Seasonal variations of ventricular arrhythmia clusters in defibrillator recipients

BACKGROUND: Clustering ventricular arrhythmias are the consequence of acute ventricular electrical instability and represent a challenge in the management of the growing number of patients with an implantable cardioverter-defibrillator (ICD). Triggering factors can rarely be identified. OBJECTIVES: Several studies have revealed seasonal variations in the frequency of cardiovascular events and life-threatening arrhythmias, and we sought to establish whether seasonal factors may exacerbate ventricular electrical instability leading to arrhythmia clusters and electrical storm. METHODS: Two hundred and fourteen consecutive defibrillator recipients were followed-up during 3.3 +/- 2.2 years. Arrhythmia cluster was defined as the occurrence of three or more arrhythmic events triggering appropriate defibrillator therapies within 2 weeks. Time intervals between two clusters were calculated for each month and each season, and were compared using Kruskal-Wallis test and Wilcoxon-Mann-Whitney test with Bonferroni adjustment. RESULTS: During a follow-up of 698 patient years, 98 arrhythmia clusters were observed in 51 patients; clustering ventricular arrhythmias were associated with temporal variables; they occurred more frequently in the winter and spring months than during the summer and fall. Accordingly, the time intervals between two clusters were significantly shorter during winter and spring (median and 95% CI): winter 16 (5-19), spring 11.5 (7-25), summer 34.5 (15-55), fall 50.5 (19-65), P = 0.0041. CONCLUSION: There are important seasonal variations in the incidence of arrhythmia clusters in ICD recipients. Whether these variations are related to environmental factors, change in physical activity, or psychological factors requires further study.

Use of hydroclimatic forecasts for improved water management in central Texas

Accurate seasonal to interannual streamflow forecasts based on climate information are critical for optimal management and operation of water resources systems. Considering most water supply systems are multipurpose, operating these systems to meet increasing demand under the growing stresses of climate variability and climate change, population and economic growth, and environmental concerns could be very challenging. This study was to investigate improvement in water resources systems management through the use of seasonal climate forecasts. Hydrological persistence (streamflow and precipitation) and large-scale recurrent oceanic-atmospheric patterns such as the El Niño/Southern Oscillation (ENSO), Pacific Decadal Oscillation (PDO), North Atlantic Oscillation (NAO), the Atlantic Multidecadal Oscillation (AMO), the Pacific North American (PNA), and customized sea surface temperature (SST) indices were investigated for their potential to improve streamflow forecast accuracy and increase forecast lead-time in a river basin in central Texas. First, an ordinal polytomous logistic regression approach is proposed as a means of incorporating multiple predictor variables into a probabilistic forecast model. Forecast performance is assessed through a cross-validation procedure, using distributions-oriented metrics, and implications for decision making are discussed. Results indicate that, of the predictors evaluated, only hydrologic persistence and Pacific Ocean sea surface temperature patterns associated with ENSO and PDO provide forecasts which are statistically better than climatology. Secondly, a class of data mining techniques, known as tree-structured models, is investigated to address the nonlinear dynamics of climate teleconnections and screen promising probabilistic streamflow forecast models for river-reservoir systems. Results show that the tree-structured models can effectively capture the nonlinear features hidden in the data. Skill scores of probabilistic forecasts generated by both classification trees and logistic regression trees indicate that seasonal inflows throughout the system can be predicted with sufficient accuracy to improve water management, especially in the winter and spring seasons in central Texas. Lastly, a simplified two-stage stochastic economic-optimization model was proposed to investigate improvement in water use efficiency and the potential value of using seasonal forecasts, under the assumption of optimal decision making under uncertainty. Model results demonstrate that incorporating the probabilistic inflow forecasts into the optimization model can provide a significant improvement in seasonal water contract benefits over climatology, with lower average deficits (increased reliability) for a given average contract amount, or improved mean contract benefits for a given level of reliability compared to climatology. The results also illustrate the trade-off between the expected contract amount and reliability, i.e., larger contracts can be signed at greater risk.

Effects of Pasture Conditions in Spring on Seasonal Forage Productivity

Fifteen beef cow-calf producers in southern Iowa were selected based on locality, management level, historical date of grazing initiation and desire to participate in the project. In 1997 and 1998, all producers kept records of production and economic data using the Integrated Resource Management-Standardized Performance Analysis (IRM-SPA) records program. At the initiation of grazing on each farm in 1997 and 1998, Julian date, degree-days, cumulative precipitation, and soil moisture, phosphorus, and potassium concentrations were determined. Also determined were pH, temperature, and load-bearing capacity; and forage mass, sward height, morphology and dry matter concentration. Over the grazing season, forage production, measured both by cumulative mass and sward height, forage in vitro digestible dry matter concentration, and crude protein concentration were determined monthly. In the fall of 1996 the primary species in pastures on farms used in this project were cool-season grasses, which composed 76% of the live forage whereas legumes and weeds composed 8.3 and 15.3%, respectively. The average number of paddocks was 4.1, reflecting a low intensity rotational stocking system on most farms. The average dates of grazing initiation were May 5 and April 29 in 1997 and 1998, respectively, with standard deviations of 14.8 and 14.1 days. Because the average soil moisture of 23% was dry and did not differ between years, it seems that most producers delayed the initiation of grazing to avoid muddy conditions by initiating grazing at a nearly equal soil moisture. However, Julian date, degree-days, soil temperature and morphology index at grazing initiation were negatively related to seasonal forage production, measured as mass or sward height, in 1998. And forage mass and height at grazing initiation were negatively related to seasonal forage production, measured as sward height, in 1997. Moreover, the concentrations of digestible dry matter at the initiation of and during the grazing season and the concentrations of crude protein during the grazing season were lower than desired for optimal animal performance. Because the mean seasonal digestible dry matter concentration was negatively related to initial forage mass in 1997 and mean seasonal crude proteins concentrations were negatively related to the Julian date, degree-days, and morphology indeces in both years, it seems that delaying the initiation of grazing until pasture soils are not muddy, is limiting the quality as well as the quantity of pasture forage. In 1997, forage production and digestibility were positively related to the soil phosphorus concentration. Soil potassium concentration was positively related to forage digestibility in 1997 and forage production and crude protein concentration in 1998. Increasing the number of paddocks increased forage production, measured as sward height, in 1997, and forage digestible dry matter concentration in 1998. Increasing yields or the concentrations of digestible dry matter or crude protein of pasture forage reduced the costs of purchased feed per cow.

Seasonal Distribution and Movements of Shortnose Sturgeon and Atlantic Sturgeon in the Penobscot River Estuary, Maine

Relatively little is known about the distribution and seasonal movement patterns of shortnose sturgeon Acipenser brevirostrum and Atlantic sturgeon Acipenser oxyrinchus oxyrinchus occupying rivers in the northern part of their range. During 2006 and 2007, 40 shortnose sturgeon (66-113.4 cm fork length [FL]) and 8 Atlantic sturgeon (76.2-166.2 cm FL) were captured in the Penobscot River, Maine, implanted with acoustic transmitters, and monitored using an array of acoustic receivers in the Penobscot River estuary and Penobscot Bay. Shortnose sturgeon were present year round in the estuary and overwintered from fall (mid-October) to spring (mid-April) in the upper estuary. In early spring, all individuals moved downstream to the middle estuary. Over the course of the summer, many individuals moved upstream to approximately 2 km of the downstream-most dam (46 river kilometers [rkm] from the Penobscot River mouth [rkm 0]) by August. Most aggregated into an overwintering site (rkm 36.5) in mid-to late fall. As many as 50% of the tagged shortnose sturgeon moved into and out of the Penobscot River system during 2007, and 83% were subsequently detected by an acoustic array in the Kennebec River, located 150 km from the Penobscot River estuary. Atlantic sturgeon moved into the estuary from the ocean in the summer and concentrated into a 1.5-km reach. All Atlantic sturgeon moved to the ocean by fall, and two of these were detected in the Kennebec River. Although these behaviors are common for Atlantic sturgeon, regular coastal migrations of shortnose sturgeon have not been documented previously in this region. These results have important implications for future dam removals as well as for rangewide and river-specific shortnose sturgeon management.

Future pandemic influenza control (FPIC) related strategic management plan based on the 2009 H1N1 pandemic influenza review of health policy decisions, their practice and implications

This cross-sectional study is based on the qualitative and quantitative research design to review health policy decisions, their practice and implications during 2009 H1N1 influenza pandemic in the United States and globally. The “Future Pandemic Influenza Control (FPIC) related Strategic Management Plan” was developed based on the incorporation of the “National Strategy for Pandemic Influenza (2005)” for the United States from the U.S. Homeland Security Council and “The Canadian Pandemic Influenza Plan for the Health Sector (2006)” from the Canadian Pandemic Influenza Committee for use by the public health agencies in the United States as well as globally. The “global influenza experts’ survey” was primarily designed and administered via email through the “Survey Monkey” system to the 2009 H1N1 influenza pandemic experts as the study respondents. The effectiveness of this plan was confirmed and the approach of the study questionnaire was validated to be convenient and the excellent quality of the questions provided an efficient opportunity to the study respondents to evaluate the effectiveness of predefined strategies/interventions for future pandemic influenza control.^ The quantitative analysis of the responses to the Likert-scale based questions in the survey about predefined strategies/interventions, addressing five strategic issues to control future pandemic influenza. The effectiveness of strategies defined as pertinent interventions in this plan was evaluated by targeting five strategic issues regarding pandemic influenza control. For the first strategic issue pertaining influenza prevention and pre pandemic planning; the confirmed effectiveness (agreement) for strategy (1a) 87.5%, strategy (1b) 91.7% and strategy (1c) 83.3%. The assessment of the priority level for strategies to address the strategic issue no. (1); (1b (High Priority) > 1a (Medium Priority) > 1c (Low Priority) based on the available resources of the developing and developed countries. For the second Strategic Issue encompassing the preparedness and communication regarding pandemic influenza control; the confirmed effectiveness (agreement) for the strategy (2a) 95.6%, strategy (2b) 82.6%, strategy (2c) 91.3% and Strategy (2d) 87.0%. The assessment of the priority level for these strategies to address the strategic issue no. (2); (2a (highest priority) > 2c (high priority) >2d (medium priority) > 2b (low priority). For the third strategic issue encompassing the surveillance and detection of pandemic influenza; the confirmed effectiveness (agreement) for the strategy (3a) 90.9% and strategy (3b) 77.3%. The assessment of the priority level for theses strategies to address the strategic Issue No. (3) (3a (high priority) > 3b (medium/low priority). For the fourth strategic issue pertaining the response and containment of pandemic influenza; the confirmed effectiveness (agreement) for the strategy (4a) 63.6%, strategy (4b) 81.8%, strategy (4c) 86.3%, and strategy (4d) 86.4%. The assessment of the priority level for these strategies to address the strategic issue no. (4); (4d (highest priority) > 4c (high priority) > 4b (medium priority) > 4a (low priority). The fifth strategic issue about recovery from influenza and post pandemic planning; the confirmed effectiveness (agreement) for the strategy (5a) 68.2%, strategy (5b) 36.3% and strategy (5c) 40.9%. The assessment of the priority level for strategies to address the strategic issue no. (5); (5a (high priority) > 5c (medium priority) > 5b (low priority).^ The qualitative analysis of responses to the open-ended questions in the study questionnaire was performed by means of thematic content analysis. The following recurrent or common “themes” were determined for the future implementation of various predefined strategies to address five strategic issues from the “FPIC related Strategic Management Plan” to control future influenza pandemics. (1) Pre Pandemic Influenza Prevention, (2) Seasonal Influenza Control, (3) Cost Effectiveness of Non Pharmaceutical Interventions (NPI), (4) Raising Global Public Awareness, (5) Global Influenza Vaccination Campaigns, (6)Priority for High Risk Population, (7) Prompt Accessibility and Distribution of Influenza Vaccines and Antiviral Drugs, (8) The Vital Role of Private Sector, (9) School Based Influenza Containment, (10) Efficient Global Risk Communication, (11) Global Research Collaboration, (12) The Critical Role of Global Public Health Organizations, (13) Global Syndromic Surveillance and Surge Capacity and (14) Post Pandemic Recovery and Lessons Learned. The future implementation of these strategies with confirmed effectiveness to primarily “reduce the overall response time’ in the process of ‘early detection’, ‘strategies (interventions) formulation’ and their ‘implementation’ to eventually ensure the following health outcomes: (a) reduced influenza transmission, (b) prompt and effective influenza treatment and control, (c) reduced influenza related morbidity and mortality.^

Diurnal and seasonal measurements of seawater chemistry, temperature and PAR in Hurricane Hole, U.S. Virgin Islands - 2010-2012

Risk analyses indicate that more than 90% of the world's reefs will be threatened by climate change and local anthropogenic impacts by the year 2030 under "business-as-usual" climate scenarios. Increasing temperatures and solar radiation cause coral bleaching that has resulted in extensive coral mortality. Increasing carbon dioxide reduces seawater pH, slows coral growth, and may cause loss of reef structure. Management strategies include establishment of marine protected areas with environmental conditions that promote reef resiliency. However, few resilient reefs have been identified, and resiliency factors are poorly defined. Here we characterize the first natural, non-reef coral refuge from thermal stress and ocean acidification and identify resiliency factors for mangrove-coral habitats. We measured diurnal and seasonal variations in temperature, salinity, photosynthetically active radiation (PAR), and seawater chemistry; characterized substrate parameters; and examined water circulation patterns in mangrove communities where scleractinian corals are growing attached to and under mangrove prop roots in Hurricane Hole, St. John, US Virgin Islands. Additionally, we inventoried the coral species and quantified incidences of coral bleaching, mortality, and recovery for two major reef-building corals, Colpophyllia natans and Diploria labyrinthiformis, growing in mangrove-shaded and exposed (unshaded) areas. Over 30 species of scleractinian corals were growing in association with mangroves. Corals were thriving in low-light (more than 70% attenuation of incident PAR) from mangrove shading and at higher temperatures than nearby reef tract corals. A higher percentage of C. natans colonies were living shaded by mangroves, and no shaded colonies were bleached. Fewer D. labyrinthiformis colonies were shaded by mangroves, however more unshaded colonies were bleached. A combination of substrate and habitat heterogeneity, proximity of different habitat types, hydrographic conditions, and biological influences on seawater chemistry generate chemical conditions that buffer against ocean acidification. This previously undocumented refuge for corals provides evidence for adaptation of coastal organisms and ecosystem transition due to recent climate change. Identifying and protecting other natural, non-reef coral refuges is critical for sustaining corals and other reef species into the future.

Seasonal evolution of soil respiration in a mixed forestry plantation of walnuts (Juglans × intermedia Carr.) and alders (Alnus cordata (Loisel.) Duby) in Domaine de Restinclières (France)

The ecological intensification of crops is proposed as a solution to the growing demand of agricultural and forest resources, in opposition to intensive monocultures. The introduction of mixed cultures as mixtures between nitrogen fixing species and non nitrogen fixing species intended to increase crop yield as a result of an improvement of the available nitrogen and phosphorus in soil. Relationship between crops have received little attention despite the wide range of advantages that confers species diversity to these systems, such as increased productivity, resilience to disruption and ecological sustainability. Forests and forestry plantations can develop an important role in storing carbon in their tissues, especially in wood which become into durable product. A simplifying parameter to analyze the amount allocated carbon by plantation is the TBCA (total belowground carbon allocation), whereby, for short periods and mature plantations, is admitted as the subtraction between soil carbon efflux and litterfall. Soil respiration depends on a wide range of factors, such as soil temperature and soil water content, soil fertility, presence and type of vegetation, among others. The studied orchard is a mixed forestry plantation of hybrid walnuts(Juglans × intermedia Carr.) for wood and alders (Alnus cordata (Loisel.) Duby.), a nitrogen fixing specie through the actinomycete Frankia alni ((Woronin, 1866) Von Tubeuf 1895). The study area is sited at Restinclières, a green area near Montpellier (South of France). In the present work, soil respiration varied greatly throughout the year, mainly influenced by soil temperature. Soil water content did not significantly influence the response of soil respiration as it was constant during the measurement period and under no water stress conditions. Distance between nearest walnut and measurement was also a highly influential factor in soil respiration. Generally there was a decreasing trend in soil respiration when the distance to the nearest tree increased. It was also analyzed the response of soil respiration according to alder presence and fertilizer management (50 kg N·ha-1·año-1 from 1999 to 2010). None of these treatments significantly influenced soil respiration, although previous studies noticed an inhibition in rates of soil respiration under fertilized conditions and high rates of available nitrogen. However, treatments without fertilization and without alder presence obtained higher respiration rates in those cases with significant differences. The lack of significant differences between treatments may be due to the high coefficient of variation experienced by soil respiration measurements. Finally an asynchronous fluctuation was observed between soil respiration and litterfall during senescence period. This is possibly due to the slowdown in the emission of exudates by roots during senescence period, which are largely related to microbial activity.

Management of Trihalomethanes in Finished Drinking Water Through Source Water Precursor Monitoring

Trihalomethanes are organic compounds formed in drinking water distribution systems as a result of disinfection. This capstone project researched and evaluated the statistical correlation of trihalomethanes in finished drinking water and total organic carbon in source water using data generated by Denver area utilities. Results of the study conclude that some drinking water supply systems show a slight correlation between source water total organic carbon levels and trihalomethane levels in finished water. Results of the study also verify the assertion that changes to treatment for the reduction of trihalomethanes, for the protection of human health under the Safe Drinking Water Act should be determined by each utility, using information from gathered data, seasonal trends, and small scale batch testing.

Ecological gradients and landscape structure affecting seasonal woodpigeon Columba palumbus densities in a coastal region (South-East Spain)

The aim of the present study is to identify and evaluate the relationship between Woodpigeon (Columba palumbus, Linnaeus, 1758) density and different environmental gradients (thermotype, ombrotype, continentality and latitudinal), land use and landscape structure, using geographic information systems and multivariate modelling. Transects (n = 396) were developed to estimate the density of Woodpigeon in the Marina Baja (Alicante, Spain) from 2006 to 2008. The highestdensity for Woodpigeon was in September-October (1.28birds/10ha) and the lowest inFebruary-March (0.34birds/10ha). Moreover, there were more Woodpigeons in areas with a mesomediterranean thermotypethan in thermomediterranean or supramediterranean ones. There was greater densityinthe intermediate zones compared to thecoast and interior. The natural or cultural landscape had the highest Woodpigeon density (1.53birds/10ha), with both denseand clear pine forest values standing out. Therefore, it is very important to conserve these traditional landscapes with adequate management strategies in order to maintain, resident and transient Woodpigeon populations. These natural areas are open places where the Woodpigeons find food and detect the presence ofpredators. Thus, this study will enable more precise knowledge of the ecological factors (habitat variables) that intervene in the distribution of Woodpigeon populations and their density.

The new Columbian White House cookery : containing toilet, medical, and cooking receipts, comprehending economical and practical information pertaining to the successful management of the home /

Includes samples of menus; household hints; some recipes include wine or liquor as an ingredient. Sample recipes: Chicken cream soup, Eels a la tartare, Lemon brandy (for cakes and puddings), Spiced nutmeg melon.

Assessing the seasonal influence of sewage and agricultural nutrient inputs in a subtropical river estuary

A combination of physical and chemical measurements and biological indicators identified nutrient impacts throughout an Australian subtropical river estuary. This was a balance of sewage inputs in the lower river and agricultural inputs in the mid-upper river, the combined influence being greater in the wet season due to greater agricultural surface runoff. Field sampling in the region was conducted at 6 sites within the river, over 5 surveys to encapsulate both wet and dry seasonal effects. Parameters assessed were tissue nitrogen (N) contents and delta(15)N signatures of mangroves and macroalgae, phytoplankton nutrient addition bioassays, and standard physical and chemical variables. Strong spatial (within river) and temporal (seasonal) variability was observed in all parameters. Poorest water quality was detected in the middle (agricultural) region of the river in the wet season, attributable to large diffuse inputs in this region. Water quality towards the river mouth remained constant irrespective of season due to strong oceanic flushing. Mangrove and macroalgal tissue delta(15)N and %N proved a successful combination for discerning sewage and agricultural inputs. Elevated delta(15)N and %N represented sewage inputs, whereas low delta(15)N and elevated %N was indicative of agricultural inputs. Phytoplankton bioassays found the system to be primarily responsive to nutrient additions in the warmer wet season, with negligible responses observed in the cooler dry season. These results indicate that the Tweed River is sensitive to the different anthropogenic activities in its catchment and that each activity has a unique influence on receiving water quality.

Change in woolgrower profits from adopting staple strength-enhancing management strategies

Wool tenderness is a significant problem in Australia, especially in areas where sheep graze under highly seasonal conditions. In this study, a profit function model is specified, estimated and simulated to assess the economic impact of staple strength-enhancing research on the profits of Australian woolgrowers. The model is based on a number of fundamental characteristics of the Australian wool industry and the staple-strength enhancing technology being assessed. The model consists of a system of demand and supply equations that are specified in terms of effective, rather than actual, prices. The interrelationships between the inputs and outputs are allowed for in the model in a manner that is consistent with theoretical restrictions. The adoption of the new feed management strategy results in a 4.4% increase in the expected profits of Australian wool producers in the short-run, and a 2.2% increase in expected profits in the long-run.

National whoppercropper - risk management discussion support software

It is a paradox that in a country with one of the most variable climates in the world, cropping decisions are sometimes made with limited consideration of production and resource management risks. There are significant opportunities for improved performance based on targeted information regarding risks resulting from decision options. WhopperCropper is a tool to help agricultural advisors and farmers capture these benefits and use it to add value to their intuition and experience. WhopperCropper allows probability analysis of the effects of a range of selectable crop inputs and existing resources on yield and economic outcomes. Inputs can include agronomic inputs (e.g crop type, N fertiliser rate), resources (e.g soil water at sowing), and seasonal climate forecast (SOI phase). WhopperCropper has been successfully developed and refined as a discussion-support process for decision makers and their advisers in the northern grains region of Australia. The next phase of the project will build on the current project by extending its application nationally and enhancing the resource management aspects. A commercial partner, with over 800 advisor clients nationally, will participate in the project.

The development of a solid waste management strategy

This research is concerned with the application of operational research techniques in the development of a long- term waste management policy by an English waste disposal authority. The main aspects which have been considered are the estimation of future waste production and the assessment of the effects of proposed systems. Only household and commercial wastes have been dealt with in detail, though suggestions are made for the extension of the effect assessment to cover industrial and other wastes. Similarly, the only effects considered in detail have been costs, but possible extensions are discussed. An important feature of the study is that it was conducted in close collaboration with a waste disposal authority, and so pays more attention to the actual needs of the authority than is usual in such research. A critical examination of previous waste forecasting work leads to the use of simple trend extrapolation methods, with some consideration of seasonal effects. The possibility of relating waste production to other social and economic indicators is discussed. It is concluded that, at present, large uncertainties in predictions are inevitable; waste management systems must therefore be designed to cope with this uncertainty. Linear programming is used to assess the overall costs of proposals. Two alternative linear programming formulations of this problem are used and discussed. The first is a straightforward approach, which has been .implemented as an interactive computer program. The second is more sophisticated and represents the behaviour of incineration plants more realistically. Careful attention is paid to the choice of appropriate data and the interpretation of the results. Recommendations are made on methods for immediate use, on the choice of data to be collected for future plans, and on the most useful lines for further research and development.

Management of allergic conjunctivitis and dry eye

Ocular allergy is a common eye condition encountered in clinical practice. However, little is known how seasonal allergic conjunctivitis (SAC), the most common subtype, is managed in clinical practice. Further, dry eye, another common eye condition, may be misdiagnosed as SAC and vice-versa as they share similar signs and symptoms. In addition, despite the frequent recommendation of non-pharmacological treatments for SAC, evidenceto support their use has not been identified in the scientific literature. The aim of this thesis was therefore to determine the actual diagnosis and management of SAC and dry eye in clinical practice and investigate the efficacy of non-pharmacological treatments for these conditions. The diagnostic and management strategies for SAC and dry eye employed by pharmacy staff are found to be inconsistent with current guidelines and scientific evidence based upon a mystery shopper design. Cluster analysis of tear film metrics in normal and dry eye patients identified several clinically relevant groups of patients that may allow for targeted treatment recommendations. Using a novel environmental chamber model of SAC, the use of artificial tears and cold compresses, either alone or combined is an effective treatment modality for acute and symptomatic SAC, on a par with topical anti-allergic medication, and has been demonstrated for the first time. In addition, eyelid warming therapy with a simple, readily available, seed filled device is an effective method of treating meibomian gland dysfunction (MGD) related evaporative dry eye, perhaps the most common dry eye subtype. A greater focus on ophthalmology must be implemented as part of the formal education and training of pharmacy staff, while greater professional communication between community pharmacists, optometrists and the population they serve is required. Artificial tears and cold compresses may be considered as front line agents for acute SAC by pharmacy staff and optometrists, to whom pharmacological treatment options are limited.