The athletes had a minimum of 5 years of training skill in the sport. They completed the Mental Imagery Test (MIT). Competitive athletes showed higher scores on mental imagery skills than non-athletes. The study contributed to increase the exploration in the definite area of mental imagery, supplying an added support for the pluridimensional nature of mental imagery and for its practicality in motor and sport sciences.Mental imagery is a fully immersive multi-sensory procedure that associates as numerous senses to create a mental image and process it without the presence of external stimuli. In the sport situation, imagery has been designated as the state in which people imagine themselves while effecting abilities to deal with the forthcoming duty or improve performance. Methodical analyses have revealed that imagery increases performance in motor tasks. This study aims at observing not the vividness of image but the cognitive abilities useful for the inspection, maintenance, generation, and manipulation of dissimilar classes of images, investigating modifications in mental imagery skills in competitive athletes and non-athletes. Participants were competitive athletes ( Mental imagery is the reproduction of perceptual experience  across mIn the sport situation, imagery has been designated as the state in which people imagine themselves while effecting abilities to deal with the forthcoming duty or improve performance. Imagery may be a consequence from both thoughtful and unconscious recall procedures; an individual sees an image, or experiences a movement as an image, without experiencing the real thing through a process. Imagery plays a significant role in this context, improving performance in motor tasks , 2019.It is usually assessed in relations of its mental and emotional characteristics, as well as motivational competence . Owing tthe intentional or unintentional conception or regeneration of an experience produced from memorial information, concerning quasi-affective and quasi-sensorial features that may occur in the absence of the tangible stimulus antecedents usually associated with the real experience” (p. 19).Various overlying terms have been utilized to refer to several sides of mental imagery in sports . Morris Within the mental mode, kinesthetic  and visual  are the most usual sensory tested mentally approaches of creating images .imagery use and imagery ability. The capability of creating vivid images is different from the competence in controlling and manipulating the created images . However, imagery is a complex construct. In the several explorations of mental imagery, researchers have investigated equally d images . Cognitiise way” , and vivn image” . Murphy In addition to the aforementioned considerations, the model of imagery suggested by Although previous investigation on mental imagery has principally concentrated on adult athletes, fewer studies have examined the young athlete population. Comparing athletes’ imagery with that of non-athletes, N = 60). Regarding imagery as the usage of all the senses to recreate or make an experience in mind, the results indicated that elite volleyball players had superior performance than non-elite ones.In a research on high school athletes, Nevertheless, little investigation has been conducted on younger athletes comparing imagery—i.e., perception without present stimuli—with other cognitive abilities .The aim of the current study is to investigate the ability of children to engage in visual and spatial mental imagery , and to compare these processes between athletes and non-athletes (8–13 years of age). This age range has been selected as it is recommended that children aged 7 and over can form kinesthetic and transformational images . In factWe expected athletes to show greater ability in controlling mental images than non-athletes.n = 48) and non-athletes (n = 48) Between the ages of 8 and 13 years. the groups Were matched so they Had the same mean and standard deviation .The participants Were competitive athletes . Forty-eight students who had no experience in any sport represented control participants. Participants did not obtain before mental abilities or imagery training. Measurements were carried in clusters of four participants. Athletes were tested in an isolated place near the training accommodations. The control group was from dissimilar classes and was tested in a separate place near the school at the end of the educational activities. Prior to the beginning of the study, ethical approval was granted from the first author’s university ethics committee. The study obtained ethical permission from the University Enna Kore Internal Review Board for psychological research .The athletes had a minimum of 5 years of training skill in the sport, and they were all associates of sport clubs. These athletes had different competitive sport backgrounds . Their hours of exercise per week ranged from 3.0 to 21.5 h  and standardized for usage in childhood :The individuals are invited, without seeing the stimuli and spending only imagination, to say which upper-case letters have curled parts .With their imagination, the individuals are asked to walk along the delineation of a large upper-case letter F earlier viewed for 30 s on a reproduced card. The individual is asked to say whether the limits encountered when moving from the lower left corner in a counter-clockwise direction are external or internal.The task necessitates imagining a clock with hands indicating 10 min past 10:00, then imagining the clock reproduced in a mirror and saying what time the mirrored clock will show after 10 min.The image of a large cube is shown for 30 s; it is collected of nine small cubes per face (3 × 3), and the external faces are colored. After the stimulus is detached, the subject is asked to state how many small cubes have three, two, one, or none external (colored) faces.A digital display with the number 88 collected of small segments is shown for 10 s. Then, another digital display with designated segments of a two-digit number is shown for 10 s. The individual is asked to imagine what two-digit number will remain after deducting the parts of the new figure from the figure with all digits seen beforehand.The individual is presented with a map of an island, with a house, a church, a lake, and a wood located on it. The instructions ask to look with attention at the map, staring at the distances among the elements located. After the map is detached, the individual is asked to answer four questions about the comparative distance between couples of the earlier seen components.The individual is asked to imagine a small ball moving in dissimilar directions, succeeding a suggested path in the imagined space, and saying if at the end of the route the ball will end up above or below the initial point, or at the similar level.The individual hears the names of 20 concrete objects  and is asked to imagine them and select if the object has a taller or larger form.p < 0.01; Root Mean Square Error of Approximation (RMSEA) = 0.09, p < 0.01; Comparative Fit Index (CFI) = 0.90; Standardized Root Mean (SRM) = 0.05; Goodness of Fit Index (GFI) = 0.93  = 0.93 .The selection of the tasks, resulting from the preceding literature on mental imagery, was designed at expressing all the functions implicated in imagery, agreeing to the classification proposed by With the aim of discriminating mental imagery abilities from those based on memory and visual perception—without necessitating active generation and/or alteration of mental images—some other cognitive standardized tasks are proposed.The individual hears gradually increasing digit series, and has to repeat them in direct or backward order. Verbal working memory is implicated in these attentive tasks.The individual, after seeing seven concrete objects for 30”, is invited to evoke as many of them as possible in a free recall. Subsequently, the individual has to recall the position in a matrix of six objects before seen for 30”.Individuals are presented for 10” with a matrix in which a number of cells are completed and, after, are required to recall where they were located using a blank matrix. Six matrices are presented, and completed cells increase gradually from 2 to 4.The tasks of memory of position, for both objects and matrices, necessitate a passive maintenance of spatial position in working memory and, consequently are useful to differentiate this skill from active elaboration of mental images.The individual is requested to copy a model in a mirror position, though really seeing the model. This task of copy includes spatial perception without active alteration of images.t-test comparisons. Moreover, Pearson correlational analyses were completed to explore possible existing relationships between mental imagery abilities, and memory and visual perception within each group of participants. Statistical analyses were performed using SPSS version 23 Statistical Software Package for Windows .Differences between the two groups of participants were assessed by SD = 13.74; females’ mean = 53.15, SD = 12.24; t = 0.05; p = 0.96. For this reason, the subsequent analyses were carried out without taking into account gender.Preliminary, for the global score of imagery, we verified that the general difference due to the gender was non-significant: males’ mean = 53.27, The analyses of differences in the performances of controls and athletes in the specific tasks are shown in Results showed high significant differences in all mental imagery abilities (except the “cube” test) and, in memory and visual perception with athletes. The only task showing a different trend is “clock,” the performance being better in the control group.SD = 7.13; for the controls group, mean = 44.02, SD = 10.74; t = −9.87, p < 0.001.In addition, the difference in the total score of imagery is highly significant: for the athletes group, mean = 62.40, Correlational analyses between imagery tasks and perceptual and memory tests were performed separately for the two groups of athletes and controls , 3. BonfResults showed that the mental imagery performances are differently correlated with perceptual and memory ones. As for group differences, an interesting exception to the general trend is the “clock” task, which is positively  correlated with memory and perception tasks in athletes, while in the control group, these correlations are null or inverse.The present study aimed to assess the ability of children to engage in visual and spatial mental imagery , and to compare these processes between athletes and non-athletes.Results showed high significant differences in all mental imagery abilities (except the “cube” test) and, in memory and visual perception with athletes. According to The only task showing a different trend is “clock”: the performance being better in the control group. This suggests that image maintenance abilities depend on stimulus complexity, according to previous research e.g., . ChildreCorrelational analyses showed that the mental imagery performances are differently correlated with perceptual and memory ones. In the group of young athletes, the significant correlations are few and with lower size, indicating that in this group, the imagery functions are more independent from perception and memory than in non-athletes, and this independence could justify the overall better performance. We know that having solid mental imagery is an advantage to resolving visual and spatial tasks; nevertheless, our results propose that persons might use diverse cognitive approaches to resolve the similar visual memory task.An interesting exception to this general trend is the “clock” task, which is positively correlated with memory and perception tasks in athletes , while in the control group, these correlations are null or inverse. In this task, the performance of the group of athletes is worse than that of the non-athletes; it could be influenced by the integration between memory and perceptual abilities, differently from controls. In fact, this task—being the most difficult—requires more than others to join visualizing and remembering the position in the space  and, therefore, an integration between imagery and other cognitive function, less present in the group of athletes as demonstrated in the other tasks. Probably, the young athletes are less able in the clock task for their less familiarity with analogical clocks, since they have more practice with digital clocks . For the same reason, in this task, the influence of the perceptual and memory abilities is more relevant in the athletes.Despite the strengths of the current study, which include novel findings for a young population, there are several limitations that should be noted. For one, the ability of children to engage in visual and spatial mental imagery could be resulted with a longitudinal design. The relationship between the variables could be identified through since to start sport. Future research should investigate the mechanism more specifically, for example, investigating the association between cognitive-specific imagery ability and learning development of athletes.In conclusion, it can be determined that imagery seems to be an instinctive psychological ability, which grows in early years of life. This finding is in line with previous studies, which showed that children often use imagery to acquire skills in a natural way . ConsequAll datasets generated for this study are included in the article/The studies involving human participants were reviewed and approved by the University Enna Kore Internal Review Board for psychological research . Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.DD, MG, SD, and MC contributed to the conception and design of the study. CG and SC were responsible for testing. MC, MG, SD, DD, and NM were responsible for data collection and statistical analysis. DD, MG, and MC were responsible for drafting and finalization of the manuscript. All authors contributed to manuscript revision and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Many felid species are of high conservation concern, and with increasing human disturbance the situation is worsening. Small isolated populations are at risk of genetic impoverishment decreasing within-species biodiversity. Movement is known to be a key behavioural trait that shapes both demographic and genetic dynamics and affects population survival. However, we have limited knowledge on how different manifestations of movement behaviour translate to population processes. In this study, we aimed to 1) understand the potential effects of movement behaviour on the genetic diversity of small felid populations in heterogeneous landscapes, while 2) presenting a simulation tool that can help inform conservation practitioners following, or considering, population management actions targeting the risk of genetic impoverishment.We developed a spatially explicit individual-based population model including neutral genetic markers for felids and applied this to the example of Eurasian lynx. Using a neutral landscape approach, we simulated reintroductions into a three-patch system, comprising two breeding patches separated by a larger patch of differing landscape heterogeneity, and tested for the effects of various behavioural movement syndromes and founder population sizes. We explored a range of movement syndromes by simulating populations with various movement model parametrisations that range from ‘shy’ to ‘bold’ movement behaviour.We find that movement syndromes can lead to a higher loss of genetic diversity and an increase in between population genetic structure for both “bold” and “shy” movement behaviours, depending on landscape conditions, with larger decreases in genetic diversity and larger increases in genetic differentiation associated with bold movement syndromes, where the first colonisers quickly reproduce and subsequently dominate the gene pool. In addition, we underline the fact that a larger founder population can offset the genetic losses associated with subpopulation isolation and gene pool dominance.We identified a movement syndrome trade-off for population genetic variation, whereby bold-explorers could be saviours - by connecting populations and promoting panmixia, or sinks - by increasing genetic losses via a ‘founder takes all’ effect, whereas shy-stayers maintain a more gradual genetic drift due to their more cautious behaviour. Simulations should incorporate movement behaviour to provide better projections of long-term population viability and within-species biodiversity, which includes genetic diversity. Simulations incorporating demographics and genetics have great potential for informing conservation management actions, such as population reintroductions or reinforcements. Here, we present such a simulation tool for solitary felids. Small populations of endangered species are of high conservation concern. Not only are they at risk due to demographic stochasticity, which can lead to extinction , 2, but Movement rates, i.e. the outcome of individual movements, are known to drive both genetic differentiation and homogenisation in subdivided populations (e.g. ). As effThe individual expression of behavioural responses, named variously “personality”  or “behaSpatially explicit individual-based models (SEIBMs) are useful tools for exploring complex systems for which dynamics at the population level emerge from individual decision-making . RecentlLynx pardinus) )Utilising such empirical information, demogenetic simulations could explicitly consider movement behaviour diversity and better constrain predicted population viability and long-term genetic diversity for reintroductions and reinforcement projects. The demogenetic model could, for example, help clarify the relationships between founder population size or sex ratio, demographic rates (e.g. breeding success) and the genetic diversity of reintroduced populations. In particular, since rules of thumb like the “one migrant per generation” rule have come under scrutiny due to their theoretical nature , 98, it There is increasing support being voiced for the value of individual differences at various levels of organisation , from spPopulations of endangered species are becoming ever more restricted in size and mobility, leaving them at risk. Movement traits could be crucial for establishing exchange between subpopulations and deciding the fate of at-risk species. Management needs to be informed of the hazards and opportunities, not only regarding extinction risk but also long-term viability, hence genetic diversity.Demogenetic simulations based on empirical field data have potential to deliver recommendations for conservation management, including population reintroductions and reinforcement projects. Here we presented the first demogenetic model for felids that includes spatially explicit movement, neutral genetic markers, realistic reproduction and inheritance processes . Such simulation tools can be applied to various at risk or endangered species, here exemplified by Eurasian lynx. In the future, this model could be used to assess the consequences of movement traits, landscape conditions and mortality on demographic viability and genetic potential under diverse scenarios. Future research should deliver prognoses and recommendations under specific management scenarios that could: 1) reinforce genetic diversity of felid populations to reach target levels, and 2) maintain target levels of genetic diversity in meta-populations. Finally, given the crucial role movement plays in population persistence, simulation studies should aim to help close knowledge gaps identified for various felid species .Additional file 1. ODD Protocol – Description of “The Eurasian Lynx Dispersal, Demographic and Genetic Model”.Additional file 2: Additional methods: S2.1 Post hoc investigation of pedigree structure, and S2.2 Interpolation of the continuous variables using smooth splines for visualisation.Additional file 3: Figure S3. “Arrival” patch λ, based on a two sub-populations structure in the 200th year after reintroduction. Simulations were carried out in neutral landscapes of varying amounts of dispersal habitat and varying degrees of fragmentation , for 3 movement syndromes  and 3 sizes of the founder population.Additional file 4: Figure S4. Simulation extinction rates for all of parameter space.Additional file 5: Figure S5. Number of disperser individuals changing breeding patch in the 200th year as a proxy for connectivity, by gender and with genetic diversity Ho.Additional file 6: Figure S6. Accumulated Local Effects (ALE) plots for RF regression analysis of genetic outputs Ho, FST and FIS, using demographic covariates.Additional file 7: Figure S7. Number of founder individuals taking part in reproduction by gender, for all simulation runs of a subset of parameter space (see S2.1). For A – 10 founders, and B – 50 founders. The mean values indicated by the dotted line.Additional file 8: Figure S8. Density distribution of total number of descendants of founder individuals 50 years after reintroduction, by gender, for all simulation runs of a subset of parameter space (see S2.1). For A – 10 founders, and B – 50 founders.Additional file 9: Figure S9. Individual inbreeding values of living individuals 50 years after reintroduction, by patch , for all simulation runs of a subset of parameter space (er space . For A –


Several studies have shown a significant relationship between smelling and olfactory imagery abilities. The primary aim of the present study was to validate a French version of the Vividness of Olfactory Imagery Questionnaire (VOIQ). The secondary aim was to investigate its capability to differentiate individuals with smell loss from healthy individuals. After having elaborated a French translation of the VOIQ (fVOIQ), we evaluated olfactory imagery abilities of 387 French participants who anonymously self-completed the fVOIQ: 121 pathologic individuals (hyposmic and anosmic), 244 normosmic individuals , and 22 fragrance experts. Significant split-half reliability as expressed by Spearman correlation coefficients for the global sample, as well as for each group separately, indicated the excellent internal consistency of the fVOIQ. Moreover, results revealed a significant effect of the smelling ability group on fVOIQ score, suggesting that daily olfactory stimulation is fundamental to maintaining the ability to create a vivid image and that severe loss of smell may result in progressive impairment of olfactory imagery. Our fVOIQ and the original English version seemingly have similarly high benefit in differentiating experts and normosmic individuals based on their olfactory imagery ability. Moreover, the fVOIQ seems capable of differentiating individuals with loss of smell from healthy individuals. These findings demonstrate the reliability and validity of the fVOIQ, and its capability to differentiate individuals’ smelling ability according to their olfactory imagery ability. Sensory imagery refers to the volitional mental simulation of sensory experiences and is known to be feasible in every sensory modality . SeveralNumerous factors influencing olfactory imagery vividness have been studied. Several authors have worked on creating questionnaires assessing sensorial imagery , though The primary aim of the present study was to validate a French version of the VOIQ (fVOIQ). The secondary aim was to investigate its capability to differentiate individuals with smell loss from healthy individuals. To accomplish this, we compared olfactory imagery abilities of fragrance expert, normosmic , and pathologic (hyposmic and anosmic) individual samples. We hypothesized that experts would have a better olfactory imagery ability as compared to healthy non-expert and pathologic individuals. Similarly, we expected better olfactory imagery ability for healthy non-expert individuals as compared to those who were pathologic.a priori into one of four groups: (1) anosmic , (2) hyposmic, (3) normosmic, and (4) expert . All participants who were recruited by the paper & pencil questionnaire declared themselves as normosmic. Each participant was then classified (according to their declaration) into one of four groups: one pathologic group (n = 121), which included hyposmic and anosmic participants, two normosmic groups (np&p = 21 and nweb = 223), and one expert group (n = 22).387 participants volunteered for this study see . They weThe original English version of the VOIQ was first transcribed into French with the help of collaborators fluent in English and native in French. The translation was then presented to a professional translator, fluent in French, and native in English, who back translated the questionnaire to English and made corrections by comparing it to the original questionnaire. In addition, French healthy internal collaborators were also asked to note whether the questionnaire translation was clearly understandable. If it was not, they had to specify which item was not understood. Thus, amendments to the French version were progressively made until both parties fully agreed on the final translated document.In the manner of the original version of VOIQ, the fVOIQ is composed of 16 items split into 4 situations for which 4 specific smells are presented see . Each paAs previously indicated, either the web or pen and paper version of the fVOIQ was self-administered. Regardless of the form of administration, participants were not asked to provide any identifying data.Raw data for each participant  were stored in a specific database. The mean fVOIQ score was calculated for each participant (sum of answers/16 items). A low mean score (close to 1) indicates a good ability to imagine smells, and vice versa.ps < 0.001). Therefore, quantitative data were expressed as medians (Med) associated with interquartile range (IQR) and qualitative data by their frequencies.All statistical analyses were performed using R version 3.6.3. The threshold for statistical significance was α = 0.05. fVOIQ score distribution for all four groups differed from the normal distribution . A Kruskal–Wallis non-parametric ANOVA was used to study group effect  on olfactory imagery ability, i.e., their median fVOIQ score. Tests were adjusted for multiple comparisons according to Bonferroni–Holm correction.p&p = 2.69 ± 0.69; Medweb = 2.31 ± 1.25; Z = −1.09; p > 0.05). Therefore, all normosmic participants were grouped for further analyses, reducing the number of groups to three: one pathologic group (n = 121), one normosmic group (n = 244), and one expert group (n = 22).There were no significant differences in fVOIQ scores between web-based and paper & pencil conditions  = 211.6; p < 0.001]. As illustrated in pat = 4.69; IQR = 1.25) was significantly higher than both normosmic and expert groups . The score for the normosmic group was also significantly higher than that of the expert group (corrected p < 0.05).The Kruskal–Wallis non-parametric ANOVA showed a significant effect of group on the median fVOIQ score [H.The differentiation power of the fVOIQ was further tested in the pathologic group, by comparing congenital anosmic participants, to those who had developed anosmia . CompariThe primary aim of this study was to validate a questionnaire allowing to assess olfactory imagery ability in French-speakers. The internal consistency of our fVOIQ was high on the global population, and in each group. In line with our hypothesis, the fVOIQ corroborated previous findings using Our results showed a wide variation in normosmic individuals, allowing us to distinguish good odor imagers, from poorer imagers . In addiLastly, it is important to note that contextualized olfactory imagery vividness depends on culture , which iA perspective of application of the fVOIQ could also be the diagnosing of olfactory impairments. Indeed, according to the European Rhinologic Society, patients today with a sudden loss of smell should be considered as potentially COVID-19 positive. A significant proportion of COVID-19 patients (20–60%) experience loss of smell or taste . Recent The fVOIQ appears to have high reliability and validity, when compared to the data of the original English VOIQ. It can therefore be used in a French population for assessing olfactory imagery ability and could also differentiate individuals with smell loss from healthy individuals.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.GH and MJ conceived, designed the study, conducted the experiments, collected, and processed the data. LF, GH, and HC analyzed the data. LF, HC, MJ, and GH wrote the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Clostridium perfringens types B and D, causes serious neurological disorders in animals. ETX can bind to the white matter of the brain and the oligodendrocytes, which are the cells forming the myelin sheath around neuron axons in the white matter of the central nervous system. After binding to oligodendrocytes, ETX causes demyelination in rat cerebellar slices. We further investigated the effects of ETX on cerebellar oligodendrocytes and found that ETX induced small transmembrane depolarization (by ~ +6.4 mV) in rat oligodendrocytes primary cultures. This was due to partial inhibition of the transmembrane inward rectifier potassium current (Kir). Of the two distinct types of Kir channel conductances (~25 pS and ~8.5 pS) recorded in rat oligodendrocytes, we found that ETX inhibited the large-conductance one. This inhibition did not require direct binding of ETX to a Kir channel. Most likely, the binding of ETX to its membrane receptor activates intracellular pathways that block the large conductance Kir channel activity in oligodendrocyte. Altogether, these findings and previous observations pinpoint oligodendrocytes as a major target for ETX. This supports the proposal that ETX might be a cause for Multiple Sclerosis, a disease characterized by myelin damage.Epsilon toxin (ETX), produced by  Clostridium perfringens strains of types B and D produce epsilon toxin (ETX), a ~30 kD peptide with very high lethality  [oneally) ,2. ETX ioneally) . Its higC. perfringens in the lumen of the intestine and is disseminated throughout the body by the bloodstream. The toxin binds to the endothelial cells of the capillary vessels of the brain [ETX is produced by he brain ,6,7. Usihe brain ,9,10. Thhe brain . In orgahe brain . In vivohe brain  and altehe brain . It is ihe brain ; 23% vs he brain . Therefohe brain ,16.2+ signaling and demyelination [m), it is possible that ETX modifies Vm without affecting the integrity of the plasma membrane.The mechanisms underlying the effects of ETX on oligodendrocytes leading to demyelination are not yet clear. Studies conducted on oligodendrocytes in rats in primary culture have shown that ETX causes an increase in extracellular glutamate that is not due to permeabilization of the plasma membrane of oligodendrocytes . Elevatilination . Since t+ ions (EK+) and adjusting the resting potential of the membrane (RMP) near EK+ [2+) and other molecules (such as polyamines) at Vm more positive than EK+ [+ ions at the Vm more negative than EK+ while impeding outward K+ current at the depolarized Vm [The membrane inward rectifier potassium channels (Kir channels) play an important role in maintaining the Nernst equilibrium potential for Knear EK+ ,18. Mainnear EK+ ,18,19,20near EK+ ,18,21,22In this paper, experiments were sought to examine whether ETX modifies RMP or/and Kir membrane current and channels in mature oligodendrocytes from rat cerebellum. Using primary cultures, we demonstrate that the application of ETX induces a small transmembrane depolarization and inhibition of a fraction of Kir transmembrane current. Moreover, we found that one of the two main types of Kir channels present in oligodendrocytes is inhibited following the ETX application.−7 M, final) was applied in the bath. After ETX, RMP was determined at the plateau of depolarisation (average Vm determined for 1s). The average RMP was −55.1 ± 2.3 mV before ETX  and −49.9 ± 2.8 mV after . Of the 15 cells that were recorded, only 12 responded to ETX by a Vm change. The latter manifested as an onset of depolarization followed by a plateau . The delay between ETX application and onset of depolarization was determined on the 12 cells responding to ETX by determining the time interval between the application artifact and the starting point for the depolarization onset . In these 12 cells, after ETX, depolarization started after an average delay of 53 ± 12 s and the average plateau depolarization was +6.4 ± 1.3 mV . The mean depolarization induced by Ba2+ ions was +54 ± 1.3 mV, and its delay was 20 ± 3 s . The depolarizing effect of ETX suggests that this toxin may act directly or indirectly on one or several types of the membrane channels controlling RMP in oligodendrocytes.Using the whole-cell clamp technique (current-clamp mode), we examined whether the extracellular application ETX modifies RMP of oligodendrocytes. In 15 experiments , RMP was first determined for 5 min (baseline) and after ETX (10 plateau . Cells wm=f(Vm) relationship under baseline conditions, oligodendrocytes membrane potential was held at −80 or −60 mV . Then, they were subjected to several series of twin symmetrical square changes in Vm, increasing by step of 5 mV  are shown in 1). m = f(Vm) established under baseline conditions. It was made by averaging (n = 12) of the mean individual cell Im determined at each Vm. Note that this Im = f(Vm) has not been corrected for the passive leak current. The inwardly rectifying shape of relationship Im = f(Vm) indicates the presence of a marked Kir current.Using the patch-clamp technique under the whole-cell clamp mode, we recorded the evoked membrane currents in rat oligodendrocyte. To establish the I−7 M, final concentration in the extracellular medium) was applied (19 recorded oligodendrocytes from 19 different culture dishes). After 7 min of incubation in the presence of the toxin, the stimulation protocols were repeated again for a duration of 12–15 min. 16 of the 19 cells responded to the ETX with changes in the whole-cell currents. In 12 of them, the maximum amplitude of current evoked by hyperpolarizing stimuli was reduced . In the four other responding oligodendrocytes, ETX effect manifested by a decrease in peak amplitude and slowing of membrane current inactivation leading to an increase in current plateau (2). In three of the 19 cells (16%), no effect on membrane current was detected (3). For each of these three cells, for each of the Vm applied to the cells, individual cell Im ± SEM determined before and after ETX were not statistically different. 4 summarizes the relative proportions of cells responding or not to ETX. Note that the proportion of cells with an unaffected whole-cell current is close to that of oligodendrocytes  whose RMP has not been modified after ETX. m = f(Vm) relationships, established before (black filled circles) and after ETX (red filled circles)  indicates that this toxin blocks a significant fraction of the membrane current evoked by hyperpolarization . −7 M) to the bath for 6 ± 0.7 min . After membrane current recordings were made during the control period, ETX (10 plateau A2. In thdetected A3. For eETX) was isolated by subtracting the current recorded after toxin application to the current recorded before toxin application (see an example of the resulting current traces in ETX = f(Vm) relationships were pooled and averaged to establish the mean IETX = f(Vm) relationship shown in ETX displays the typical inwardly rectifying properties of Kir currents.The membrane current fraction sensitive to ETX  under 3 conditions: (a) control  (−4 M BaCl2 (m = f(Vm)  are shown in m = f(Vm) relationships were significantly distinct .The next series of experiments were aimed at determining whether I control Aa, (b) t, final) Ab, and  corresponding to the leak current is almost linear . After the application of BaCl2 to the control ones  with a linear relationship Im = f(Vm) similar to that displayed in The voltage-dependent component of whole-cell current in oligodendrocytes  was obtained by subtracting the current traces remaining after further addition of BaClETX  was obtained (as described in § 2.2) by subtracting each of the traces of membrane current remaining after ETX from those recorded under control (m = f(Vm) curve in ETX displayed the relationship Im = f(Vm) typical of a Kir current , no change in the whole-cell membrane current was observed (data not shown). For instance, following the application of BaCl2, Im = −27 ± 4 pA at Vm =−90 mV, and after subsequent addition of ETX  Im = −39 ± 15,  at the same Vm. The fact that the prior inhibition of Kir channels by BaCl2 occludes ETX effects provided support to propose that IETX is a fraction of IKir.I2 (traces ‘c’ in m=f(Vm) curves for the voltage-dependent current fraction insensitive to ETX but sensitive to Ba2+ (Subtracting the current traces obtained after adding ETX and then BaClm=f(Vm) curves in p < 0.001; n = 5) in terms of amplitude. However, when corrected for the leak current (m = f(Vm) obtained by subtraction of current traces and normalized to their respective maximum amplitude have almost similar voltage-dependence and rectifying properties. Importantly, there is no significant difference between the two components of IKir: IETX and I2+ sensitive but ETX insensitiveBa . The fraction of the evoked voltage-dependent membrane current  inhibited by ETX was expressed (in %) by the ratio 100 × (‘a–b’) / (‘a–c’) using the data from Kir by ETX was between 40 and 50% in this series of five experiments.The three I current D their vpatch) of −40 mV, relative to the oligodendrocyte RMP  more, two different types of unitary channel currents were observed (channel) (right panels in A and B) was determined by adjusting the channel current amplitude histogram distribution by a Gaussian function. According to Ohms’ law, ichannel = γchannel ∗ Vpatch. Hence, channel opening conductance was determined from the slopes of ichannel=f(Vpatch) relationships, from -120 to +60 mV relative to oligodendrocyte RMP. patch axis at ≈ +55 mV. Since the RMP in oligodendrocytes as been determined ≈ −55 mV  and should be in the same range as the intracellular concentration of K+. Thus, EK+ would be close to 0 mV, which corresponds to a Vpatch ≈ +55 mV. The observed reversal potential for ichannel  slopes permitted determination of the opening elementary conductance of the two types of Kir channels, γchannel: 8.5 pS  and 25 pS (large), respectively.We analyzed the effects of ETX on the unitary activity of Kir channels on intact oligodendrocytes, using the patch-clamp method under the cell-attached configuration. Steady-state hyperpolarization of the membrane patches revealed the presence of marked ionic channel activity (openings and closures), in the recorded patches. When membranes patches were maintained at a potential  to the extracellular medium surrounding the patch pipette resulted in a rapid and marked reduction in Kir channel activity, with the large openings almost completely disappearing. In two of the 11 experiments, no ETX effects on Kir channel activity were detected. Kir reported in The effect of ETX on Kir channels activity was examined. In the first series of experiments, the membrane patches were hyperpolarized by 40 mV relative to RMP for the whole duration of the experiments A. In then = 4 experiments), openings of the high-conductance channels were absent or very rare (0.001 s−1 in presence of ETX as compared to 1.5 s−1 before the toxin was applied). The low amplitude openings were still present (channel = f(Vpatch) (determined as explained above) corresponding to these ETX-resistant Kir activities was similar to that established under control condition for small conductance Kir openings (compare ETX-resistant channel = 9.8 pS) was close to that determined  under control conditions. In another series of experiments, we analyzed the activity of channels directly exposed to ETX in a long-lasting manner. When oligodendrocytes were incubated with ETX for at least 15 min before cell-attached patch recordings were made  ETX induces small but significant RMP depolarization (by +6.4 mV); (ii) ETX reduces amplitude of evoked transmembrane current of type Kir; (iii) ETX induces inhibition of the activity of the high conductance Kir channel (~25 pS) without affecting that of the low conductance channels (<10 pS). In this discussion, we examine whether these different observations are caused by direct or indirect effects of ETX, are causally related to each other, and how this can inform ETX mechanisms.The deleterious effect of ETX on oligodendrocytes leads to myelin damage due to toxin action against oligodendrocytes ,12,13,14m=f(Vm) in ETX can act on rat oligodendrocytes without forming pores in their plasma membrane . This st2+ and polyamines increases significantly with depolarization of the plasma membrane [m = f(Vm) typical of the Kir current . Kir it would require a depolarization of Vm by at least 30 mV. This excludes the possibility that the small membrane depolarization induced by ETX (+6.4 mV) may be responsible for the marked inhibition of the Kir current (m) was modeled using the Goldman–Hodgkin–Katz constant field equation [PKir is much higher than the other ones in oligodendrocytes [P) for ions , this yields an Em ~−55 mV  suggesting that the ETX delay is due to the mechanisms underlying its cellular effects rather than its diffusion in the extracellular medium after its application to the bath. Since different intracellular pathways can modulate Kir channel activity [The application of ETX in the extracellular medium during cell recording inhibits the 25 pS Kir channels enclosed at the tip of the patch pipette. The very high electric resistance (>Giga–Ohms) of the tight seal between the tip of the patch-pipette and the plasma membrane does not allow the diffusion of the bath ETX into the intra-pipette medium, thus preventing any direct action of the toxin on the Kir channels whose activity is recorded by the patch-pipette. To date, ETX has never been found internalized  or actinactivity , the mosactivity ,18 and Eactivity ,27 and eactivity . Since tactivity  has not In this study, we found that ETX had no effect on a fraction of the recorded oligodendrocytes. Indeed, (i) the RMP remains unchanged after ETX in three of the 15 (20%) cells (§ 2.1), (ii) three of the 19 (16%) cells showed unchanged whole-cell current after ETX application (§ 2.2), (iii) and in two of the 11 18%) membrane patches no change in Kir channel activity was detected after ETX (§ 2.4). Using the same type of primary culture and experimental conditions as in this study, we reported the absence of ETX binding on 21% of cultured oligodendrocytes ,18,25. % membran+ in the white matter. This allows maintaining axonal RMP and nodal function, and favors rapid propagation of action potentials along axons [+ in the white matter; prevents axonal transmission of high-frequency repetitive action potentials [m, the modification of Kir channel activity and the depolarized RMP that ensues results in an alteration of the glutamate transporter activity [Kir channels play an essential role in the homeostasis of extracellular Kng axons ,18,19,20ng axons . These mng axons ,4 or aftng axons . Whethertentials . Therefotentials . Given tactivity ,32. TherKir current and RMP depolarization—this article—increase in extracellular glutamate, activation of mGluR1, and activation of intracellular Ca2+ signaling [This study revealed the new effects of ETX on oligodendrocytes. They consist of decreased amplitude of membrane Kir current due to selective inhibition of activity of high-conductance Kir channels (25 pS) and ensuing small membrane depolarization. The inhibition of high-conductance Kir channels does not result from a direct action of ETX on them, and involves undefined intracellular mechanisms. Inhibition of Kir channels by ETX could represent the first step in a cascade of events  causingignaling ,10,12,13All experimental procedures were in accordance with European and French guidelines for animal experimentation, and have been approved by the Bas-Rhin veterinary office, Strasbourg, France (authorization number 67–26 to BP) and by the Paris veterinary office, France (authorization number 75–279 to MP) applying at the time when experiments were performed.C. perfringens type D strain NCTC2062 as previously described [−5 M diluted in physiological medium (§ 5.4) were prepared and stored frozen. When needed, 1 aliquot (10 µL) was added to the extracellular medium (1 mL) bathing the oligodendrocytes in primary cultures. Extracellular medium was gently mixed using an automatic pipette (200 µL tip) to obtain a final concentration of 10−7 M.ETX was purified from escribed . AliquotPrimary cultures of newborn (P0–P1) rat cerebellum  have been prepared as detailed elsewhere . In summ2 2, MgCl2 2, HEPES 10, pH 7.4 with Tris/OH. Mature oligodendrocytes were selected, by eye, according to their typical round cell body shape from which processes emerge radially. Electrophysiological recordings of Vm or whole-cell current (Im) were made using the patch-clamp technique in whole-cell configuration, in the current- or voltage-clamp mode. Recording of unitary activity of the membrane ionic channels was made using the cell-attached configuration under the voltage-clamp mode. Recording micropipettes (resistance 5 ΩM) were filled with a solution containing in mM: potassium glutamate (KGlu) or KCl 130, NaCl 2, MgCl2 1, CaCl2 2, EGTA 10, HEPES 10, the pH 7.2. The correction for the liquid junction potential was made a priori. The Vm of each recorded cell was held at −60 or −80mV under voltage-clamp. Before the electrophysiological experiments, the culture medium was replaced by an external solution containing in mM: NaCl 130, KCl 2.6, CaClm and Vm (Im=f(Vm)), each of the recorded cells were submitted to series of twin symmetrical square changes in Vm, 400 ms duration each, every 1 s, increasing by step of 5 mV  amplitude ± SEM at each Vm. This allowed to establish the relationship Im = f(Vm) for the pooled cells under each of the different experimental conditions. The statistical significance of the differences in the mean Im = f(Vm) curves established before and after a treatment was tested using the Wilcoxon matched-pairs signed-ranks test.The electrophysiological voltage or current signals, under the whole-cell or cell-attached configuration, were acquired (filtered at 5 kHz) using an Axopatch 200A amplifier (axon Instrument) and digitized at 50 kHz using a digidata-1322A (Axon Instruments) before being recorded using the Clampex-10.2 software. Clampfit-10.2 software was used for offline analysis. Before the analysis, all king of the digitized signals were re-filtered with a cut-off frequency of 1 kHz (whole cell current traces) or 1.5 kHz (unitary channel activity) ,35. The t-test.The analysis of the unitary activity of ion channels was carried out as described elsewhere ,35. The 2, i.e., during the control period of time, were designed as ‘control’ or ‘baseline’ in the text and figures. Average data are presented as mean ± SEM (otherwise stated). The statistical analysis and graph presentations of the data were made using Sigma-plot-12.5 software. The data obtained before treatment with ETX or BaClpatch) is a function of RMP: Vpatch = RMP-Vpipette. However, the actual RMP remains unknown. It is therefore specified in the text by how much (in mV) Vpatch differs (hyperpolarized or depolarized) from RMP by mentioning the value of Vpatch relative to RMP.When cell-attached recordings are made, the actual membrane potential of the membrane patch (Vp < 0.05; * denotes p between 0.05 and 0.01; **, p between 0.01 and 0.001; ***, p values < 0.001. Goodness of fit was determined based on the lower prediction error.Statistical comparison of normally distributed data before and after treatment were tested using appropriate paired Student’t-test. When measurements were non-normally distributed, paired comparisons before and after were tested using the Wilcoxon Signed Rank Test, and unpaired comparisons using the Mann Whitney rank sum test. The data were considered statistically significant when probability


Nebulizer disinfection/maintenance score was excellent in only 31.48%. Most families kept the nebulizer clean and used appropriate disinfection method, but only half of them replaced the nebulizer and nebulizer cup at the recommended time intervals. Nebulizer disinfection/maintenance score was positively affected by a number of nebulized medications and negatively by years of equipment use . Even though inhalation technique and disinfection/maintenance practices were found to be adequate in a large proportion of cases, there is still a need for regular review and education. The type of nebulizer was associated with improved inhalation technique, but more data are required before making specific recommendations.Nebulizers are used by the great majority of cystic fibrosis patients for delivery of cornerstone treatments. Inhalation technique and adequate disinfection and maintenance are important for optimizing medication delivery. In this study, inhalation technique and nebulizer disinfection/maintenance were assessed in cystic fibrosis patients by direct observation in clinic and completion of a scoring sheet. A total of 108 patients were recruited. The maximum inhalation technique score was attained by 30.5% and adequate inhalation technique score by 74.08% of patients. The inhalation technique score was best with the vibrating mesh nebulizer ( Life expectancy and quality of life in cystic fibrosis (CF) patients has greatly improved in recent years as a result of aggressive treatment ,2. Many There is often confusion on what is the best way to clean and disinfect a nebulizer, an issue that adds extra burden to patients and their families ,10,11. I1 percent predicted would have better inhalation technique and that nebulizer cleaning/maintenance scores would be higher if fewer inhaled medications were used. Hence, the aims of the present study were: (i) to assess patient inhalation technique; (ii) to evaluate appropriateness of nebulizer disinfection method and maintenance; and (iii) to identify factors affecting inhalation technique and nebulizer disinfection/maintenance.Current clinical practice at our institution is that patients and their families be instructed on cleaning and disinfecting the nebulizer whenever a new device is purchased. The first dose of any nebulized medication is administered in clinic, and the appropriate technique is reviewed. Inhalation technique and nebulizer cleaning/maintenance are assessed at regular intervals. However, limited published information is available regarding the factors that affect inhalation technique and equipment maintenance. It was hypothesized that older children with better FEV1 percent predicted during the visit. The Quanjer 2012 Global Lung Initiative Equations were used for FEV1 percent calculation [Cystic fibrosis patients followed at the Cystic Fibrosis Department of Agia Sofia Children’s Hospital were recruited for this prospective study. The study was approved by the Agia Sofia Scientific Council on 24 May 2017, Ref Number: 3685/14-02-2017. Written informed consent was obtained from the children’s parents or patients if older than 18 years. There were no exclusion criteria. Families were contacted by phone and were instructed to bring their home nebulizer for assessment at a clinic visit or during a hospitalization. Information collected was age, nebulizer type (vibrating mesh nebulizer vs. jet nebulizer), number of nebulized medications, and FEVculation .A scoring sheet was developed to assess nebulizer disinfection methods, nebulizer maintenance, and patient inhalation technique . The scoThe same health care provider (ET) completed all assessments and assignment of scores. Questions to patients or their families were asked in an open-ended format. Inhalation technique and disinfection/maintenance scores (primary outcome measures) were calculated by adding individual scores for each of the questions . The maximum score for disinfection/maintenance score was 9, while a score of 6 or greater was defined as adequate.1 percent predicted (for children older than 6 years). It was thought that older children and children that have been using a nebulizer for a longer time would have higher technique scores. It was also hypothesized that children with higher FEV1 percent predicted would have higher scores. Regarding maintenance score, higher number of medications increases treatment burden and might negatively affect maintenance scores, as the nebulizer would be used more frequently. It is unknown if nebulizer type affects inhalation technique or maintenance, however faster nebulization might improve technique, as it decreases treatment time.Explanatory variables that were selected for analysis included: patient age, years of nebulizer use, number of nebulized medications, nebulizer type (vibrating mesh vs. jet nebulizer), and FEV1 percent predicted as explanatory variables in children aged >6 years; (iii) nebulizer disinfection/maintenance score as outcome measure and years of nebulizer use, number of nebulized medications, and type of nebulizer (vibrating mesh nebulizer vs. jet nebulizer) as explanatory variables.Three regression analysis models were tested: (i) patient inhalation technique as primary outcome and patient age, number of nebulized medications, and nebulizer type as explanatory variables; (ii) patient inhalation technique as primary outcome and patient age, number of nebulized medications, nebulizer type, and FEV1 percent predicted was 99% (range 36–147%). Thirty-six (33.33%) participants used a vibrating mesh nebulizer and the remaining 72 (66.66%) subjects used a jet nebulizer. Twenty-six (24.07%) patients were receiving one nebulized medication, 43 (39.81%) two medications, 23 (21.30%) three medications, and 16 (14.81%) four medications.A total of 108 patients were studied, with a median age of 10 years (range 2–21 years), 37% of whom were male. Ninety-one patients were older than 6 years and provided reliable spirometry results; median FEVThe inhalation technique score was maximal in about a third of cases (31.48%). Approximately one third of patients (30.56%) attained the maximum score for nebulizer disinfection/maintenance score and approximately three quarters (74.08%) had an adequate score (6 and above). Results are summarized in When subscores were considered, many patients had excellent inhalation technique and posture scores, but the majority still required guidance for further improvement . Most fa1 percent predicted were not significantly associated with the score (Nebulizer type (vibrating mesh compared to jet nebulizer) positively affected the inhalation technique score, while patient age, number of nebulized medications, and FEVhe score . Patienthe score .In the current study, inhalation technique and nebulizer disinfection and maintenance status were assessed in patients with cystic fibrosis by direct observation in clinic and completion of a scoring sheet. Excellent inhalation technique and nebulizer disinfection/maintenance scores were attained by only one-third of patients/families. Inhalation technique was best with a vibrating mesh nebulizer, while only half of patients/families replaced the nebulizer and nebulizer cup at recommended time intervals. Thus, nebulizer condition was negatively affected by the years of equipment use.Inspiratory flow rate and body posture influence the surface area of lung deposition . It is rA vibrating mesh nebulizer was related to higher inhalation technique scores relative to the jet nebulizer. While type of nebulizer has been shown to affect treatment time, little is known about how the nebulizer type could affect inhalation technique in patients with cystic fibrosis ,19. More1 percent predicted was also not associated with technique score, but this finding could be secondary to the high proportion of subjects with normal lung function in our patient cohort (median FEV1 percent predicted 99%).Interestingly, the number of nebulized medications and patient age are not associated with the inhalation technique score, indicating that adequate technique is feasible in children with cystic fibrosis regardless of their age and their treatment burden. In the subset of patients with available spirometry results, FEVNebulizer cleaning and disinfection is an important aspect of care in patients with cystic fibrosis. There have been studies indicating that appropriate disinfection is related to reduced nebulizer contamination with pathogens ,22. AvaiMoreover, replacement of the nebulizer cup at the recommended intervals is of paramount importance as particle formation and medication delivery change with equipment use and especially when using vibrating mesh nebulizers . In the P. aeruginosa but not for other important pathogens like S. aureus [Most families disinfected the nebulizer using one of the methods recommended in published guidelines ,12. In tP. aeruginosa infection. Hence, we speculate that patients using more nebulized treatments might better recognize the importance of being meticulous with disinfection compared to patients with less severe disease or without P. aeruginosa infection.Interestingly using more nebulized medications was associated with a better maintenance score. There is no clear explanation for this study finding. Higher number of nebulized treatments is often associated with higher disease severity and many of the nebulized medications are antibiotics for A limitation of the present study is that family attitudes towards the importance of disinfection have not been assessed. In a recent study, a gap between recognition of the importance of disinfection and the actual consistency in following the recommended disinfection procedures was identified . In addiEven though inhalation technique and disinfection practices were found to be adequate in a large proportion of cases, there is still a need for regular review and education of patients and their families. Type of nebulizer was associated with improved inhalation technique, but more data are necessary before making a specific recommendation. Number of nebulized medications did not affect inhalation technique or disinfection/maintenance scores, underscoring that family engagement and adherence to treatment might be more important than the actual treatment burden.


Salinity is a major obstacle to wheat production worldwide. Salt-affected soils could be used by improving salt-tolerant genotypes depending upon the genetic variation and salt stress response of adapted and donor wheat germplasm. We used a comprehensive set of morpho-physiological and biochemical parameters and simple sequence repeat (SSR) marker technique with multivariate analysis to accurately demonstrate the phenotypic and genetic variation of 18 wheat genotypes under salinity stress. All genotypes were evaluated without NaCl as a control and with 150 mM NaCl, until the onset of symptoms of death in the sensitive plant . The results showed that the relative change of the genetic variation was high for all parameters, heritability (>60%), and genetic gain (>20%). Stepwise regression analysis, noting the importance of the root dry matter, relative turgidity, and their respective contributions to the shoot dry matter, indicated their relevance in improving and evaluating the salt-tolerant genotypes of breeding programs. The relative change of the genotypes in terms of the relative turgidity and shoot dry matter during salt stress was verified using clustering methods. For cluster analysis, the genotypes were classified into three groups: tolerant, intermediate, and sensitive, representing five, six, and seven genotypes, respectively. The morphological and genetic distances were significantly correlated based on the Mantel test. Of the 23 SSR markers that showed polymorphism, 17 were associated with almost all examined parameters. Therefore, based on the observed molecular marker-phenotypic trait association, the markers were highly useful in detecting tolerant and sensitive genotypes. Thus, it considers a helpful tool for salt tolerance through marker-assisted selection. Soil salinization and poor water quality are a worldwide problem in crop production. A high level of salt reduces growth, motivates leaf damage, and ultimately, causes the death of the crop. Therefore, salinization may threaten the sustainability of crop production and affect human life in areas prone to salinity, which incorporates all of today’s irrigated land . In addiTriticum aestivum L.) are generally sensitive to salinity. It has been demonstrated that the genotypes that are tolerant of salinity can remain alive but the productivity is greatly reduced at a greater level of 120 mM NaCl /100 [−1 FW mL−1), peroxidase , and polyphenol oxidase , as described by Aebi [For enzyme extractions, fresh leaf samples (0.5 g) were crushed in liquid nitrogen, to grind them into a fine powder, and placed in an ice-bath with 4 mL of a homogenized 50 mM potassium phosphate buffer (pH 7.8), including 1% (w/v) polyvinylpolypyrrolidone. The homogenate was then centrifuged at 14000 rpm for 10 min at 4 °C. This supernatant is used as the rough extract of assays for catalase , as they have been linked with salt tolerance in wheat  of each genotype were crushed in liquid nitrogen. The genomic DNA of each genotype was extracted using the Wizard Genomic DNA Purification Kit . A spectrophotometer  was used to measure the DNA concentration at 260 nm, and the extract was electrophoresed on 0.8% agarose to ensure the quality. After that, the refined DNA was standardized at 25 ng μL-1, and the final concentration was kept at −20 °C. The 43 SSR markers used in this study were selected from previous studies ,31,32,44in wheat . For eac2) and genetic gain (GG) were calculated for all studied parameters, as described by Abdolshahi et al. [Phenotypic Data Analysis: All studied parameters were subjected to an analysis of variance (ANOVA) using SAS software . The broad sense heritability  or absent (0), to create a binary matrix. The polymorphic information content (PIC) for each marker was calculated as described by Smith et al. . The disp < 0.01) differences for the 13 measured traits among the wheat genotypes in the control and salinity treatments. In general, the tolerant check cultivar (Sakha-93) had better mean values for all traits than the sensitive check cultivar (Gemmeiza-9) under salinity treatment, with the moderate check cultivar (Giza-168) midway between them  and genetic gain (GG) showed high values  for all measured traits, which ranged from 79.91% to 97.98% and 44.62% to 288.11%, respectively , while also showing that the RN, RL, SL, MSI, PPO, CAT, WD, RDM, and RT contributed towards 0.988 , produced three major clusters, and reflected the distance between the three clusters with similar genotypes . The firp < 0.0001) regarding the RT and SDM. Moreover, least squared mean comparisons between the three groups for the RT and SDM traits were significantly different for T compared to I and S, excluding group T, which was insignificantly different for the SDM  across three groups, explained that the groups were highly significantly different . The significance of the correlation between the two matrices  may suggest that there is some linkage between the SSR markers used and morphological characters chosen.The genetic relationship between the genotypes was evaluated to determine parental genotypes for the breeding program and whether the observed classification of the 18 genotypes, based on their DNA profile, corresponds with their reaction to salinity stress. Conclusions reached from Nei’s genetic distances  revealed2 ranging from 0.077 for wmc60 in the relative change regarding the SL to 0.832 for gwm241 in the salinity treatment regarding the RT and WD), as highlighted by the partial coefficient of determination presented in 2 ranged from 0.435 to 0.931) compared to the control treatment, for all parameters excluding the POD (The genotypic data obtained from the 23 informative SSR loci (out of 42) were used to identify the markers associated with the different parameters and treatments used in the current study. The analysis used stepwise marker regression to identify the markers that have contributed the most to each parameter (quantitative variation). The results show that 17 of the SSR markers are associated with the parameters  in the cells at the subcellular level, particularly in chloroplasts and mitochondria, important sources of ROS in plants subjected to salt stress, which can affect the photosynthetic process, resulting in growth inhibition and a low grain yield . Plants 2 < 60 and GG > 30 for all traits, shows that the variation in these traits is mainly due to genetic contributions, meaning they could be drawn upon during the selection process and suggesting that the majority of the gene effects are additive  of 0.907 from 1.000. In this study, the two independent variables, RDM and RT, could be unbiased parameters for assessing the salinity tolerance, given their contribution in the production of the SDM as a dependent variable. The great contribution of the RT on the SDM supported its significance as a selective standard in wheat. Therefore, it may be used as a criterion in screening and selection to measure the optimum genotypes for salt tolerance after removing the RDM trait due to its weak contribution, measurement difficulties, and high cost [Simple correlations, without the consideration of the interactions between the SDM and related traits, may mislead plant breeders from achieving their primary objective . Therefoigh cost ,63,64.The genotypes showed natural genetic differences among themselves, given that genotypes that excel in one trait will simultaneously be inferior in other traits . A dendr2 fixation [RT integrates the leaf water potential with the effects of osmotic adjustment (a robust mechanism to maintain cellular hydration) as a barometer of plant water status. The tolerant genotype has the power to minimize stress through the conservation of turgid leaves under stress conditions, which will have physiological advantages, such as growth and stomatal activity, and will protect and maintain the photosystem complex . The relfixation . Another important conclusion in this study is the identification of information concerning genetic diversity. The degree of genetic variation between and within groups is the outcome of various factors, such as gene flow, hybridization, the selection effect, genetic drift, and natural and/or artificial mutagens . KnowingSSRs are powerful markers used in assessing polymorphisms and the degree of genetic variation of many plant species, including wheat . In thisIn our results, the salt-intermediate group (I) showed the highest genetic variability , indicating more diversity among themselves compared to the salt-sensitive group (S), which showed the lowest variability  . The higThe genetic structure analysis results showed that all genotypes were assigned to three groups or clusters based on their salinity response, as indicated by the groups in p < 0.0001, alpha = 0.05). In addition, the SSR markers were successfully used for gene tagging or used in marker-assisted selection for agronomic traits [A comparison of genetic and morphological distances using the Mantel test is one of the most popular approaches to determine the relationship between the two. According to the Mantel test, the clustering pattern in this study is caused by both the genetic and morphological distances, as a significant positive correlation was observed , which could be considered as important indicators for describing the genetic diversity of salt tolerance in wheat. Given the importance of the relative change of the SDM and RT for the clustering of the phenotypic data, we found the cumulative coefficient of determination of the markers were powerful, being 0.853 and 0.826, respectively. Furthermore, the Xgwm 312 marker, which is used to detect the Nax1gene and seeks for Na exclusion as described by [2 were 0.749 and 0.628, respectively; −) from the plant cells could be used to avoid the negative effects of these ions on plant physiological processes. Given the importance of the markers associated with the parameters and their contribution to the tolerance, we found 17 markers associated with the phenotypic trait  was observed based on the Mantel test. In total, 17 markers showed linkages with all examined parameters (R2 ranged from 0.077 to 0.832), and thus, they are extremely useful in detecting tolerant and sensitive genotypes to determine their usefulness for salt tolerance through marker-assisted selection.Our results confirm the importance of the RT and SDM, based on the relative change in the classification of DHLs for salt tolerance compared to check cultivars. Moreover, a strong significant correlation between the morphological and genetic distances (r = 0.514,


Lama glama) are invaluable resources of Peru. Despite their importance, their population is decreasing. The Camelid Germplasm Bank—Quimsachata was created as a guardian of this South American camelid (SAC) species and established a bank of llamas from their two types, Ch’aku and Q’ara. However, these populations need to present high genetic diversity to be considered suitable conservation stocks. Thus, in the present study, 13 microsatellites specific for the SAC were used to assess the current genetic variability and differentiation of the llama population from the Bank. The global population showed high genetic diversity with a total of 157 different alleles, with an average of 12.08 alleles per microsatellite, an expected and observed heterozygosity of 0.758 and 0.707, respectively, and an average polymorphic information content (PIC) of 0.723. Although considered as two different breeds and managed separately, the genetic differentiation between Ch’aku and Q’ara was low (FST = 0.01). Accordingly, the gene flow value was high (Nm = 30.5). Overall, our results indicate the existence of high genetic variation among individuals, and thus, this llama population could be considered a suitable genetic stock for their conservation and for sustainability programs. Additionally, the 13 microsatellites can be used to study other Peruvian llama populations and monitor the genetic variability of llamas from the Camelid Germplasm Bank—Quimsachata.Llamas ( Lama glama) are the largest South American camelids (SACs) and the best adapted to a wide range of environmental conditions [Llamas  established the “Camelid Germplasm Bank—Quimsachata” in Puno, Peru, oriented to the recovery and conservation of colored alpacas and the two llama types, Ch’aku and Q’ara . HoweverMicrosatellite markers (hereafter referred to as microsatellites), due to their high polymorphism and abundant distribution throughout the genome , are impTherefore, this is the first population genetics study employing microsatellites carried out on the llama population of the Camelid Germplasm Bank—Quimsachata, whose biodiversity represents the natural, economic, cultural, and historical patrimony of Peru, and it aims to (i) assess its genetic diversity and structure and (ii) estimate the genetic differentiation between the two llama subpopulations, Ch’aku and Q’ara.n = 92, 67 females and 25 males) and Q’ara  were collected at the Camelid Germplasm Bank—Quimsachata, located in the district of Santa Lucia in the Department of Puno, Peru . Genotyping was performed using GeneMapper v.4.0 software (Applied Biosystems).Genomic DNA was amplified by polymerase chain reaction (PCR) using a Mastercycler Pro S . Microsatellites with similar PCR conditions were co-amplified using a multiplex PCR, and the fluorescent labeling of the forward primers allowed for the design of multiloading panels. Each PCR run was performed in a total volume of 10 μL, containing 50 ng of DNA. Reaction mixtures contained 1x PCR buffer, 2 mM of MgClIS, FIT, and FST; [The most used genetic diversity parameters, such as the number of alleles per microsatellite, allelic frequencies, mean number of alleles per microsatellite, private alleles, expected and observed heterozygosity , and polymorphic information content (PIC), were calculated for each of the 13 microsatellite markers, using the CERVUS 3.0.3  and GENEand FST; ) using Gand FST; . The effand FST; ) was estThe genetic structure was determined through a grouping analysis of the individuals in a different number of inferred clusters (K) using an analysis based on the ‘admixture’ ancestry model implemented in the STRUCTURE 2.3 software . The burThe 13 microsatellites used in this study were polymorphic and revealed a high level of genetic diversity in the population of llamas from the Camelid Germplasm Bank—Quimsachata. The number of alleles, He, Ho, and PIC values for each microsatellite for Ch’aku and Q’ara as separated populations and as a global population are shown in In total, 157 alleles were found across the 251 individuals, with an average of 12.08 alleles per microsatellite . The He value was higher than the Ho value, with an average of 0.707 in the global population. Additionally, the He and Ho values were always higher in the Ch’aku subpopulation compared to the Q’ara. The PIC value ranged from 0.517 (LCA54) to 0.883 (YWLL08). p < 0.05). The inbreeding coefficient (FIS) was estimated for each microsatellite for the global population and for the Ch’aku and Q’ara subpopulations, and they were positive and significantly different from zero (p > 0.05)  . Moreove > 0.05) . The exi > 0.05) . On the  > 0.05) .ST) between the Ch’aku and Q’ara types showed very low genetic differentiation (FST = 0.01)  , whereas = 0.01) . The FST 2.9.3.2 . Bayesian analysis carried out by the STRUCTURE software , using sThere has been an upsurge in attempts to conserve natural resources, since it is well known that the loss of genetic variability diminishes the ability to recover endangered species  and decrn = 251) was analyzed by using 13 microsatellites specific to the SAC. The results showed a high level of genetic diversity in the population of llamas, with an average of 12.08 alleles per microsatellite and an expected heterozygosity of 0.758. The Camelid Germplasm Bank—Quimsachata keeps the birth and mating records of each individual and that information is used to avoid mating between close relatives [A representative sample of llama individuals n = 25 was analelatives ) and BolAll the microsatellites analyzed were highly polymorphic (PIC > 0.5), especially YWLL08 (0.883), YWLL44 (0.863), YWLL59 (0.819), and LCA85 (0.8). Interestingly, we found alleles previously unrecorded in their original studies; for instance, YWLL08, YWLL44, YWLL59, LCA82, LCA83, GLM4, and LGU76 reported 13, 11, 10, 5, 7, 9, and 8 alleles in the first studies, respectively ,27,28,40IS media value for the total population (0.063) and the microsatellites showing deviations from the HWE were explained by heterozygote deficiency. The excess of homozygotes in a domestic population indicates loss of genetic variability and could be explained by a lack of random mating, which occurs during the artificial selection of herds [The Fof herds , populatof herds . Indeed,of herds ,54. A deST) was 0.0102 along with a high gene flow value (Nm = 30.5). These values, according to [Regarding the llama population structure from the Camelid Germplasm Bank—Quimsachata, although we found a large number of private alleles in the Ch’aku and Q’ara subpopulations  and the males and females of the same phenotype are only brought together for breeding. Therefore, the low genetic structure is most likely a result of their own ancestral domestication process, which involved frequent exchanges of reproductive males and, hence, crossbreeding between both types. For future studies to elucidate a potential genetic differentiation between these phenotypes, we propose the use of genes related to observed phenotypic traits , which could help to identify allelic variants related to the studied phenotypes , or the L. glama) population from the Camelid Germplasm Bank—Quimsachata utilizing microsatellites. The set of microsatellites used was highly polymorphic and, hence, can be utilized to track the genetic variability of these animals to avoid a reduction in the effective population size. Overall, our results show that the llama population of the Camelid Germplasm Bank—Quimsachata presents a high level of genetic diversity; thus, it can be considered as an adequate stock for the conservation of this natural resource. However, it would be important to identify other Peruvian llama populations that could help to increase the diversity of the Bank and enable a higher representation of Peruvian llamas.This study is the first assessment of the genetic diversity and structure of the Peruvian llama (On the other hand, although bred separately and managed as two distinct subpopulations, we observed low genetic differentiation between the Ch’aku and Q’ara phenotypes. Therefore, additional analysis with genes related to phenotypic observed differences should be carried out to assess potential genetic differentiation between these two phenotypes.


Advances in diagnostics testing and treatment of genetic conditions have led to increased demand for genetic services in the United States. At the same time, there is a shortage of genetic services professionals. Thus, understanding the models of service delivery currently in use can help increase access and improve outcomes for individuals identified with genetic conditions.This review aims to provide an overview of barriers and facilitators to genetic service delivery models to inform future service delivery.We conducted a scoping literature review of the evidence to more fully understand barriers and facilitators around the provision of genetic services.There were a number of challenges identified, including the limited number of genetics specialists, wait time for appointments, delivery of services by nongenetics providers, reimbursement, and licensure. The ways to address these challenges include the use of health information technology such as telehealth, group genetic counseling, provider-to-provider education, partnership models, and training; expanding genetic provider types; and embedding genetic counselors in clinical settings.The literature review highlighted the need to expand access to genetic services. Ways to expand services include telehealth, technical assistance, and changing staffing models. In addition, using technology to improve knowledge among related professionals can help expand access. Advances in diagnostic testing and treatment options for genetic conditions have led to increased demand for genetic services in the United States. The gateway to genetic services is through multiple paths. For example, newborn screening programs test all infants shortly after birth for a variety of genetic conditions. Other avenues include clinical diagnosis from a broad array of specialists, such as neurologists, oncologists, and geneticists. We sought to understand how genetic services are provided and identify the most cost-effective methods of meeting growing needs for services. Understanding the current delivery models being used can help strengthen the long-term follow-up of individuals identified with genetic conditions and, ultimately, improve outcomes for patients and families.The goal of this study is to identify evidence from the literature regarding the challenges and potential solutions to improve service delivery models. We sought to understand the following research questions: (1) What are the current practice methods and models for genetic services? (2) What are the barriers or challenges presently being encountered that impede the provision of timely genetic services? and (3) What are the best practices, lessons learned, and service offerings that can inform future efforts?We conducted a series of 3 iterative literature searches with increasing specificity of search terms. The searches enabled the research team to amass a broad base of literature related to genetic service models spanning from genetic services delivered in early infancy, as part of newborn screening, to services delivered in adulthood, with the onset of health conditions such as cancer. This was intended to explore models that may have been implemented successfully in other health areas or populations that could potentially be of interest for application or adoption in the United States. Search parameters were consistent in all 3 searches , and seaIn total, 2 researchers reviewed all search results for initial inclusion. Researchers independently reviewed each abstract and made notations related to reported challenges and potential solutions regarding the delivery of genetic services. These notations guided inclusion and exclusion decisions. Researchers reviewed each other’s notations, discussed any areas of disagreement, and ultimately came to a consensus on whether the article should be obtained and included in the review. Full-text articles were obtained for all search results that met these initial criteria; each article was reviewed, and themes were extracted.LanguageEnglishPeriod2010-2020Geographic populationUnited States and internationalDatabasesPubMed EmbasePsycINFO Web of Science Search 1Genetics AND service delivery OR modelSearch 2Genetic(s) service(s) provision OR genetic(s) service(s) delivery OR genetic(s) service(s) delivery model(s) OR genetic health care service(s) delivery OR genetic(s) support delivery OR genetic(s) support model(s) OR genetic(s) service(s) delivery structure OR genetic(s) services delivery system OR genetic(s) delivery of health care OR genetic counseling services OR genetic diagnostic servicesSearch 3Pediatric genetic counseling OR newborn screening follow-up AND genetic(s) service(s) provision OR genetic(s) service(s) delivery OR genetic(s) service(s) delivery model(s) OR genetic health care service(s) delivery OR genetic(s) support delivery OR genetic(s) support model(s) OR genetic(s) service(s) delivery structure OR genetic(s) services delivery system OR genetic(s) delivery of health care OR genetic counseling services OR genetic diagnostic servicesThe search yielded 187 unique abstracts or references . Of thesAfter an initial review, 93 articles related to genetic service models from across the 3 searches were selected for a full-text review. Three researchers categorized the articles by theme together and carried out full-text reviews. The shortage of genetics professionals coupled with a rapidly growing need has been described as one of the biggest challenges facing the field . There iIn a survey of state newborn screening coordinators within the Southeast Regional Newborn Screening and Genetics Collaborative, close to half of the respondents indicated that the adequacy of the number of genetic counselors, dietitians, and medical or biochemical geneticists was minimal to insufficient . One stuHowever, as the need for these professionals continues to grow, the number of clinical geneticists entering the field is decreasing, with approximately 50% of medical genetics residency positions unfilled each year . In someTwo of the main challenges related to the delivery of genetic services were the time intensiveness of providing genetic counseling and wait times for appointments. Despite the fact that genetic service delivery models have changed over the years and fewer visits per patient are common, this is not the case for all areas of genetic counseling; genetic counseling continues to be a time- and resource-intensive process . In a suSeveral studies have explored the delivery of genetic services by nongenetics professionals and the resulting challenges and impacts on patients ,11,13-15Although primary care providers are well positioned to recognize whether genetic tests or referral to genetic counseling is appropriate, there are still gaps in identifying the need for genetic services . In addiPatients can experience adverse outcomes from delivery of services by nongenetics providers. A web-based survey and structured telephone interview with genetic counselors revealed patients’ negative outcomes on receiving genetic services from nongenetics professionals in Minnesota. These outcomes included adverse psychosocial effects, medical mismanagement, inadequate counseling, negative shifts in attitudes toward medical providers, and unnecessary use of resources . AnotherThere are inherent challenges related to difficulties in implementing, sustaining, and scaling alternative delivery models ,5. Some The use of telehealth practices in the field of genetics, often referred to as telegenetics, has increased steadily in the past decade. Most often, this is through the use of video-based technology, although phone-based delivery of services to patients has also been used. A landscape review article by Terry et al  found thThose who have used telegenetics to deliver services to patients indicate that it allows providers to see more patients, reduces wait time, and improves costs ,19-21. IDNA-direct, with a telephone pretest counseling model accompanied by mailed educational materials, followed by an in-person posttest consultation. Rayes et al [A mini-review by Buchanan et al  identifies et al  describeOutcomes reported through telegenetics are fairly well documented, with most focusing on the delivery of telegenetic counseling. When compared with baseline scores or in-person genetic service delivery, most patients reported reduced anxiety and high levels of knowledge . TelephoAnother possible option for improving the efficiency of genetic services is the delivery of genetic counseling services through a group model. Two studies compared group counseling with individual counseling ,33. In bIn this model, primary care providers have access to specialty providers to gain knowledge regarding care and monitoring of patients with special health care needs. Much of this work has been patterned after the Extension for Community Healthcare Outcomes model. This approach is gaining traction in the field of genetics .In addition to telegenetics, the use of a team-based or collaborative approach has been suggested as an alternative genetic service delivery model . KubendrOther studies have discussed a partnership model between genetic counselors and physicians in oncology . One stuOne study in Hong Kong used a new model to provide clinical genetic services . An instPartnership models with other health professionals, such as social workers and psychologists, also emerged as potential models for patient-centered genetic care. Telfair argues that social work education should include the basics of genomics because social workers may play a large role in genetic counseling, noting their ability to ensure that clients have access to counseling and testing . Other aWith genetics and nongenetics professionals alike, training and educational resources were indicated as needs ,6,14,15.Another approach to the delivery of genetic services is to embed genetic services or genetic counselors into nongenetic clinical practices. In 2012, Battista et al  carried recommend or strongly recommend response).One study assessed the attitudes and barriers of incorporating a genetic counselor into a cystic fibrosis clinic in New York . Among cThis model has been translated into and tested in multiple clinical settings, including cancer care. In a gynecologic oncology clinic in Ohio, a higher number of patients were referred for genetic consultation after changing to a genetics-embedded model; referrals increased from 21% to 44% of patients . In addiThe use of genetic counseling assistants (GCAs) has also been explored as a solution to the shortage of genetic counselors. Pirzadeh-Miller et al  exploredIn a recent survey, members of the NSGC responded to a survey regarding the role of GCAs and the impact they may have on the genetic counseling profession . Themes A handful of studies described various technologies that are being implemented to support the delivery of genetic services. Flannery  identifiKearney et al  describeA few recent papers explored how to best implement or evaluate the use of alternate service delivery models. For example, Chou et al  developeOther quality improvement initiatives have underscored the potential for new and innovative frameworks or learning collaboratives to address existing shortcomings and challenges in genetic service delivery. Russ et al  describeLimited number of genetics specialistsPatient-to-provider telegeneticsGroup genetic counselingUse of genetic counseling assistantsUse of health technologies and patient educational toolsImplementation and evaluation of alternate service delivery modelsWait time for and length of genetics appointmentsPatient-to-provider telegeneticsUse of health technologies and patient educational toolsImplementation and evaluation of alternate service delivery modelsEmbedding genetic counselors within clinical settingsDelivery of services by nongenetics providersProvider-to-provider telegenetic consultationPartnership models between genetics and nongenetics providersTraining and educational resourcesUse of health technologies and patient educational toolsImplementation and evaluation of alternate service delivery modelsReimbursement and licensureUse of genetic counseling assistantsImplementation and evaluation of alternate service delivery modelsThe literature review pointed out several challenges that are currently facing the field of genetics. Those that cause the most concern for access to genetic services are the limited number of genetics specialists available to meet the growing demand for services and the long wait times needed to get appointments. However, several possible solutions highlighted in this literature review could be implemented to address these challenges.The use of telehealth is one of the main ways to increase access to genetic services. On the basis of the literature review, there is ample evidence to support the use of telehealth. Several challenges can be addressed through the use of telehealth. First, because of the vastness of the United States and the dearth of genetic service providers, each of the genetic services centers serves a large catchment area. Thus, there are geographic barriers to access to care. Telehealth can help alleviate these barriers. Second, many states have a large Spanish-speaking population. However, there is a shortage of Spanish-speaking providers. Through telehealth, bilingual providers can expand their reach. In addition, telehealth can facilitate the use of remote translation services. Finally, there is a nationwide shortage of genetic service providers across the continuum. Telehealth expansion can help with workforce issues by obviating the need for staff to travel to multiple locations. In addition, telehealth can help with load-balancing staff across locations.Increasing the use of telehealth services, however, may require additional assistance or planning. Other needs related to the expansion of telehealth may emerge. For example, providers may need access to training opportunities, to purchase equipment, or to feel prepared to implement telehealth. Support for training can come through existing resources, such as those provided by Telehealth Resource Centers . ReadineIn addition to telehealth, there are a few possible solutions related to clinical workflow that may improve access to genetic services. The use of GCAs has been rated favorably in many of the studies included in the literature review. For high-volume clinics, another consideration to improve clinic flow could be the use of group genetic counseling for low-risk populations followed by an individual in-person or telephone session. Another possibility is the use of patient education tools to assist with the amount of time genetic counselors spend with patients individually.Given that fewer genetics professionals are entering the field and the current workforce issues, there is a need to build genetics knowledge and expertise among nongenetics professionals. This can be accomplished by using one or more possible approaches that were revealed during the literature review. Partnership models were used to expand access to genetic services in collaboration with nongenetics professionals, sometimes through telehealth. These solutions allow patients and families to access a genetics specialist and build relationships with nongenetics providers, which enhances their expertise. This could be accomplished through outreach to primary care settings of existing patients who see a genetics professional. Similarly, provider-to-provider telegenetic consultation is a strategy that can be employed to pair genetics providers with nongenetics providers. Through consultation with experts, nongenetics professionals gain a better understanding of their patients and are better able to care for their unique needs. Both these approaches would also help to address the noted challenges of nongenetics providers delivering services without the support of a genetics specialist .Another possible solution to improve the knowledge and expertise of nongenetics professionals is to embed genetics providers within primary care settings. Typically, genetic counselors are hired to be part of primary care settings to assist with referrals and provide long-term support to patients. This approach, though, may be more challenging to implement, given there is still an insufficient number of genetic counselors, although the field is growing. It may also be more difficult, given that the state does not have the authority to direct how primary care providers structure their office staff.The literature review illuminated the challenges and identified possible solutions that could be implemented to improve the delivery of genetic services. Options that include telehealth applications may be the most straightforward and immediate option for genetic centers to pilot. However, a more long-term investment will be to complement telehealth models with the education of nongenetics professionals. Given the likely continued shortage of providers in the field of genetics, a transdisciplinary approach will be needed to build the expertise of primary care providers and other health care professionals to best serve the needs of patients and families.