glucosidase (SGD) leads to a pool of uncharacterized reaction products that are diverted into the different MIA families, but the downstream reactions are uncharacterized. Screening of 3600 EMS (ethyl methane sulfonate) mutagenized C. roseus plants to identify mutants with altered MIA profiles yielded one plant with high ajmalicine, and low catharanthine and vindoline content. RNA sequencing and comparative bioinformatics of mutant and wildtype plants showed up-regulation of SGD and the transcriptional repressor Zinc finger Catharanthus transcription factor (ZCT1) in the mutant line. The increased SGD activity in mutants seems to yield a larger pool of uncharacterized SGD reaction products that are channeled away from catharanthine and vindoline towards biosynthesis of ajmalicine when compared to the wildtype. Further bioinformatic analyses, and crossings between mutant and wildtype suggest a transcription factor upstream of SGD and ZCT1 to be mutated, leading to up-regulation of Sgd and Zct1. The crossing experiments further show that biosynthesis of the different MIA families is differentially regulated and highly complex. Three new transcription factors were identified by bioinformatics that seem to be involved in the regulation of Zct1 and Sgd expression, leading to the high ajmalicine phenotype. Increased cathenamine reductase activity in the mutant converts the pool of SGD reaction products into ajmalicine and its stereoisomer tetrahydroalstonine. The stereochemistry of ajmalicine and tetrahydroalstonine biosynthesis in vivo and in vitro was further characterized. In addition, a new clade of perakine reductase-like enzymes was identified that reduces the SGD reaction product vallesiachotamine in a stereo-specific manner, characterizing one of the many reactions immediately downstream of SGD that determine the different MIA families. This study establishes that RNA sequencing and comparative bioinformatics, in combination with molecular and biochemical characterization, are valuable tools to determine the genetic basis for mutations that trigger phenotypes, and this approach can also be used for identification of new enzymes and transcription factors.

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Systemic Acquired Resistance (SAR) is a type of plant systemic resistance occurring against a broad spectrum of pathogens. It can be activated in response to pathogen infection in the model plant Arabidopsis thaliana and many agriculturally important crops. Upon SAR activation, the infected plant undergoes transcriptional reprogramming, marked by the induction of a battery of defense genes, including Pathogenesis-related (PR) genes. Activation of the PR-1 gene serves as a molecular marker for the deployment of SAR. The accumulation of a defense hormone, salicylic acid (SA) is crucial for the infected plant to mount SAR. Increased cellular levels of SA lead to the downstream activation of the PR-1 gene, triggered by the combined action of the Non-expressor of Pathogenesis-related Gene 1 (NPR1) protein and the TGA II-clade transcription factor (namely TGA2). Despite the importance of SA, its receptor has remained elusive for decades. In this study, we demonstrated that in Arabidopsis the NPR1 protein is a receptor for SA. SA physically binds to the C-terminal transactivation domain of NPR1. The two cysteines (Cys521 and Cys529), which are important for NPR1’s coactivator function, within this transactivation domain are critical for the binding of SA to NPR1. The interaction between SA and NPR1 requires a transition metal, copper, as a cofactor. Our results also suggested a conformational change in NPR1 upon SA binding, releasing the C-terminal transactivation domain from the N-terminal autoinhibitory BTB/POZ domain. These results advance our understanding of the plant immune function, specifically related to the molecular mechanisms underlying SAR. The discovery of NPR1 as a SA receptor enables future chemical screening for small molecules that activate plant immune responses through their interaction with NPR1 or NPR1-like proteins in commercially important plants. This will help in identifying the next generation of non-biocidal pesticides.

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Objective: To determine which socio-demographic, exposure, morbidity and symptom variables are associated with health-related quality of life among former and current heavy smokers. Methods: Cross sectional data from 2537 participants were studied. All participants were at ≥2% risk of developing lung cancer within 6 years. Linear and logistic regression models utilizing a multivariable fractional polynomial selection process identified variables associated with health-related quality of life, measured by the EQ-5D. Results: Upstream and downstream associations between smoking cessation and higher health-related quality of life were evident. Significant upstream associations, such as education level and current working status and were explained by the addition of morbidities and symptoms to regression models. Having arthritis, decreased forced expiratory volume in one second, fatigue, poor appetite or dyspnea were most highly and commonly associated with decreased HRQoL. Discussion: Upstream factors such as educational attainment, employment status and smoking cessation should be targeted to prevent decreased health-related quality of life. Practitioners should focus treatment on downstream factors, especially symptoms, to improve health-related quality of life.