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recent systematic analysis showed 2011 314 296 331 million children younger 5 years mildly moderately severely stunted 258 240 274 million mildly moderately severely underweight developing countries in iran study among 752 high school girls sistan baluchestan showed prevalence 16.2% 8.6% 1.5% underweight overweight obesity respectively the prevalence malnutrition among elementary school aged children tehran varied 6% 16% anthropometric study elementary school students shiraz revealed 16% suffer malnutrition low body weight snack 300 400 kcal energy could provide 5 10 g protein day nowadays school nutrition programs running national programs world wide national school lunch program united states there also reports regarding school feeding programs developing countries vietnam school base program showed improvement nutrient intakes iran national free food program nffp ) is implemented elementary schools deprived areas cover poor students however program conducted slums poor areas big cities many malnourished children low socio economic situation covered nffp although rate poverty areas known deprived higher areas many students deprived areas actually poor afford food hence nutritional value nffp lower scientific recommended snacks age group furthermore lack variety food packages decreased tendency children toward nffp hand the important one ministry education moe iran responsible selecting providing packages targeted schools the ministry health moh supervising health situation students health needs welfare organizations along charities indirect effect nutritional status students financial support family provincial governors also role coordinating supervising activities organizations parent teacher association community based institution participates school policy nffp in addition organizations nutritional literacy students parents teachers important issue could affect nutritional status school age children therefore present study conducted aim improving nffp resources poor children covered even big cities moreover food packages replaced nutritious diverse packages accessible non poor children according aim study multiple factors could affect problem public health advocacy chosen best strategy deal issue therefore present study determines effects nutrition intervention advocacy process model prevalence underweight school aged children poor area shiraz iran this interventional study carried 2009 2010 shiraz iran this survey approved research committee shiraz university medical sciences coordination education organization fars province two elementary schools one middle school third region urban area shiraz selected randomly schools all students 2897 7 13 years old screened based body mass index bmi nutritionists according convenience method all students divided two groups based economic situation family revenue head household job nutrition situation first group poor malnourished students group well nourished well students for report children height weight entered center disease control prevention cdc calculate bmi bmi age z scores based cdc diseases control prevention growth standards the significance difference proportions calculated using two tailed z tests independent proportions implementing interventions the advocacy process model weight nearest 0.1 kg balance scale model seca scale standing height measured nearest 0.1 cm wall mounted stadiometer advocacy group formation step started stakeholder analysis identifying stakeholders the team formed representatives stakeholders include education organization welfare organization deputy health shiraz university food cosmetic product supervisory office several non governmental organizations charities situation analysis carried use existing data formal report organizations literature review focus group experts the prevalence malnutrition related factors among students determined weaknesses strengths nffp analyzed accordingly three sub groups established research evaluation education justification executive group designing strategies : three strategies identified education justification campaign nutritional intervention providing nutritious safe diverse snacks networking performing interventions interventions implementing selected schools providing diverse nutritious snack package along nutrition education groups first group poor malnourished students utilized package free charge education justification intervention regarding literature review expert opinion educational group affiliated advocacy team prepared educational booklets nutritional information level degree accordingly education booklets integrated regular education students educated justified better nutrition life style it leads educational group hold several meeting student parents justify project benefit children after meetings parental desire participation project illustrated effectiveness justification meeting for educate fifteen talk show programs tv radio 12 published papers local newspaper implemented mobilize community gain support healthy diet importance breakfast snack adolescence wrong food habits among school age children role family improve food habit children main topics media campaign focused nutritional intervention snack basket students replaced traditional nutritious diverse foods general new snack package average provided 380 kcal energy 15 g protein along sufficient calcium iron low economic malnourished children supported executive group affiliated advocacy team rest prepare snack research evaluation step literacy anthropometric indices bmi students assessed interventions the reference anthropometric measures world health organization national center health statistics nchs standards cut offs two standard deviations sd mean each student malnourished poor taken account free food nutritious snacks demographic information height weight knowledge students measured use validated reliable cronbach alpha 0.61 questionnaire this project granted shiraz university medical sciences charities welfare organization education organization fars province statistical analyses performed using statistical package social sciences spss software version 17.0 spss inc the results expressed mean sd proportions appropriated order determine effective variables malnutrition status paired test used compare end values baseline ones group in project z score cut offs used follow using bmi age z scores overweight 1 sd i.e. z score 1 equivalent bmi 25 kg obesity 2 sd equivalent bmi 30 kg thinness 2 sd severe thinness 3 sd this interventional study carried 2009 2010 shiraz iran this survey approved research committee shiraz university medical sciences coordination education organization fars province two elementary schools one middle school third region urban area shiraz selected randomly schools all students 2897 7 13 years old screened based body mass index bmi nutritionists according convenience method all students divided two groups based economic situation family revenue head household job nutrition situation first group poor malnourished students group well nourished well students for report children height weight entered center disease control prevention cdc calculate bmi bmi age z scores based cdc diseases control prevention growth standards the significance difference proportions calculated using two tailed z tests independent proportions implementing interventions weight nearest 0.1 kg balance scale model seca scale standing height measured nearest 0.1 cm wall mounted stadiometer advocacy group formation step started stakeholder analysis identifying stakeholders the team formed representatives stakeholders include education organization welfare organization deputy health shiraz university food cosmetic product supervisory office several non governmental organizations charities situation analysis carried use existing data formal report organizations literature review focus group experts the prevalence malnutrition related factors among students determined weaknesses strengths nffp analyzed accordingly three sub groups established research evaluation education justification executive group designing strategies : three strategies identified education justification campaign nutritional intervention providing nutritious safe diverse snacks networking performing interventions interventions implementing selected schools providing diverse nutritious snack package along nutrition education groups first group poor malnourished students utilized package free charge duration intervention 6 months education justification intervention regarding literature review expert opinion educational group affiliated advocacy team prepared educational booklets nutritional information level degree accordingly education booklets integrated regular education students educated justified better nutrition life style obviously student families remarkable effect children food habit it leads educational group hold several meeting student parents justify project benefit children after meetings parental desire participation project illustrated effectiveness justification meeting educate fifteen talk show programs tv radio 12 published papers local newspaper implemented mobilize community gain support healthy diet importance breakfast snack adolescence wrong food habits among school age children role family improve food habit children main topics media campaign focused nutritional intervention snack basket students replaced traditional nutritious diverse foods general new snack package average provided 380 kcal energy 15 g protein along sufficient calcium iron low economic malnourished children supported executive group affiliated advocacy team rest prepare snack research evaluation step literacy anthropometric indices bmi students assessed interventions the reference anthropometric measures world health organization national center health statistics nchs standards cut offs two standard deviations sd mean each student malnourished poor taken account free food nutritious snacks demographic information height weight knowledge students measured use validated reliable cronbach alpha 0.61 questionnaire this project granted shiraz university medical sciences charities welfare organization education organization fars province advocacy group formation step started stakeholder analysis identifying stakeholders the team formed representatives stakeholders include education organization welfare organization deputy health shiraz university food cosmetic product supervisory office several non governmental organizations charities situation analysis carried use existing data formal report organizations literature review focus group experts the prevalence malnutrition related factors among students determined weaknesses strengths nffp analyzed accordingly three sub groups established research evaluation education justification executive group designing strategies three strategies identified education justification campaign nutritional intervention providing nutritious safe diverse snacks networking performing interventions interventions implementing selected schools providing diverse nutritious snack package along nutrition education groups first group poor malnourished students utilized package free charge education justification intervention regarding literature review expert opinion educational group affiliated advocacy team prepared educational booklets nutritional information level degree accordingly education booklets integrated regular education students educated justified better nutrition life style obviously student families remarkable effect children food habit it leads educational group hold several meeting student parents justify project benefit children after meetings parental desire participation project illustrated effectiveness justification meeting educate fifteen talk show programs tv radio 12 published papers local newspaper implemented mobilize community gain support healthy diet importance breakfast snack adolescence wrong food habits among school age children role family improve food habit children main topics media campaign focused nutritional intervention snack basket students was replaced traditional nutritious diverse foods general new snack package average provided 380 kcal energy 15 g protein along sufficient calcium iron low economic malnourished children supported executive group affiliated advocacy team rest prepare snack research evaluation step literacy anthropometric indices bmi students assessed interventions the reference anthropometric measures world health organization national center health statistics nchs standards cut offs two standard deviations sd mean each student malnourished poor taken account free food nutritious snacks demographic information height weight knowledge students measured use validated reliable cronbach alpha 0.61 questionnaire this project granted shiraz university medical sciences charities welfare organization education organization fars province statistical analyses performed using statistical package social sciences spss software version 17.0 spss inc chicago il usa the results expressed mean sd proportions appropriated order determine effective variables malnutrition status paired test used compare end values baseline ones group two sided p 0.05 considered statistically significant project the z score cut offs used follow using bmi age z scores overweight 1 sd i.e. z score 1 equivalent bmi 25 kg obesity 2 sd equivalent bmi 30 kg thinness 2 sd severe thinness 3 sd study population contains 2897 children 70.8% primary school students 29.2% secondary school students 2336 80.5% total students well 561 children 19.5% indigent 19.5% subjects case group n 561 80.5% control group n 2336 the mean age welfare group 10.0 2.3 10.5 2.5 non welfare group demographic characteristics school aged children shiraz iran table 2 shows frequency subjects different categories bmi age non welfare welfare groups school aged children separately among boys girls nutrition intervention based advocacy process model shiraz iran the frequency subjects bmi lower 2 sd decreased significantly intervention among non welfare girls p 0.01 however significant decreases frequency subjects bmi lower 2 sd boys when assess effect intervention total population without separating sex groups found significant change population table 3 bmi age iranian students aged 7 14 years based gender according growth standards 2007 bmi age iranian students aged 7 14 years according growth standards 2007 non welfare welfare groups total population table 4 shown prevalence normal bmi mild moderate severe malnutrition non welfare welfare groups school aged children separately among boys girls nutrition intervention based advocacy process model according table there significant differences prevalence mild moderate severe malnutrition among girls boys table 4 also shows mean anthropometric indices changed significantly intervention among girls boys the pre- post test education assessment groups showed student average knowledge score significantly increased 12.5 3.2 16.8 4.3 p 0.0001 bmi height weight non welfare welfare groups school aged children separately males females nutrition intervention based advocacy process model shiraz iran according study finding odds ratio sever thinness thinness non welfare compared welfare 3.5 3.5 confidence interval ci 2.5 3.9 p 0.001 furthermore finding showed overweight obesity welfare compared non welfare 19.3 19.3 ci 2.5 3.9 p 0.04 the result community intervention study revealed nutrition intervention based advocacy program successful reduce prevalence underweight among poor girls this study shows determinant factor nutritional status school age children socio economic level according knowledge this first study determines effect community intervention based advocacy process malnutrition indices big city shiraz iran the program iran nffp specified deprived area conducted big cities allocating millions dollars nffp government selecting malnourished students active screening system primary middle schools paying attention policy makers student nutrition provided opportunity combat problem however negligence poverty line providing poor snacks terms nutritional value lack variety main defects program advocacy definition blending science ethics politics comprehensive approaching health issues using advocacy program california among high school students improving nutrition physical activity angeles unified school district participants emphasized nutrition classes families well students addition interventions present study another study revealed evaluability assessment gave stakeholders opportunity reflect project implementation issues it seems iran free food program among students needed deprived areas also performed big cities shiraz baseline no significant difference founded among wealthy students pre- post nutritional status intervention in contrast numbers students malnutrition decreased 44% 39.4% identified significant among impecunious girls students there also significant increase proportion children bmi normal age 2 1 sd published community interventions showed better results among females compared males this difference impact nutritional interventions male female might related different age puberty female population compared male population age range present study female although nffp big cities iran programs improving nutritional status providing free milk schools a recent publication shown school feeding programs focus milk supplementation beneficial effects physical function school performances specifically among girls iran the results mentioned study showed improvement weight children psychological test scores grade point average following school feeding program the intervention present study focused snack intake school time there reports regarding nutrition transition iran shows importance nutrition intervention provide healthy eating dietary habits among welfare groups adolescents hence nutrition intervention especially form nutrition education needed big cities among welfare children adolescents although study among iranian adolescents showed dietary behavior adolescents accord knowledge emphasize necessity community intervention programs recent study regarding major dietary pattern among iranian children showed presence four major dietary patterns fast food pattern sweet pattern two major dietary patterns mentioned among iranian children advocacy program audience analysis accordingly one prominent strategies study working media meeting parent teacher association secondary target audiences also took account policy makers different levels national local primary audiences advocacy team several meetings management planning organization national level education organization fars province well principal targeted schools providing nutritious snacks need contribution private sector food industries factories benefits warranted another choice community involvement achieved female health volunteers working health system advocacy team using support charities female health volunteers could establish local factory produced student snacks based new definition however challenges way expanding program mass production proposed snacks according different desires cultures getting involvement food industries respect marketing issues one challenges moreover providing supportive environment order change food habits students parents among wide range population require sustainable continuous inter sector collaboration although limited number schools study interventions advocacy program successful expanding model another areas around country depends convincing policy makers national level this regard advocacy team prepare evidenced based profile transitional planning convince policy makers improving rule regulation nffp the study studies also emphasized must efforts strengthen capacity within schools deal nutritional problems either overweight obesity malnutrition using educational nutritional intervention assessing dietary adherence important nutrition intervention among population population children adolescents limitation blood sample collection assess subject dietary adherence furthermore intervention focused intake snack school time comprehensive information dietary intake children adolescents school day the investigators propose investigation different areas country based socio cultural differences order make necessary modification adapt model areas regarding nutritional needs school age children provision good platform implementing expanding efficient model whole country based upon socio economic situation region advisable moh moe community nutrition intervention based advocacy process model effective reducing prevalence underweight specifically among female school aged children

background : the present study was carried out to assess the effects of community nutrition intervention based on advocacy approach on malnutrition status among school - aged children in shiraz , iran.materials and methods : this case - control nutritional intervention has been done between 2008 and 2009 on 2897 primary and secondary school boys and girls ( 7 - 13 years old ) based on advocacy approach in shiraz , iran . the project provided nutritious snacks in public schools over a 2-year period along with advocacy oriented actions in order to implement and promote nutritional intervention . for evaluation of effectiveness of the intervention growth monitoring indices of pre- and post - intervention were statistically compared.results:the frequency of subjects with body mass index lower than 5% decreased significantly after intervention among girls ( p = 0.02 ) . however , there were no significant changes among boys or total population . the mean of all anthropometric indices changed significantly after intervention both among girls and boys as well as in total population . the pre- and post - test education assessment in both groups showed that the student 's average knowledge score has been significantly increased from 12.5 3.2 to 16.8 4.3 ( p < 0.0001).conclusion : this study demonstrates the potential success and scalability of school feeding programs in iran . community nutrition intervention based on the advocacy process model is effective on reducing the prevalence of underweight specifically among female school aged children .

occurs 50% patients may reach 90% certain types cancers especially patients undergoing chemotherapy and/or radiation therapy.1 anemia defined inadequate circulating level hemoglobin hb hb 12 g dl may arise result underlying disease bleeding poor nutrition chemotherapy radiation therapy preliminary studies suggest survival loco regional control radiation therapy especially head neck cancers may compromised anemia.24 anemia often worsens symptoms fatigue weakness dyspnea thus may negative effect quality life qol performance status patients cancer thus improve physical functioning qol prognosis patients cancer would reasonable take proactive approach identifying populations need treatment cancer associated anemia caa provide timely management blood transfusion effective way replace depleted hb within short period effect unfortunately temporary cause serious adverse risks increased mortality randomized clinical trials patients caa erythropoiesis stimulating agents esas produced significant increases hb level decreased transfusion requirements improved qol.57 however 30%50% patients respond agents in addition use esas often causes concern severe adverse reactions.6,8 several studies esas found shorten overall survival time time tumor progression patients whose hb level reached 12 g dl these studies included patients different primary cancers breast lung head neck cervix lymphomas.911 lack response erythropoietin stimulation patients cancer partly attributed functional iron deficiency state high rate erythropoiesis exceeds delivery usable iron despite adequate iron stores.12 absolute iron deficiency contrast occurs iron delivery impaired iron stores depleted serum ferritin 100 ng ml transferring saturation 20%).13 hepcidin peptide hormone produced liver regulated chronic inflammatory states including cancer hepcidin inhibits iron transport across cell membranes thus decreasing accessibility stored iron gastrointestinal absorption dietary iron leading increased frequency iron restricted erythropoiesis.1416 many randomized trials examined role intravenous iv iron addition esas treatment anemia patients cancer many studies showed improvement esa response time maximal response reduction esa dose improvement qol parameters measured favor combination esas alone the observed benefit independent baseline iron parameters.1721 one study found 36% reduction number patients transfused.21 pilot study assessed efficacy feasibility iv iron monotherapy patients cancer anemia undergoing treatment chemotherapy and/or radiation therapy without use esas patients received study treatment 12 weeks followed 4-week follow period eligible patients least 18 years old start cycle chemotherapy and/or radiation therapy within 1 week inclusion nonmyeloid malignancy hb levels 11.0 g dl less life expectancy 24 weeks eastern cooperative oncology group performance status 02 patients also required serum ferritin level 100 ng ml higher transferrin saturation tsat levels 15% higher received esas iv iron therapy within 30 days oral iron therapy 27 mg day within 7 days enrollment patients excluded leukoerythroblastic features blood film hemolysis gastrointestinal bleeding folate vitamin b12 deficiency elevated serum ferritin 900 ng ml transferrin saturation tsat 35% levels pregnancy lactation liver dysfunction grade 2 higher based national cancer institute common toxicity criteria renal dysfunction serum creatinine levels 2.0 mg dl active infection requiring systemic antibiotics personal family history hemochromatosis comorbidities precluding study participation hypersensitivity iv iron red blood cell transfusion within last 2 weeks investigational agent within 30 days enrollment patients allowed take vitamin mineral herbal supplements containing 27 mg iron per day 100 mg vitamin c per day study follow period blood transfusions permitted primary physician discretion hb levels decreased 8 g dl less patients considered treatment failures written informed consent provided patients study participation protocol supporting documents approved institutional review board king hussein cancer center the study conducted accordance declaration helsinki good clinical practice contained us code federal regulations governs protection human subjects obligations clinical investigators patients received 200 mg ferric hydroxide sucrose diluted 100 ml normal saline infused course 1 hour weekly total 12 weeks first dose given first clinic visit 4 days initiation chemotherapy radiation therapy tsat monitored protocol mandated withholding iron therapy tsat levels higher 50% first clinic visit week 1 baseline blood sample obtained laboratory assessments study treatment started patients attended weekly clinic visits treatment assessment returned follow visits week 14 included complete physical examination complete blood count tsat done every 3 weeks 2 weeks last treatment week 14 complete laboratory assessment hb serum ferritin reticulocyte count transferrin tsat serum iron total iron binding capacity red cell indices white blood cell count differential platelet count serum chemistries done week 1 week 14 end study adverse events assessed clinic visit study completion withdrawal 30 days last study treatment hb test results presented mean median range 12 weeks comparison means hb level made baseline hb hb levels following weeks using test significance criterion p 0.05 used analysis all analyses performed using sas version 9.1 sas institute inc cary nc usa patients received study treatment 12 weeks followed 4-week follow period eligible patients least 18 years old start cycle chemotherapy and/or radiation therapy within 1 week inclusion nonmyeloid malignancy hb levels 11.0 g dl less life expectancy 24 weeks eastern cooperative oncology group performance status 02 patients also required serum ferritin level 100 ng ml higher transferrin saturation tsat levels 15% higher received esas iv iron therapy within 30 days oral iron therapy 27 mg day within 7 days enrollment patients excluded leukoerythroblastic features blood film hemolysis gastrointestinal bleeding folate vitamin b12 deficiency elevated serum ferritin 900 ng ml transferrin saturation tsat 35% levels pregnancy lactation liver dysfunction grade 2 higher based national cancer institute common toxicity criteria renal dysfunction serum creatinine levels 2.0 mg dl active infection requiring systemic antibiotics personal family history hemochromatosis comorbidities precluding study participation hypersensitivity iv iron red blood cell transfusion within last 2 weeks investigational agent within 30 days enrollment patients allowed take vitamin mineral herbal supplements containing 27 mg iron per day 100 mg vitamin c per day study follow period blood transfusions permitted primary physician discretion hb levels decreased 8 g dl less patients considered treatment failures written informed consent provided patients study participation protocol supporting documents approved institutional review board king hussein cancer center the study conducted accordance declaration helsinki good clinical practice contained us code federal regulations governs protection human subjects obligations clinical investigators patients received 200 mg ferric hydroxide sucrose diluted 100 ml normal saline infused course 1 hour weekly total 12 weeks the first dose given first clinic visit 4 days initiation chemotherapy radiation therapy tsat monitored protocol mandated withholding iron therapy tsat levels higher 50% at first clinic visit week 1 baseline blood sample obtained laboratory assessments study treatment started patients attended weekly clinic visits treatment assessment returned follow visits week 14 included complete physical examination complete blood count tsat done every 3 weeks 2 weeks last treatment week 14 complete laboratory assessment hb serum ferritin reticulocyte count transferrin tsat serum iron total iron binding capacity red cell indices white blood cell count differential platelet count serum chemistries done week 1 week 14 end study adverse events assessed clinic visit study completion withdrawal 30 days last study treatment hb test results presented mean median range 12 weeks comparison means hb level made baseline hb hb levels following weeks using test significance criterion p 0.05 used analysis all analyses performed using sas version 9.1 sas institute inc cary nc usa twenty five patients 17 women 8 men eligible consented included study mean age standard deviation sd 56 years 13.0 years chemotherapy varied according primary cancer included anthracycline platinum taxanes cyclophosphamide high dose ifosfamide vincristine vinblastine bleomycin others many included patients chemotherapy treatment second- third line therapy patients characteristics including age primary tumor active anticancer treatment summarized table 1 one patient died study tumor week 2 five patients withdrew study inconvenience three week 3 two week 4 nineteen 76.0% patients completed minimum three treatments 15 60.0% completed nine treatments 14 56.0% completed twelve planned weekly treatments as seen table 2 mean hb level 25 patients baseline 9.6 g dl median 9.9 g dl range 6.9 g dl10.9 g dl 15 patients completed least nine treatments mean change hb level 1.7 g dl median 1.1 g dl range 1.9 g dl 3.2 g dl for 14 patients completed whole treatment period 12 weeks mean hb level change 2.1 g dl median 1.3 g dl range 0.2 g dl 4.6 g dl p 0.0007 eight 42.1% 19 patients completed least three iron infusions 1 g dl increase hb level hemoglobin level changes 14 patients completed twelve iron infusions shown figure 1 no iv iron related adverse events reported among patients study follow period tsat monitored study period patients tsat levels increase 50% the highest ferritin level among patients completed least nine iv iron treatments 1,170 ng ml mean level end study period whole group 379 ng ml five 20.0% patients received blood transfusions considered treatment failures three week 3 transfused hb levels 6.9 g dl 7.8 g dl 5.4 g dl one week 4 transfused hb level 8.2 g dl one week 9 transfused hb level 7.2 g dl low hb levels associated diminished qol possibly decreased overall survival.2 successful treatment anemia undeniable benefits patients often yielding dramatic symptomatic improvement although role esas well established treating caa big concerns recently raised negative effect esas survival patients cancer.911 concerns risk thromboembolism patients cancer higher hb levels receiving esa also addressed many trials.22,23 addition possible immunosuppressive effects blood product transfusions may relevance neoplasia progression addressed before.24 25 pilot study tested feasibility using iron supplementation alone treat anemia patients cancer undergoing chemotherapy without use esas blood transfusion could valid alternative especially patients curable cancers oral iron easier administer relatively inexpensive low patient adherence poor enteral absorption poor tolerance wide range troublesome gastrointestinal adverse effects limit overall effectiveness.26 anemia chronic disease may occur patients cancer associated increase hepcidin levels decreases oral iron absorption bone marrow iron use negating possible effect regular doses oral iron.15 iv iron therapy significantly improves response epoetin alfa compared oral iron iron anemic patients cancer receiving chemotherapy.1721 oral iron supplements esas showed significant benefit esas alone treating caa.21 sodium ferric gluconate iron sucrose appear favorable safety profiles iron dextran a large prospective safety comparison trial failed show serious anaphylactoid reactions,27 confirmed study patients developed reactions patients withdrew study adverse effects given mean hb increase using esas iv iron one large controlled trial 2.4 g dl,21 results obtained study clinically significant these findings confirmed better assessed larger studies questions optimal timing iv iron therapy respect chemotherapy optimal total dose iv iron determined the use iv iron monotherapy recently reviewed group germany studied use ferric carboxymaltose replace esa blood transfusions treatment caa iron deficient patients treated ferric carboxymaltose alone n 233 median 1.4 g dl increase hemoglobin levels compared receiving additional treatment esas n 46 median 1.6 g dl study however peculiar using iron therapy non iron deficiency state.28 iron overload iv iron therapy potential concerns risk developing secondary cancers infection might raised the highest serum ferritin level present study patients completed least 9 weeks iv iron therapy 1,170 ng ml literature addressing cancer infections iron overloaded patients comes patients hemochromatosis patients undergoing hemodialysis published reviews report increase hepatocellular carcinoma patients hemochromatosis develop cirrhosis.29 similarly data supporting association iv iron therapy higher infection rate weak well supported.30 fact anemia risk factor infections patients receiving hemodialysis.31 multivariate analysis associations iron mortality 58,000 patients receiving hemodialysis reported increased death rate serum ferritin levels high 1,200 ng ml.30 increasing cost therapy patients cancer grave concern could additional benefit iv iron use esas patients address many questions raised our team planning bigger trial iv iron patients cancer anemia confirm results discussed pilot trial in addition looking predictors response iv iron serum hepcidin level iv iron therapy alone safe may effective improving hb levels patients cancer undergoing active anticancer therapy further randomized trials needed address many questions raised pilot study

backgroundanemia in patients with cancer who are undergoing active therapy is commonly encountered and may worsen quality of life in these patients . the effect of blood transfusion is often temporary and may be associated with serious adverse events . erythropoiesis - stimulating agents are not effective in 30%50% of patients and may have a negative effect on overall survival.aimsto assess the efficacy and feasibility of intravenous iron therapy in patients with cancer who have non - iron - deficiency anemia and who are undergoing treatment with chemotherapy without the use of erythropoiesis - stimulating agents.methodsadult patients with solid cancers and non - iron - deficiency anemia were included . ferric sucrose at a dose of 200 mg was given in short intravenous infusions weekly for a total of 12 weeks . hemoglobin level was measured at baseline , every 3 weeks , and 2 weeks after the last iron infusion ( week 14 ) . adverse events related to intravenous iron were prospectively reported.resultsof 25 patients included , 19 ( 76.0% ) completed at least three iron infusions and 14 ( 56.0% ) finished the planned 12 weeks of therapy . the mean hemoglobin level of the 25 patients at baseline was 9.6 g / dl ( median , 9.9 g / dl ; range , 6.9 g / dl 10.9 g / dl ) . the mean change in hemoglobin level for the 15 patients who completed at least 9 treatments was 1.7 g / dl ( median , 1.1 g / dl ; range , 1.9 g / dl to 3.2 g / dl ) ; it reached 2.1 g / dl ( median , 1.3 g / dl ; range , 0.2 g / dl to 4.6 g / dl ; p = 0.0007 ) for the 14 patients who completed all 12 weekly treatments . five ( 20.0% ) patients were transfused and considered as treatment failures . no treatment - related adverse events were reported.conclusionintravenous iron treatment alone is safe and may reduce blood transfusion requirements and improve hemoglobin level in patients with cancer who are undergoing anticancer therapy . further randomized studies are needed to confirm these findings .

tardive dystonia td rarer side effect longer exposure antipsychotics characterized local general sustained involuntary contraction muscle muscle group twisting movements generally slow may affect limbs trunk neck face td shown develop 3% patients long term exposure antipsychotics low risk td atypical antipsychotics thought result weak affinity dopamine receptors compared typical atypical antipsychotic agents greater affinity serotonin 5-ht2a dopamine d2 receptors low propensity induce td among olanzapine is thought preferential action mesolimbic nigrostriatal dopaminergic pathways therefore associated low incidence extrapyramidal symptom eps furthermore retrospective analysis controlled multicentric trials suggested olanzapine also improves preexisting symptoms tardive movements we report case 20-year old male belonging lower socioeconomic class educated 2 standard presented severe unilateral dystonic left sided neck movements figure 1 careful history exploration revealed taking risperidone 2 mg irregularly 2 months olanzapine 5 mg another 4 months picture neck dystonia patient 19 years patient presented occasional anger outbursts getting provoked small matters beating family members running away home screaming episodes occasionally fearfulness sleep disturbance 2 days precipitated fever according mother one friend might threatened made fun actually patient stopped going house displayed mentioned symptoms this interpreted psychosis persecutory ideas treated risperidone 2 mg day 2 months olanzapine 5 mg day 4 months last two follow ups patient present mother reported unusual neck movements taken part overall psychopathology taken seriously slight intermittent neck movements reported missed part adolescent behavior problems mimicking hero movies neck dystonia increased patient severe disability patient keep hands behind head support the movement would decrease patient lying absent sleep he even stopped taking food due severe neck movements making chewing swallowing difficult his birth early developmental milestones normal 210 years age patient inattentive mildly hyperactive other siblings educated master degree patient also sent school due inattention restlessness pass 2 standard three attempts he left schooling average executive functioning life skills worked unskilled laborer neighborhood shops helping hand found getting familiar cheerful moody short tempered sometimes patient inappropriate social judgment friends made fun teased mental status assessment routine investigations thyroid function tests electroencephalogram fundus examination cervical x ray magnetic resonance imaging brain normal consulting neurophysician wilson disease secondary causes dystonia ruled the patient treated clonazepam 1 mg total dissolved solid tds tetrabenazine 25 mg tds trihexiphenidyl 2 mg bipolar disorder bd 2 months improvement around 30% baclofen 10 mg added increased 20 mg trihexyphenidyl reduced 2 mg little improvement 4 months treatment dystonia levodopa carbidopa 100 25 added neurophysician increased tablet tds baclofen omitted after 12 months treatment patient improved around 90% tetrabenazine 75 mg levodopa carbidopa 100 25 tablet bd clonazepam 1 mg bd earlier case reports reported td developing high dose atypical antipsychotics olanzapine 20 mg aripiprazole 15 mg longer duration exposure around 1215 months established psychiatric illness like schizophrenia psychotic illness eps general tardive dyskinesia particular extensively studied schizophrenia even though number studies suggest bipolar patients experience higher rates eps parkinsonism dystonia akathisia td compared patients diagnosis schizophrenia research within bd population limited the risk found 3 5 times higher elderly patients compared young patients in addition age risk directly proportional female gender daily total dose antipsychotic drug presence mood disorder use anticholinergics neuroleptics previous physical therapies electroconvulsive therapy presence physical illness diabetes organic disorder younger age exposure presence extrapyramidal symptoms early treatment this patient severe dystonic neck movements developed within short period 6 months exposure atypical antipsychotics risperidone 2 mg olanzapine 5 mg cause minimal extrapyramidal side effects case risk factors developing serious disabling td neuroleptic exposure borderline intellectual functioning externalizing behavior probable misdiagnosis overlooking early indicators side effects this case highlights dangers casually prescribing low dose second generation antipsychotics patient hyperthymic temperament borderline intellectual functioning vague short lasting presenting complaints probably misdiagnosed psychosis leading severe adverse effects patients organic brain damage prone develop adverse effects like td thus judicious use antipsychotics detailed frequent assessments important emergent stereotyped behavior unexplained movements must examined carefully taken seriously the authors certify obtained appropriate patient consent forms form patient(s ) has given consent images clinical information reported journal the patients understand names initials published due efforts made conceal identity anonymity guaranteed the authors certify obtained appropriate patient consent forms form patient(s ) has given consent images clinical information reported journal the patients understand names initials published due efforts made conceal identity anonymity guaranteed

tardive dystonia ( td ) is a serious side effect of antipsychotic medications , more with typical antipsychotics , that is potentially irreversible in affected patients . studies show that newer atypical antipsychotics have a lower risk of td . as a result , many clinicians may have developed a false sense of security when prescribing these medications . we report a case of 20-year - old male with hyperthymic temperament and borderline intellectual functioning , who developed severe td after low dose short duration exposure to atypical antipsychotic risperidone and then olanzapine . the goal of this paper is to alert the reader to be judicious and cautious before using casual low dose second generation antipsychotics in patient with no core psychotic features , hyperthymic temperament , or borderline intellectual functioning suggestive of organic brain damage , who are more prone to develop adverse effects such as td and monitor the onset of td in patients taking atypical antipsychotics .

lepidoptera include agricultural pests feeding activities negatively affect stored grains food fiber crops 2 3 since single lepidoptera adult produce hundreds eggs primary food source typically plant material cause significant damage agricultural crops although biological agents help manage insect pests insecticides currently essential large scale effective economical pest control these insecticides also affect non target organisms including pollinators application disrupts natural ecosystems also reduces yields crops rely pollination 5 6 the non target effect pesticides part due effects insect immunity necessary insect survival natural environments for example currently used pesticides shown affect cellular 710 humoral 11 12 immune responses interfere grooming behavior 13 14 these effects immunity likely non specific negatively impact health target pest beneficial arthropods therefore need novel target specific approaches control insect pests without affecting beneficial arthropods although immune pathways generally non specifically inhibited pesticides also likely source candidate molecules could inhibited target specific insect control since multiple classes insect immunity genes including signaling pathways strong selection diversification fundamental mechanisms innate immunity comprising cellular humoral pathways conserved throughout animal kingdom controlled signaling pathways activated various stimuli 17 18 including pathogen recognition immune surveillance systems despite overall conservation aspects immune systems subject strong selection evolve response varying pathogen exposure pathogen evolution virulence determinants modulate immunity 15 1921 co evolutionary dynamics promote diversification conserved elements immunity well recruitment novel effectors as investigation insect immune pathways mechanisms pathogen modulation yield insights components may susceptible inhibition for example insect pathogen xenorhabdus nematophila suppresses cellular humoral immunity lepidopteran moths manduca sexta spodoptera exigua 23 24 dipteran fly drosophila melanogaster suggesting stage immunity suppressed x. nematophila may absent d. melanogaster present lepidoptera since dipteran flies serve pollinators 26 27 decomposers food sources animals pest control agents capitalizing possible differences dipteran lepidopteran immune signaling cascades help identification targets pest specific inhibition knowledge hand pest management achieved developing small molecule inhibitors targets suppress pest insect immunity lead increased susceptibility environmental pathogens indeed many insecticides may contribute insect target non target death modulating aspects immunity the feasibility targeted pest control via insect immune inhibition established termites small molecule inhibitor immune surveillance protein led faster termite death upon exposure various pathogens much current knowledge insect immune signaling pathways receptor effector function based premiere model organism d. melanogaster extensive genetic tools several fully sequenced genomes well established lepidopteran insect models silkworm bombyx mori tobacco hornworm m. sexta also widely used study insect immunity these organisms particularly useful investigating hemolymph proteins hemocyte function relatively large larval size hemolymph volume many insects order lepidoptera easy rear laboratory conditions new tools rna interference implemented successfully study genetics immune systems 30 31 also immune signaling pathways gradually revealed genomic transcriptomic data 3238 based model insect systems fairly detailed picture immunity pathogen detection effector function emerging though many gaps remain particularly regard components unique different insect orders here we review aspects insect immunity emphasis similarities distinctions d. melanogaster representative lepidoptera in insects cellular immune response includes phagocytosis nodulation encapsulation 3942 humoral response involves expression antimicrobial peptides amps 43 44 well pro phenol oxidase propo proteolytic cascade results formation melanized nodules toxic reactive compounds 45 46 amps small cationic peptides insert disrupt microbial membranes thereby killing clearing pathogens they synthesized hemocytes greater extent fat body released insect hemolymph rapidly microbial infection 43 47 amps also expressed extra embryonic tissues eggs may help protect developing embryo infection amps conserved component immunity plants animals diverse structures assigned larger families cecropins attacins defensins diptericins their diversity immune effector function well variant representation among insects table 1 made central focus study invertebrate pathology 30 52 d. melanogaster amp synthesis each pathways activated detection microbial components via different pattern recognition receptors prrs trigger complex regulatory cascades nuclear factor kappa b nf-b dependent transcription genes encoding amps after amps translated cytoplasm released hemolymph high concentrations broad activity thought enhance clearance invading microorganisms insect bioinformatic experimental data support existence amp inducing toll imd pathways lepidopterans though components identified model organisms m. sexta 32 35 the conserved presence amps immunity coupled possibility certain elements induction pathways may vary among insects enhances probability microbially induced amp expression could inhibited pest specific manner remainder review focus pathways leading amp gene expression in d. melanogaster transcription amp encoding genes activated nf-b family transcription factors response infection 6569 distinct nf-b family transcription factors responding toll immune deficiency imd signal transduction pathways response toll pathway activation the nf-b inhibitor cactus phosphorylated degraded allowing targets nf-b factors dif dorsal translocated nucleus imd pathway activity culminates nf-b factor relish activated stimulus induced proteolytic cleavage case dif dorsal gram positive bacterial fungal infections primarily serve stimuli induce degradation cactus toll signaling pathway general gram negative bacterial infections d. melanogaster stimulate proteolytic cleavage relish imd pathway nucleus transcription factors drive transcription immune effectors including amp genes whose promoters contain nf-b binding sites 70 72 overall nf-b proteins dna binding specificities conserved among organisms including lepidoptera studied date 73 74 however nfb binding regions inhibitor b ib proteins e.g. cactus conserved suggesting diversification co adaptation ib nfb pairs also recent work indicates nf-b nuclear co regulators may contribute species specific regulation amp gene expression therefore modulation inhibitors nuclear co regulators nf-b dependent transcription may one avenue target specific immune suppression could achieved d. melanogaster nf-b dependent amp induction toll imd pathways activated detection microbial components via different pattern recognition receptors prrs prrs soluble membrane bound proteins bind specific microbe associated molecular patterns mamps lipopolysaccharide lps lipoteichoic acid lta peptidoglycan pgn -1,3-glucan released found cell surfaces bacteria fungi upon interaction mamps prrs directly agglutinate pathogens trigger proteolytic signaling cascades cytokine release turn lead activation downstream cellular humoral pathways including pro po activation amp gene expression 16 65 76 pgn recognition proteins pgrps -1,3-glucanase related proteins grps discovered lepidopteran silkworm b. mori assaying plasma components activate propo cascade pgrps subsequently shown conserved across mammals insects d. melanogaster role induction amp gene expression toll imd pathways response pgn well documented 7983 similarly grps shown induce amp expression toll pathway response fungal infections 79 84 in contrast dearth literature linking specific pgrps grps amp induction lepidoptera such link possible since pgn -1,3-glucan activate amp gene expression m. sexta b. mori 8590 multiple infection induced pgrp- grp encoding genes identified lepidoptera 32 38 54 55 9194 however numerous hints lepidoptera diptera may evolved divergent mechanisms linking pathogen detection conserved toll imd signal transduction cascades first genome comparison b. mori d. melanogaster failed identify 1:1 pgrp orthologs similarly b. mori gram negative binding protein gnbp m. sexta microbe binding protein mbp members -1,3-glucanase related protein superfamily 76 95 appear distantly related d. melanogaster gnbps suggesting divergence group proteins m. sexta mbp expression strongly regulated fat body immune challenge shows specific binding lta lps dap pgn also contrast situation d. melanogaster highly purified lps lta inducers amp gene expression lepidoptera though potently crude lps contaminating pgn purified pgn 85 90 96 97 this raises possibility different mamps combinations mamps efficacious eliciting amp gene expression lepidoptera relative diptera also since purified lps elicit amp expression lepidoptera d. melanogaster lepidoptera either distinct repertoire prrs responsible lps dependent triggering imd toll pathways yet undiscovered pathway links lps amp induction testing ideas awaits identification suite prrs signal transduction pathways responsible transducing lps lta pgn combinatorial microbial signals amp gene expression one class lepidopteran prr may mediate infection dependent induction amps c type lectins ctls ca dependent secreted proteins carbohydrate binding capabilities similar ctls d. melanogaster several ctls m. sexta b. mori 54 99 reported mediate induction cellular responses propo cascade although nomenclature quickly becomes confusing ctls include lipopolysaccharide binding protein lbp m. sexta iml-1 binds gram positive gram negative bacteria well yeast iml-2 shows specific binding lps iml-3 iml-4 show specific binding lps lta iml-3 also bind laminarin -1,3-glucan 103 104 diversity ctl carbohydrate binding specificities may result lineage specific pathogen recognition signal transduction connections of particular relevance theme review prrs present lepidoptera diptera table 1 general orders insects encode grps pgrps however specific representatives class restricted lepidoptera table 1 for example lepidopteran grp-2 binds fungal cell wall -1,3 glucans lta absent diptera such derived grp pgrps may contribute lepidopteran specific transduction signals downstream pathways other lepidoptera specific prrs hemolin hemolymph proteinase-14 precursor prohp14 table 1 like iml c type lectins hemolin lps- lta binding prr roles mediating cellular responses opsonin enhance phagocytosis hp14 shown detect bind broad range mamps may coordinate grp1 grp2 activate propo 60 106 the potential role prrs discussed mediating expression amp genes remains determined study lepidoptera specific immune surveillance proteins divergent activities conserved prrs likely yield novel avenues pest control d. melanogaster mamp dependent mamp independent routes activate toll pathway mamp dependent toll induction bacterial lys pgn typical gram positive bacteria ) is detected pgrp sa pgrp sd presence gnbp-1 yeast fungal -1,3-glucan detected gnbp-3 85 108 109 figure 1 mamp independent stimuli virulence determinants proteases chitinases secreted microbes dubbed mamps mamp independent stimuli trigger distinct proteolytic cascade culminate cleavage cytokine sptzle serine protease sptzle processing enzyme spe interaction active sptzle c terminal domain c-106 surface localized toll receptor triggers intracellular signal transduction terminating induced expression amps cellular responses some basic components toll pathway present lepidoptera figure 2 m. sexta hemocytes express infection induced toll like receptor genome b. mori encodes 14 genes predicted encode toll like receptors well homologs intracellular components toll dependent signaling 85 114 115 both m. sexta b. mori encode homologs d. melanogaster toll activating cytokine sptzle figure 2 also m. sexta b. mori experimental evidence linking toll pathway amp induction 116118 m. sexta toll pathway results expression several antimicrobial peptides including attacin-1 cecropin-6 moricin lysozyme in addition transcript level hemolin pattern recognition protein exclusive lepidopterans table 1 induced injection activated sptzle c108 larvae despite conservation certain aspects toll pathway extracellular cascades lead sptzle activation may diverged d. melanogaster two lepidoptera figure 1 for example contrast known d. melanogaster m. sexta toll pathway activated gram negative associated mamps 115 118 also genome b. mori lacks 1:1 orthologs grass spirit persephone d. melanogaster serine proteases responsible mamp prr dependent mamp independent cleavage spe figure 1 progress made identifying m. sexta proteolytic cascade results processing pro sptzle active c terminal domain c-108 the direct cleavage mediated hemolymph proteinase hp 8 11 13 homolog d. melanogaster spe turn hp8 processed active form hp6 hp6 similar d. melanogaster persephone protease activates spe response mamp independent stimuli 110 113 this hemolymph proteinase activated response gram positive gram negative bacteria response -1,3-glucan however prrs proteolytic cascade transduce mamp signals amp induction unknown figure 1 the findings reviewed demonstrate overall architecture toll pathway conserved among insects specific identities proteolytic cascade members distinct many gaps remain understanding toll activation lepidoptera filling gaps reveal potential lineage specific molecules serve targets hinder activation toll pathway agricultural pests d. melanogaster the imd pathway also contributes amp gene induction triggered direct interaction dap pgn mamp typical gram negative bacteria transmembrane receptor pgrp lc 82 83 125 126 for example pgrp le act intracellular receptor monomeric pgn truncated form enhance pgrp lc mediated recognition dap pgn pgrp lc interaction activates intracellular imd recruits fas associated death domain fadd death related ced-3/nedd2-like protein dredd form complex 129 130 current evidence supports idea dredd caspase like molecule cleaves nf-b transcription factor relish imd also appears activate phosphorelay transforming growth factor- tgf)-activated kinase 1 tak1 phosphorylates ikb kinase ikk relish cleavage activated amino terminal transcriptional regulator domain allows translocation nucleus activates amp gene expression the translocation relish nucleus regulated two recently discovered components pathway inhibitor apoptosis 2 iap2 transforming growth factor activated kinase 1 tak1)-binding protein 2 tab2 132 133 both iap2 tab2 act upstream relish downstream imd iap2 functions downstream tak1 132 134 particular importance amp gene expression iap2 knockdown hampers sustained expression amp genes iap2 tab2 necessary imd signal transduction gene product pirk recently characterized gene interacts directly imd pgrp lc pirk overexpression analyses revealed acts negative regulator reducing expression amp genes attacin b cecropin b diptericin b control imd pathway most information available imd pathway lepidoptera comes bioinformatics orthologs intracellular components imd pathway found b. mori 54 137 m. sexta however experiments done characterize molecular mechanisms leading activation imd pathway insects m. sexta several genes imd pathway including encoding imd fadd tak1 dredd relish regulated fat body immune challenged 5th instar larvae midgut b. mori wandering stage genes encoding lysozyme moricin defensin amps also regulated midgut b. mori wandering stage consistent possibility amp induction imd mediated finally lepidopteran beet armyworm spodoptera exigua rnai mediated knockdown relish expression resulted loss cecropin induction upon fungal infection strengthening idea imd pathway may contribute amp gene expression lepidoptera though perhaps triggered distinct signals further study needed elucidate imd mediated amp induction lepidoptera reveal differences pathway diptera lepidoptera in d. melanogaster transcription amp encoding genes activated nf-b family transcription factors response infection 6569 distinct nf-b family transcription factors responding toll immune deficiency imd signal transduction pathways response toll pathway activation the nf-b inhibitor cactus phosphorylated degraded allowing targets nf-b factors dif dorsal translocated nucleus imd pathway activity culminates nf-b factor relish activated stimulus induced proteolytic cleavage case dif dorsal gram positive bacterial fungal infections primarily serve stimuli induce degradation cactus toll signaling pathway general gram negative bacterial infections d. melanogaster stimulate proteolytic cleavage relish imd pathway nucleus transcription factors drive transcription immune effectors including amp genes whose promoters contain nf-b binding sites 70 72 overall nf-b proteins dna binding specificities conserved among organisms including lepidoptera studied date 73 74 however nfb binding regions inhibitor b ib proteins e.g. cactus conserved suggesting diversification co adaptation ib nfb pairs also recent work indicates nf-b nuclear co regulators may contribute species specific regulation amp gene expression therefore modulation inhibitors nuclear co regulators nf-b dependent transcription may one avenue target specific immune suppression could achieved in d. melanogaster nf-b dependent amp induction toll imd pathways activated detection microbial components via different pattern recognition receptors prrs prrs soluble membrane bound proteins bind specific microbe associated molecular patterns mamps lipopolysaccharide lps lipoteichoic acid lta peptidoglycan pgn -1,3-glucan released found cell surfaces bacteria fungi upon interaction mamps prrs directly agglutinate pathogens trigger proteolytic signaling cascades cytokine release turn lead activation downstream cellular humoral pathways including pro po activation amp gene expression 16 65 76 pgn recognition proteins pgrps -1,3-glucanase related proteins grps discovered lepidopteran silkworm b. mori assaying plasma components activate propo cascade pgrps subsequently shown conserved across mammals insects d. melanogaster role induction amp gene expression toll imd pathways response pgn well documented 7983 similarly grps shown induce amp expression toll pathway response fungal infections 79 84 in contrast dearth literature linking specific pgrps grps amp induction lepidoptera such link possible since pgn -1,3-glucan activate amp gene expression m. sexta b. mori 8590 multiple infection induced pgrp- grp encoding genes identified lepidoptera 32 38 54 55 9194 however numerous hints lepidoptera diptera may evolved divergent mechanisms linking pathogen detection conserved toll imd signal transduction cascades first genome comparison b. mori d. melanogaster failed identify 1:1 pgrp orthologs similarly b. mori gram negative binding protein gnbp m. sexta microbe binding protein mbp members -1,3-glucanase related protein superfamily 76 95 appear distantly related d. melanogaster gnbps suggesting divergence group proteins m. sexta mbp expression strongly regulated fat body immune challenge shows specific binding lta lps dap pgn also contrast situation d. melanogaster highly purified lps lta inducers amp gene expression lepidoptera though potently crude lps contaminating pgn purified pgn 85 90 96 97 this raises possibility different mamps combinations mamps efficacious eliciting amp gene expression lepidoptera relative diptera also since purified lps elicit amp expression lepidoptera d. melanogaster lepidoptera either distinct repertoire prrs responsible lps dependent triggering imd toll pathways yet undiscovered pathway links lps amp induction testing ideas awaits identification suite prrs signal transduction pathways responsible transducing lps lta pgn combinatorial microbial signals amp gene expression one class lepidopteran prr may mediate infection dependent induction amps c type lectins ctls ca dependent secreted proteins carbohydrate binding capabilities similar ctls d. melanogaster several ctls m. sexta b. mori 54 99 reported mediate induction cellular responses propo cascade although nomenclature quickly becomes confusing ctls include lipopolysaccharide binding protein lbp m. sexta iml-1 binds gram positive gram negative bacteria well yeast iml-2 shows specific binding lps iml-3 iml-4 show specific binding lps lta iml-3 also bind laminarin -1,3-glucan 103 104 diversity ctl carbohydrate binding specificities may result lineage specific pathogen recognition signal transduction connections particular relevance theme review prrs present lepidoptera diptera table 1 general orders insects encode grps pgrps however specific representatives class restricted lepidoptera table 1 for example lepidopteran grp-2 binds fungal cell wall -1,3 glucans lta absent diptera such derived grp pgrps may contribute lepidopteran specific transduction signals downstream pathways other lepidoptera specific prrs hemolin hemolymph proteinase-14 precursor prohp14 table 1 like iml c type lectins hemolin lps- lta binding prr roles mediating cellular responses opsonin enhance phagocytosis hp14 shown detect bind broad range mamps may coordinate grp1 grp2 activate propo 60 106 the potential role prrs discussed mediating expression amp genes remains determined study lepidoptera specific immune surveillance proteins divergent activities conserved prrs likely yield novel avenues pest control d. melanogaster mamp dependent mamp independent routes activate toll pathway mamp dependent toll induction bacterial lys pgn typical gram positive bacteria ) is detected pgrp sa pgrp sd presence gnbp-1 yeast fungal -1,3-glucan detected gnbp-3 85 108 109 figure 1 mamp independent stimuli virulence determinants proteases chitinases secreted microbes dubbed mamps mamp independent stimuli trigger distinct proteolytic cascade culminate cleavage cytokine sptzle serine protease sptzle processing enzyme spe interaction active sptzle c terminal domain c-106 surface localized toll receptor triggers intracellular signal transduction terminating induced expression amps cellular responses some basic components toll pathway present lepidoptera figure 2 m. sexta hemocytes express infection induced toll like receptor genome b. mori encodes 14 genes predicted encode toll like receptors well homologs intracellular components toll dependent signaling 85 114 115 m. sexta b. mori encode homologs d. melanogaster toll activating cytokine sptzle figure 2 also m. sexta b. mori experimental evidence linking toll pathway amp induction 116118 m. sexta toll pathway results expression several antimicrobial peptides including attacin-1 cecropin-6 moricin lysozyme in addition transcript level hemolin pattern recognition protein exclusive lepidopterans table 1 induced injection activated sptzle c108 larvae despite conservation certain aspects toll pathway extracellular cascades lead sptzle activation may diverged d. melanogaster two lepidoptera figure 1 for example contrast known d. melanogaster m. sexta toll pathway activated gram negative associated mamps 115 118 also genome b. mori lacks 1:1 orthologs grass spirit persephone d. melanogaster serine proteases responsible mamp prr dependent mamp independent cleavage spe figure 1 progress made identifying m. sexta proteolytic cascade results processing pro sptzle active c terminal domain c-108 the direct cleavage mediated hemolymph proteinase hp 8 11 13 homolog d. melanogaster spe turn hp8 processed active form hp6 hp6 similar d. melanogaster persephone protease activates spe response mamp independent stimuli 110 113 this hemolymph proteinase activated response gram positive gram negative bacteria response -1,3-glucan however prrs proteolytic cascade transduce mamp signals amp induction unknown figure 1 findings reviewed demonstrate overall architecture toll pathway conserved among insects specific identities proteolytic cascade members distinct many gaps remain understanding toll activation lepidoptera filling gaps reveal potential lineage specific molecules serve targets hinder activation toll pathway agricultural pests in d. melanogaster imd pathway also contributes amp gene induction triggered direct interaction dap pgn mamp typical gram negative bacteria transmembrane receptor pgrp lc 82 83 125 126 for example pgrp le act intracellular receptor monomeric pgn truncated form enhance pgrp lc mediated recognition dap pgn pgrp lc interaction activates intracellular imd recruits fas associated death domain fadd death related ced-3/nedd2-like protein dredd form complex 129 130 current evidence supports idea dredd caspase like molecule cleaves nf-b transcription factor relish imd also appears activate phosphorelay transforming growth factor- tgf)-activated kinase 1 tak1 phosphorylates ikb kinase ikk relish cleavage activated amino terminal transcriptional regulator domain allows translocation nucleus activates amp gene expression the translocation relish nucleus regulated two recently discovered components pathway inhibitor apoptosis 2 iap2 transforming growth factor activated kinase 1 tak1)-binding protein 2 tab2 132 133 both iap2 tab2 act upstream relish downstream imd iap2 functions downstream tak1 132 134 particular importance amp gene expression iap2 knockdown hampers sustained expression amp genes iap2 tab2 necessary imd signal transduction gene product pirk recently characterized gene interacts directly imd pgrp lc pirk overexpression analyses revealed acts negative regulator reducing expression amp genes attacin b cecropin b diptericin b control imd pathway most information available imd pathway lepidoptera comes bioinformatics orthologs intracellular components imd pathway found b. mori 54 137 m. sexta however experiments done characterize molecular mechanisms leading activation imd pathway insects m. sexta several genes imd pathway including encoding imd fadd tak1 dredd relish regulated fat body immune challenged 5th instar larvae midgut b. mori wandering stage genes encoding lysozyme moricin defensin amps also regulated midgut b. mori wandering stage consistent possibility amp induction imd mediated finally lepidopteran beet armyworm spodoptera exigua rnai mediated knockdown relish expression resulted loss cecropin induction upon fungal infection strengthening idea imd pathway may contribute amp gene expression lepidoptera though perhaps triggered distinct signals further study needed elucidate imd mediated amp induction lepidoptera reveal differences pathway diptera lepidoptera insecticides necessary guarantee effective insect pest management agricultural settings however cost target effects insecticides directly indirectly increase economic burden latter affecting beneficial arthropods pollinators study insect immunity provide tools development target specific cost effective approaches control agricultural pests directed suppression pest immune defenses predicted render susceptible environmental applied biocontrol pathogens recently demonstrated termites bulmer colleagues the studies summarized suggest many aspects insect immunity including recognition factors serine proteases diverged d. melanogaster lepidoptera continued comparative immunity broad array species diptera lepidoptera and other insect orders reveal possible candidate immunity factors target specific approaches enable effective control insect pests however approaches realized details lepidopteran immune signaling pathways must elucidated the relatively large sizes last instar larvae many lepidopteran species facilitate biochemical approaches studies establishment immune inducible lepidopteran cell lines uga cie1 cell line enable characterization molecular mechanisms leading imd pathway activation contribution amp gene expression finally ongoing investigations immune modulatory mechanisms entomopathogens help identify key steps immunity susceptible manipulation contributing development natural cost effective non toxic alternatives chemical insecticides currently used pest management

many lepidopteran insects are agricultural pests that affect stored grains , food and fiber crops . these insects have negative ecological and economic impacts since they lower crop yield , and pesticides are expensive and can have off - target effects on beneficial arthropods . a better understanding of lepidopteran immunity will aid in identifying new targets for the development of specific insect pest management compounds . a fundamental aspect of immunity , and therefore a logical target for control , is the induction of antimicrobial peptide ( amp ) expression . these peptides insert into and disrupt microbial membranes , thereby promoting pathogen clearance and insect survival . pathways leading to amp expression have been extensively studied in the dipteran drosophila melanogaster . however , diptera are an important group of pollinators and pest management strategies that target their immune systems is not recommended . recent advances have facilitated investigation of lepidopteran immunity , revealing both conserved and derived characteristics . although the general pathways leading to amp expression are conserved , specific components of these pathways , such as recognition proteins have diverged . in this review we highlight how such comparative immunology could aid in developing pest management strategies that are specific to agricultural insect pests .

syncope caused transient diffuse cerebral hypoperfusion characterized transient loss consciousness rapid onset followed spontaneous complete recovery clinical features syncope may include myoclonic jerks often multifocal asynchronous convulsions urinary incontinence making difficult differentiate epileptic seizure clinical features alone significant fluctuations cerebral perfusion pressure prevented autoregulation cerebral circulation may conditions mechanism may compensate adequately cough syncope rare form syncope may result transient failure cerebral autoregulatory mechanism cope sudden decrease cerebral blood flow we present unusual case recurrent cough syncope initially diagnosed treated seizures context left sided glomus jugulare tumor benign paraganglioma a 43-year old right handed woman history glomus jugulare tumor left jugular fossa intracranial extension posterior cranial fossa transferred another hospital recurrent seizure like spells she 90% surgical resection tumor done 2011 followed radiation therapy september 2012 her episodes occurred multiple times day 7 per day average wakeful state they triggered coughing usually bout cough characterized staring unresponsiveness well stiffening body mild shaking upper extremities she diagnosed epileptic seizures continued episodes treatment antiepileptic drugs aeds phenytoin levetiracetam lamotrigine escalation aed therapy made increasingly drowsy three aforementioned aeds time presentation her physical examination remarkable excessive drowsiness mild dysarthria right sixth cranial nerve palsy mild hypertonia hyperreflexia lower extremities left right bilateral left right ankle clonus she lumbar puncture done outside hospital opening cerebrospinal fluid csf pressure reported 25 cm blood work also unremarkable except mild anemia hemoglobin 9.4 g dl mild hyponatremia 132 meq l mild hypokalemia 3.1 meq l antiepileptic drug levels within therapeutic range free phenytoin 1.3 g ml levetiracetam 5.9 g ml lamotrigine 2.3 g ml all started bout cough patient lying bed supine lateral position followed brief less minute distal upper extremity tremor subtle proximal upper extremity myoclonic jerks prolonged unresponsiveness 10 min all episodes associated hypotension 7278/3147 mm hg revealed continuous arterial pressure monitoring bradycardia 5459 bpm the eeg spells characterized generalized synchronous asynchronous high amplitude 1- 2-hz delta activity progressed generalized attenuation transitioned generalized delta activity recovery fig 1 a head ct showed recurrence glomus jugulare tumor communicating hydrocephalus external ventricular drain evd ) after placement evd drowsiness gradually started improve episodes decreased frequency one per day 3 showed enhancing t2 hyperintense left skull base mass region left jugular foramen extension posterior cranial fossa base skull brain imaging showed evidence hydrocephalus increased compared previous brain imaging done 2 months back her mental status continued improve one mild episode triggered cough next two days discharge repeat surgical resection tumor recommended otolaryngology team patient declined based clinical features eeg findings episodes observed patient consistent cough syncope the mechanism underlying cough syncope definitively established postulated coughing increases intrathoracic intraabdominal pressures leading transient increase icp increased icp turn causes decrease cerebral perfusion pressure drops critical level may result global cerebral hypoperfusion leading syncope transient cerebral circulatory arrest demonstrated transcranial doppler measurements cough syncope patient also drop blood pressure heart rate probably sufficient cause syncope cough syncope associated posterior fossa mass lesions tonsillar herniation hydrocephalus it may speculated bouts cough caused transient herniation cerebellar tonsils obstructing csf flow contributed increase icp coughing decrease frequency events following placement evd relieve icp lends support notion paragangliomas rare tumors extraadrenal chromaffin cell origin commonly occur head neck region catecholamine hypersecreting paraganglionomas uncommon head neck region patients 95% hypersecreting paraganglionomas hypertension hypotension accompanying syncope observed patient orthostasis related patient always supine spells likely related cough identified subset patients cough syncope lacked blood pressure overshoot expected response relief straining valsalva maneuver the authors postulate cough syncope patients might result delayed recovery hypotension follows paroxysm cough likely contributing global cerebral hypoperfusion patient this case highlights fact cough syncope rare form syncope may associated intracranial mass lesions indirectly exaggerate increase icp response cough glomus caroticum tumor presenting recurrent unexplained syncope posterior fossa meningioma presenting recurrent cough syncope described recurrent cough syncope trigger search factors including brain tumors potential cause transient elevation icp this case also illustrates important role ceeg monitoring video distinguishing syncope seizures cough syncope cases

we present an unusual case of recurrent cough syncope in a 43-year - old woman , which was initially thought to be seizures . syncopal episodes were triggered by paroxysms of cough and were characterized by unresponsiveness and myoclonic jerks in her extremities . she had a left - sided glomus jugulare tumor that extended into the posterior cranial fossa with evidence of worsening communicating hydrocephalus on brain imaging . we postulate that bouts of cough produced increased intracranial pressure both by raising intrathoracic and intraabdominal pressures as well as by transient obstruction to cerebrospinal fluid flow secondary to intermittent tonsillar herniation during cough . this resulted in diffuse decrease in cerebral blood flow causing syncope . the patient 's syncopal episodes decreased in frequency once an external ventricular drain was placed followed by a ventriculoperitoneal shunt . search for factors that can increase intracranial pressure seems warranted in patients with recurrent cough syncope .

world wide infertility affects 1015% couples trying conceive 15% cases caused male factors affect 1 20 men general population most cases male infertility idiopathic apart several etiologies obstruction deferent duct varicocele sexual dysfunction cryptorchidism although assisted reproductive technology art helped many sterile couples conceive non obstructive azoospermia noa accounts considerable proportion male infertility dramatically lower rate sperm retrieval clinical pregnancy the etiological mechanism noa unknown factors oxidative stress considered effects spermatogenesis antioxidants effective protecting spermatogenesis therefore helpful explore underlying pathogenesis noa patients micrornas class small rnas code amino acid sequences play fundamental roles regulating gene expression transcription lian et al found 154 regulated mirnas 19 regulated mirnas testes noa patients compared fertile males using microarray technologies furthermore mirnas shown affect proliferation apoptosis dna damage germ cells 911 mir-210 one 19 regulated mirnas testes noa patients located within genomic loci transcript ak123483 it induced hypoxia plays essential role cell adaptation hypoxia mir-210 also affects regulation diverse physiological processes angiogenesis cell survival proliferation cell cycle arrest protein modification dna damage repair although mir-210 shown involved regulation physiological processes various diseases regulated mirna testes noa patients remains unknown mir-210 affects spermatogenesis hence aim study investigate underlying mechanisms mir-210 involved pathogenesis spermatogenesis we enrolled 25 patients aged 1841 years azoospermia proven 3 semen analyses testicular biopsies first affiliated hospital anhui medical university pathological examinations performed testicular specimen combined clinical features 4 patients diagnosed sertoli cell syndrome scos 7 patients diagnosed maturation arrest 8 patients diagnosed hypospermatogenesis 6 patients diagnosed obstructive azoospermia oa patients provided informed consent participation study our local medical ethics committee approved study began examine location insulin like growth factor ii ( igf2 human testicular tissues performed immunohistochemistry staining detect igf2 expression tissues cut sections immunoperoxidase staining treated 4% pfa paraffin wax after specific treatment standard procedure immunohistochemistry staining described lian et al sections incubated igf2 antibody abcam overnight 4c biotinylated secondary antibody abcam 2 h room temperature detect expression mir-210 rnas extracted nt-2 cells tissues subjected real time pcr described lian et al briefly rna extraction performed following standard trizol protocol real time pcr carried abi step one system applied biosystems sybr premix ex taq ii kit takara bio inc used primers q rt pcr follows forward primer 5-caataactgtgcgtgtgacagc-3 reverse primer 5-tatggttttgacgactgtgtgat-3 forward primer 5-cagcacatatactaaaattggaacg-3 reverse primer 5-acgaatttgcgtgtcatcc-3 western blot analysis carried detect protein expression igf2 human testicular tissues 3 groups nt2 cells anti igf2 abcam used western blot analysis used -actin loading control detect expression igf2 we supplemented medium 10% fetal bovine serum life technology inc 1% antibiotics 100 units ml penicillin 100 ug ml streptomycin life technology inc cells incubated 37c humidified incubator 5% co2 transfect oligonucleotides plasmids nt-2 cells lipofectamine rnaimax invitrogen fugene hd roche ) all processes performed accordance protocols supplied manufacturers study experiments performed independently least 3 times we enrolled 25 patients aged 1841 years azoospermia proven 3 semen analyses testicular biopsies first affiliated hospital anhui medical university pathological examinations performed testicular specimen combined clinical features 4 patients diagnosed sertoli cell syndrome scos 7 patients diagnosed maturation arrest 8 patients diagnosed hypospermatogenesis 6 patients diagnosed obstructive azoospermia oa patients provided informed consent participation study to examine location insulin like growth factor ii igf2 human testicular tissues performed immunohistochemistry staining detect igf2 expression tissues cut sections immunoperoxidase staining treated 4% pfa paraffin wax after specific treatment standard procedure immunohistochemistry staining described lian et al sections incubated igf2 antibody abcam overnight 4c biotinylated secondary antibody abcam 2 h room temperature rnas extracted nt-2 cells tissues subjected real time pcr described lian et al briefly rna extraction performed following standard trizol protocol real time pcr carried abi step one system applied biosystems sybr premix ex taq ii kit takara bio inc used primers q rt pcr follows forward primer 5-caataactgtgcgtgtgacagc-3 reverse primer 5-tatggttttgacgactgtgtgat-3 forward primer 5-cagcacatatactaaaattggaacg-3 reverse primer 5-acgaatttgcgtgtcatcc-3 western blot analysis carried detect protein expression igf2 human testicular tissues 3 groups nt2 cells anti igf2 abcam used western blot analysis used -actin loading control detect expression igf2 we supplemented medium 10% fetal bovine serum life technology inc 1% antibiotics 100 units ml penicillin 100 ug ml streptomycin life technology inc cells incubated 37c humidified incubator 5% co2 transfect oligonucleotides plasmids nt-2 cells lipofectamine rnaimax invitrogen fugene hd roche ) the igf2 gene part cluster imprinted genes expressing single polypeptide igf2 produced paternal allele the maternal allele transcriptionally silent clarify location igf2 human testicular tissues we found igf2 located spermatocytes testes patients oa figure 1 igf2 located spermatocytes testis detected expression igf2 cases hypospermatogenesis oa scos patients we found igf2 regulated patients hypospermatogenesis compared oa patients considered control group normal spermatogenesis although without significant difference figures 2 3 possibly fewer samples longer preservation times samples quantitative real time pcr performed examined mir-210 expression testis patients hypospermatogenesis oa found mir-210 significantly regulated testis hypospermatogenesis patients compared oa patients figure 4 however due errors rna extraction preliminary experiment 3 testis samples 1 hypospermatogenesis oa patients damaged tested targetscan database 3utr igf2-mrna putative mir-210-binding site igf2 predicted potential target mir-210 identify whether igf2 gene targeted mir-210 directly renilla luciferase reporters include wild type full length 3utr forms mir-210 seeding sites figure 5 shows 60% decrease luciferase activity cotransfection mir-210 mimic renilla luciferase reporters nt2 cells inhibiting mir-210 expression increased activity reporter renilla luciferase expression igf2 protein also significantly lower nt2 cells transfected mir-210 mimics control cells knockdown mir-210 mir-210 inhibitor increased protein expression igf2 figures 6 the igf2 gene part cluster imprinted genes expressing single polypeptide igf2 produced paternal allele the maternal allele transcriptionally silent clarify location igf2 human testicular tissues we found igf2 located spermatocytes testes patients oa figure 1 because igf2 located spermatocytes testis detected expression igf2 cases hypospermatogenesis oa scos patients we found igf2 regulated patients hypospermatogenesis compared oa patients considered control group normal spermatogenesis although without significant difference figures 2 3 possibly fewer samples longer preservation times samples quantitative real time pcr performed examined mir-210 expression testis patients hypospermatogenesis oa found mir-210 significantly regulated testis hypospermatogenesis patients compared oa patients figure 4 however due errors rna extraction preliminary experiment 3 testis samples 1 hypospermatogenesis oa patients damaged tested in targetscan database 3utr igf2-mrna putative mir-210-binding site igf2 predicted potential target mir-210 identify whether igf2 gene targeted mir-210 directly renilla luciferase reporters include wild type full length 3utr forms mir-210 seeding sites used figure 5 shows 60% decrease luciferase activity cotransfection mir-210 mimic renilla luciferase reporters nt2 cells inhibiting mir-210 expression increased activity reporter renilla luciferase expression igf2 protein also significantly lower nt2 cells transfected mir-210 mimics control cells knockdown mir-210 mir-210 inhibitor increased protein expression igf2 figures 6 during recent decades several studies focused effects mirnas spermatogenesis male infertility 911,17 however understood mir-210 one regulated mirnas testes patients noa involved spermatogenesis male infertility the transformation diploid spermatogonia mature haploid cells spermatogenesis complex biological process testes males the insulin igf system takes part processes cell proliferation cell growth differentiation survival affects nearly every organ body also insulin igf plays important role proper function testis males igf2 binds igf1r insr high affinity binds insr igf1r insr b igf1r lower affinity found inactivated insr igf1r 79% reduction daily sperm production adult mouse testes conditional ko approach taken together aforementioned data suggest igf2 might involved process spermatogenesis examine specific mechanism mir-210 associated process spermatogenesis quantitative real time pcr performed detect mir-210 expression we found mir-210 significantly regulated testes subjects hypospermatogenesis patients compared oa these results agree findings lian et al using microarray technologies performed noa normal controls several studies suggested mirna could mediated hypoxia participate various types regulation angiogenesis cell survival proliferation cell cycle arrest protein modification 1214 furthermore researchers even found mir-210 might considered one indicated markers diseases clear cell renal cell carcinoma acute myeloid leukemia present study found igf2 targeted mir-210 directly vitro experiment nt2 cells mir-210 might associated spermatogenesis targeting igf2 male infertility firstly errors occurred rna extraction preliminary experiment mir-210 3 testes samples damaged detected subsequent quantitative real time pcr experiment might affected results secondly investigate functions mir-210 igf2 vitro vivo plan future research we demonstrated mir-210 might associated spermatogenesis targeting igf2 male infertility future mechanistic studies role mir-210/igf2 process spermatogenesis male infertility provide new insights diagnosis management male infertility

backgroundmicrornas ( mirnas ) play pivotal roles in spermatogenesis . microrna-210 ( mir-210 ) expression was up - regulated in the testes of sterile men with non - obstructive azoospermia ( noa ) . however , the underlying mechanisms of mir-210 involved in the spermatogenesis in patients with noa are unknown.material/methodsexpression of mir-210 and insulin - like growth factor ii ( igf2 ) in the testes of noa cases ( only including maturation arrest and hypospermatogenesis ) were detected in this study . we carried out in vitro experiments to determine if igf2 was directly targeted by mir-210 in nt2 cells.resultscompared with obstructive azoospermia ( oa ) as normal control , our results suggest that mir-210 was significantly up - regulated in testis of patients with noa ( p<0.05 ) , and igf2 was down - regulated , but without a significant difference . the results also indicated that igf2 was directly targeted by mir-210 in nt2 cells.conclusionsthe results showed that mir-210 was involved in spermatogenesis by targeting igf2 in male infertility .

midwife led primary delivery care low risk pregnant women labor reported various advantages increased odds high maternal satisfaction decrease unnecessary medical interventions 18 although maternity care system low risk pregnant women peculiar one country easily compared countries consumer demands humanization obstetric care arisen various countries 18 date found evidence midwife led primary obstetric care unsafe low risk pregnant women comparison obstetric care favorable cooperation obstetricians midwives japan 912 in addition 85% low risk pregnant women request give birth receiving midwife led primary delivery care therefore safe midwife led delivery care backup obstetricians may also required low risk pregnant women japan complications occur threaten occur primary midwife led delivery care midwives refer woman obstetricians neighboring hospital private obstetric clinic soon possible this deliveries managed independent midwives japan many intervention measures oxytocin infusion epidural anesthesia episiotomy suture instrumental delivery available based japanese legal restrictions institute one main tokyo city perinatal centers 3 japanese systems midwife led delivery care follows 1 intending give birth home managed midwives belong hospital 2 planning give birth futons ( i.e. japanese style bedding japanese tatami mat delivery rooms hospital managed midwives belong hospital 3 planning give birth japanese tatami mat delivery rooms managed midwives belong hospital the objective study describe trends transfers perinatal outcomes among labors using 3 japanese systems midwife led primary delivery care the protocol analysis approved ethics committee japanese red cross katsushika maternity hospital addition informed consent analysis retrospective database obtained subject hospital visit hospital pregnant women initially considered low risk 3436 weeks gestation choose freely 3 systems midwife led care obstetric shared care in midwife led care units midwives practice autonomously fully accountable practice unsupervised obstetricians factors used exclude women low risk group comprise following 912 1 medical history pregnancy induced hypertension chronic hypertension diabetes mellitus renal disease idiopathic thrombocytopenia systemic illnesses 2 gynecological history history infertility therapies vitro fertilization congenital uterine anomalies uterine myomatosis adnexal anomaly 3 obstetric history narrowing pelvic outlet cephalopelvic disproportion previous cesarean section previous anal sphincter injury previous postpartum hemorrhage 1,000 ml blood transfusion previous manual removal placenta previous gestational diabetes history severe preeclampsia 4 complications present pregnancy multiple pregnancy nonvertex presentation obesity maternal body mass index pregnancy 25 and/or third trimester 28 anemia hemoglobin 9.0 g dl epilepsy treatment polyhydramnios oligohydramnios low set placenta placenta previa fetal growth restriction heavy date fetus gestational diabetes pregnancy induced hypertension risk factors present women managed obstetricians midwives 5 complications labor intrauterine infection thick meconium staining prolongation labor active phase dilation 1 cm hour duration second stage labor 2 hours prolonged rupture membranes 24 hours uterine inertia arrest labor fetal heart rate abnormality nonreassuring fetal status factors present women transferred managed mainly obstetricians obstetric shared care standard western style delivery room surgery room hospital a retrospective study performed examine trends transfers perinatal outcomes among labors started using 3 systems midwife led primary delivery care study student test used continuous variables test categorical variables odds ratios ors 95% confidence intervals cis also calculated differences p between 2009 2012 total 678 low risk women placed 3 forms midwife led primary delivery care onset labor pains and/or rupture membranes 3741 weeks gestation 123 18% intended give birth home 88 13% planned give birth japanese tatami mat rooms hospital managed midwives belong hospital 467 59% planned give birth managed midwives belonging hospital table 1 shows clinical descriptions 678 pregnant women initially considered low risk receiving midwife led primary delivery care systems significant differences maternal age parity among 3 groups table 2 shows rate transfers 3 groups midwife led primary delivery care systems the total rate transfers system run midwives belonging hospital 56% higher 2 systems run independent midwives 31% planned home birth 1.87 95% ci 1.23.0 p 0.01 38% planned hospital birth 2.51 95% ci 1.73.8 p 0.01 in addition timing transfers system run midwives belonging hospital second stage labor 52% earlier 2 systems 21% planned home birth 4.12 95% ci 2.66.6 p 0.01 20% planned hospital birth 4.29 95% ci 2.57.4 p 0.01 however classified nulliparous parous women significant differences rate transfers among 3 groups shown table 1 in addition among 3 groups significant differences rate main 2 indications transfer fetal heart rate abnormality failure progress the main indications transfer delivery maternal postpartum hemorrhage neonatal respiratory distress associated asphyxia table 3 shows obstetric neonatal outcomes pregnant women initially considered low risk receiving midwife led primary delivery care systems significant differences outcomes among 3 groups our obstetric care system involves division women labor low- high risk groups 912 the women initially considered low risk choose freely midwife led care obstetric shared care complications occur risk factors arise labor primary midwife led care transferred obstetric shared care this may first report concerning differences timing transfers midwife led care obstetric shared care among 3 systems midwife led primary delivery care japan study evidence primary midwife led care unsafe low risk pregnant women 3 midwife led delivery care systems however significant differences timing referrals midwife led care obstetric shared care system led midwives belong hospital hospital midwifery system systems led midwives belong hospital hospital midwifery system timing transfers seemed earliest due ease transfer within hospital administrator setting hand the rate transfers delivery 2 systems higher hospital midwifery care period main indications transfers maternal postpartum hemorrhage and/or neonatal respiratory distress associated asphyxia fortunately difference associated adverse obstetric neonatal outcomes however unfortunately led early mother child separation especially cases planned home birth healthy puerperal women newborns transferred home hospital according japanese law although home birth might comfortable involved must prepared mother child separation cases referrals delivery the major limitations study small sample size lack long term follow mothers children consider potential findings based context there cases fetal neonatal death midwife led delivery care the evaluated outcome midwife led delivery satisfaction pregnant women development mother child relationships delivery in addition might bias related backgrounds selection systems randomized trial study therefore large prospective study long term follow may needed there significant differences perinatal outcomes among 3 systems however differences status transfers obstetric shared care

objective . the objective of this study was to describe the recent clinical characteristics of labor using 3 systems of japanese midwife - led primary delivery care , as follows : ( 1 ) those intending to give birth at home managed by midwives who do not belong to our hospital , ( 2 ) those planning to give birth in our hospital managed by the same midwives , and ( 3 ) those planning to give birth managed by midwives who belong to our hospital . methods . a retrospective cohort study was performed . results . there were no significant differences in the obstetric or neonatal outcomes among the 3 groups . the rate of transfers during labor with the system involving midwives belonging to our hospital was higher than those with the other 2 systems . in addition , the timing of transfers in the system with the midwives belonging to our hospital was earlier than with the other 2 systems . among the 3 groups , there were no significant differences in the rate of the main 2 indications for transfers : fetal heart rate abnormality and failure to progress . conclusion . there were no significant differences in perinatal outcomes among the 3 systems ; however , there were some differences in the status of transfers to obstetric shared care .

diabetes decreases overall life expectancy cause heavy burden public health 1 moreover asia pacific region considered verge emerging diabetes epidemic 2 the development type 2 diabetes affected genetic environmental determinants 3 recently one study investigated whether common variants functional positional candidate genes including adrb3 pparg enpp1 capn10 determinants type 2 diabetes 4 enpp1 also called k121q glutamine substitution lysine codon 121 5 type 2 diabetes characterized insulin resistance 6 enpp1 plays important role insulin resistance 7 8) enpp1 interacts -subunit insulin receptor interrupt signaling 9 previous studies k121q polymorphism human pc-1 gene strongly associated insulin resistance 1 3 7 10 12 however association insulin resistance k121q variant 13 14 in addition discrepancies impact enpp1 polymorphism obesity ethnic groups 5 10 13 15 19 obesity increases concentration insulin plasma major contributor insulin resistance 20 obesity appears effect modifier type 2 diabetes d1057 carriers 21 the association obesity genetic variant insulin receptor substrate identified studies 21 22 chinese han population the pc-1 q121 allele associated insulin resistance women carriers q allele had increased risk obesity development 3 caucasians african americans 121q carriers association increased body mass index bmi 23 three allele risk type haploid qdeltg q allele increased risk obesity 24 ) however danish population differences distribution frequencies dominant types kk wild type kq qq variant type alleles 19 the complexity type 2 diabetes related factors genetic heterogeneity interactions genes modulating role played environment 4 spite limitations studies type 2 diabetes genetic factors obesity can predict risks development type 2 diabetes obesity order assist primary prevention korea appropriate country studies homogeneity racial composition lifestyle 25 therefore aim study analyze presence enpp1 polymorphism studied yet korean population identify association genotypes allele type 2 diabetes obesity this company electric power company located kori yonggwang ulchin wolsung seoul korea there 195 male workers age 48.26.7 yr bmi 24.672.64 kg diagnosed diabetics medical examinations conducted march 2004 october the 1,750 male workers age 45.27.7 yr bmi 24.772.64 kg control group selected randomly subjects included met one criteria onset age older 20 yr old exclude type 1 diabetes 1 blood sugar level meal exceeded 126 mg dl twice 2 blood sugar level meal exceeded 126 mg dl blood sugar level two hours meal exceeded 200 mg dl 3 reported history diabetes questionnaire taken oral hypoglycemic agents the workers included obesity group whose bmi 25 kg collecting blood sample vein fasting 8 hr status measured blood sugar level insulin lipid profile also measured height weight calculate bmi fasting glucose levels greater 126 mg dl checked 2 hr post prandial plasma glucose level site within 1 month height weight measured autoanalyzer health guard fanics seoul korea the fasting blood level analyzed glucose oxidase assay using autochemistry analyzer determine lipid profile total cholesterol analyzed enzyme assay using cholesterol oxidase cod high density lipoprotein hdl cholesterol glycerol phosphate oxidase assay low density lipoprotein ldl cholesterol direct surfactant assay we carried study approval ethnics committee asan medical center obtained written consent subjects providing subjects sufficient explanation obtain informed consent we extracted genomic dna buffy coats using generall blood sv kit general biosystem seoul korea following instructions suggested manufacturer the method genotyping used identify k121q polymorphism enpp1 exon 4 polymerase chain reaction restriction fragment length polymorphism pcr rflp using dna treated restriction enzyme pcr based paper reported abate et al we carried student test analyze effects genotypes biochemical parameters using genotypes factors the hardy weinberg equilibrium computed based goodness fit test we also investigated differences frequencies genotypes type 2 diabetic normal groups obesity normal groups fisher exact test the spss 12.0 window statistical software package used statistical analysis this company electric power company located kori yonggwang ulchin wolsung seoul korea there 195 male workers age 48.26.7 yr bmi 24.672.64 kg diagnosed diabetics medical examinations conducted march 2004 october the 1,750 male workers age 45.27.7 yr bmi 24.772.64 kg control group selected randomly subjects included met one criteria onset age older 20 yr old exclude type 1 diabetes 1 blood sugar level meal exceeded 126 mg dl twice 2 blood sugar level meal exceeded 126 mg dl blood sugar level two hours meal exceeded 200 mg dl 3 reported history diabetes questionnaire taken oral hypoglycemic agents the workers included obesity group whose bmi 25 kg collecting blood sample vein fasting 8 hr status measured blood sugar level insulin lipid profile also measured height weight calculate bmi fasting glucose levels greater 126 mg dl checked 2 hr post prandial plasma glucose level site within 1 month height weight measured autoanalyzer health guard fanics seoul korea the fasting blood level analyzed glucose oxidase assay using autochemistry analyzer determine lipid profile total cholesterol analyzed enzyme assay using cholesterol oxidase cod high density lipoprotein hdl cholesterol glycerol phosphate oxidase assay low density lipoprotein ldl cholesterol direct surfactant assay we carried study approval ethnics committee asan medical center obtained written consent subjects providing subjects sufficient explanation obtain informed consent we extracted genomic dna buffy coats using generall blood sv kit general biosystem seoul korea following instructions suggested manufacturer the method genotyping used identify k121q polymorphism enpp1 exon 4 polymerase chain reaction restriction fragment length polymorphism pcr rflp using dna treated restriction enzyme pcr based paper reported abate et al we carried student test analyze effects genotypes biochemical parameters using genotypes factors the hardy weinberg equilibrium computed based goodness fit test we also investigated differences frequencies genotypes type 2 diabetic normal groups obesity normal groups fisher exact test the spss 12.0 window statistical software package used statistical analysis the frequencies kk type kq type qq type enpp1 k121q 82.1% 17% 0.9% respectively the homozygous type q carrier qq type added heterozygous type kq type frequency qq type low 0.9% we investigated differences age blood pressure bmi results clinical examinations according genotypes enpp1 k121q type 2 diabetic non diabetic groups table 1 type 2 diabetics non diabetics pooled n=1,945 significant differences bmi systolic pressure diastolic pressure glucose value fasting status total cholesterol ldl cholesterol hdl cholesterol triglyceride c reactive protein homa ir kk type kq+qq type in addition significant differences characteristics type 2 diabetic group non diabetic groups table1 obese group non obese groups table2 the frequencies genotypes accordance hardy weinberg equilibrium p=0.85 the odds ratio kq+qq genotype 0.85 diabetics versus non diabetics the odds ratio q allele 0.91 diabetics versus non diabetics however significant difference genotypic allelic distribution type 2 diabetics non diabetics table3 the odds kq+qq genotype 0.93 obese versus non obese subjects furthermore odds q allele 0.96 obese versus non obese subjects however significant difference genotypic allelic distribution obese non obese table4 the frequency kk type enpp1 k121q genotypes 82.1% kq+qq type 17.9% q allele 9.4% there statistically significant difference distribution among genotypes alleles p=0.81 p=0.89 respectively although 121q carrier q allele obese and/or diabetics seemed differ slightly non obese non diabetics reference group determining prevalence q allele carriers kq qq subjects q allele significant differences genotypic allelic distribution respect phenotypes data shown after adjusting effects obesity probability type 2 diabetes kq+qq type 0.858 data shown q allele 1.095 showing significant difference table 5 moreover adjusting effects type 2 diabetes probability developing obesity kq+qq type 0.936 data shown q allele 1.038 showing significant difference table 6 the results studies association enpp1 k121q variants type 2 diabetes obesity several races disparate we carried study investigate association k121q variants type 2 diabetes obesity korean male workers insulin resistance major component pathogenesis type 2 diabetes 27 insulin receptor kinase activity impaired muscle insulin sensitive tissue many type 2 diabetic patients 28 potential inhibitor insulin receptor tyrosine kinase identified plasma cell membrane differentiation antigen-1 pc-1 29 therefore significant analyze enpp1 pc-1 polymorphism previous studies association type 2 diabetes polymorphism enpp1 k121q missense mutation increased odds ratio type 2 diabetes dominican 10 south asian caucasian 16 finnish 18 french populations 24 moreover according meta analysis association enpp1 k121q variant type 2 diabetes odds ratios 1.30 95% confidence interval ci 1.13 1.50 16 1.17 95% ci 1.10 1.25 19 showing significant association study 121q associated type 2 diabetes showing consistent results japanese population 5 danish caucasians 13 oji cree population 17 finnish population 18 danish white subjects 19 most type 2 diabetes koreans characterized non obesity thus enpp1 k121q mutant relevant insulin resistance possibly could candidate gene appropriate explain susceptibility type 2 diabetes this possible explanation lack association enpp1 121q carrier type 2 diabetes study obesity main risk factor development type 2 diabetes 20 linear association obesity type 2 diabetes 3 previous studies association obesity polymorphism enpp1 121q carriers and/or q allele associated obesity chinese han population bmi obesity group 27 kg 3 caucasians bmi obesity group 90th percentile african american adults bmi obesity group 80th percentile 23 french population bmi obesity group 95th percentile 24 dominican population bmi obesity group 30 kg 10 however study bmi obesity group 25 kg difference distribution obesity 121q carriers presence q allele this result consistent study 7,333 danes 19 spanish population 14 bmi obesity group 25 kg higher hand matsuoka study the percentage subjects whose bmi 30 kg higher low 2.5% investigate effect k121q genotype obesity the results present study showed frequencies q allele 8.7% type 2 diabetic group 9.2% obesity group lower finnish swedish populations 12.9 15.1% 11 danish caucasians 14 16% 13 south asians chennai 14% caucasians dallas 16% south asians dallas 19% 16 dominican population 54.2% 10 black children 77% 30 the frequencies q allele investigated study might smaller statistical power explain association either type 2 diabetes obesity 121q carriers kq+qq and/or q allele conclusion present study suggests enpp1 k121q polymorphism associated type 2 diabetes obesity the results negative associations study might attributable low prevalence obesity relatively younger age low frequencies 121q carriers large prospective studies needed confirm preliminary observation korean population

type 2 diabetes is characterized by insulin resistance , and enpp1 plays an important role in insulin resistance . we investigated the association of the enpp1 k121q polymorphism with both diabetes and obesity ( body mass index [ bmi ] ) in korean male workers . the study design was case - control . subjects were 1,945 male workers ( type 2 diabetes , 195 ; non - diabetes , 1,750 ) of nuclear power plants who received examinations from march to october in 2004 . we collected venous blood samples under fasting ( 8 hr ) conditions , calculated bmi by height and weight , and assessed relevant biochemical factors . the results of this study demonstrated that the enpp1 121q genotype ( kq+qq types ) was not associated with type 2 diabetes ( odds ratios [ or ] , 0.854 ; 95% confidence interval [ ci ] , 0.571 - 1.278 ) or obesity ( or , 0.933 ; 95% ci , 0.731 - 1.190 ) . in addition , the frequency of the q allele was not related to type 2 diabetes ( or , 0.911 ; 95% ci , 0.630 - 1.319 ) or obesity ( or , 0.962 ; 95% ci , 0.767 - 1.205 ) . we concluded that the enpp1 121q allele is not a critical determinant for either diabetes or obesity in korean males . the discordance between the results of this study and those derived from studies of dominican , south asian , caucasian , finnish , and french populations might be due to differences in genetic backgrounds between these populations .

lipid apheresis provides safe effective means treating patients severe hyperlipidemia it functions first separating plasma blood cells cell separator using either adsorption apolipoprotein b affinity columns containing anti apolipoprotein b antibodies dextran sulphate precipitation low ph heparin lipid apheresis allows patients attain lower levels low density lipoprotein ldl usually attainable traditional drug therapy alone leaving high density lipoprotein hdl levels generally unaffected used conjunction statins lipid lowering drugs lipid apheresis may also induce regression coronary atherosclerotic plaque familial hypercholesterolemia fh patients fh group autosomal dominant genetic defects resulting elevated serum ldl cholesterol levels heterozygous state fh relatively common serious genetic disorder incidence 1 500 persons general population fh associated increased risk atherosclerosis premature coronary heart disease heart failure 3 4 fh caused mutation affecting apolipoprotein b proprotein convertase subtilisin kexin type 9 pcsk9 enzyme involved ldl receptor degradation commonly ldl receptor gene resulting defective ldl receptors and/or diminished number ldl receptors 7 8 these mutations cause ldl catabolized slower rate thus accumulate circulation currently fh treated using variety cholesterol lowering drugs notably statins hmg coa reductase inhibitors many patients however statins viable treatment option either intolerance ineffectiveness lipid apheresis alternative form treatment fh patients well persistently elevated ldl levels despite treatment because apheresis performed highly specialized centers relatively low volume little literature discussing effectiveness lipid apheresis reduction lipid profiles prevention future cardiac events this study therefore reports experience single metropolitan center treating patients hyperlipidemia lipid apheresis retrospective chart reviews performed questionnaire surveys given active lipid apheresis patients minneapolis heart institute mhi abbott northwestern hospital anw minneapolis minnesota mhi anw divisions allina health large healthcare provider minnesota western wisconsin patients identified electronic health record ehr screen ambulatory patients representing patients seen allina health metro area regional locations 2009 2012 epic systems verona wi patients criteria qualify apheresis based united states food drug administration fda approval recommendations currently fda supports ldl apheresis patients six months adequate response diet therapy maximum drug therapy due either ineffectiveness intolerance meet following criteria functional homozygotes ldl cholesterol 500 mg dl without cad functional heterozygotes ldl cholesterol 300 mg dl without cad functional heterozygotes ldl cholesterol 200 mg dl documented coronary heart disease functional homozygotes ldl cholesterol 500 mg dl without cad functional heterozygotes ldl cholesterol 300 mg dl without cad functional heterozygotes ldl cholesterol 200 mg dl documented coronary heart disease the date birth gender date apheresis initiation lipid disorder diagnosis apheresis frequency family history cardiac events recorded patients noted fh active problem list contained diagnosis fh determine patients fh used national lipid association nla criteria 80% probable fh diagnosis using highest ldl recorded patient chart follows age 20 ldl 190 mg dl age 2029 ldl 220 mg dl age 30 ldl 250 mg dl potential homozygous fh hofh patients defined untreated ldl 500 mg dl treated statin ldl 300 mg dl addition clinical evidence xanthomas age 10 years two parents heart disease high lipids identifiable secondary causes marked hyperlipidemia excluded analysis examining ehr chart potential homozygote current cholesterol lowering medications also recorded focusing use statins colesevelam welchol ezetimibe zetia niacin aspirin a significant cardiovascular event defined myocardial infarction mi percutaneous transluminal coronary angioplasty ptca stenting procedure coronary artery bypass graft cabg using ehr documented icd-9 criteria cardiac events separated occurrence patient began apheresis total number events recorded group multiple cardiac events occurring hospitalization mi followed ptca counted single event cardiac event rate calculation pre- postapheresis cardiac event rates calculated adding total number cardiac events dividing total person years time period the preapheresis time period describes time first documented ehr visit date apheresis initiation the postapheresis time period describes time date apheresis initiation study date unverifiable events noted ehr occurring prior first documented ehr visit noted excluded cardiac event rate calculation mean acute ldl reductions calculated averaging recorded ldl values prior immediately treatment sessions mean acute total cholesterol hdl cholesterol triglyceride reductions calculated using lipid profile recent treatment session ldl apheresis performed abbott northwestern hospital using kaneka liposorber la-15 system kaneka medical products the system consists kaneka ma-03 machine integrated sulflux kp-05 plasma separator consists porous hollow fibers separate plasma whole blood two disposable liposorber la-15 adsorption columns adsorb apolipoprotein b containing lipoproteins patient plasma patients confirmed information ehr risk factors answered questions relating awareness fh family previously tested provided level satisfaction apheresis program indicated interest learning alternative treatments the data questionnaires cross referenced data patient charts ensure accuracy descriptive statistics displayed means sds continuous variables number percentage characteristic given categorical variables categorical variables analyzed using pearson chi square fisher exact tests continuous variables analyzed using student test value p 0.05 considered significant p values two sided possible all statistical calculations plots done stata 11.2 college station tx institutional review board approval obtained data collection follow data analysis of 8 72.7% male 10 90.9% caucasian 1 9.1% african american 10 90.9% carried diagnosis fh 2 18.2% patients identified probable homozygotes 1 9.1% diagnosed familial combined hyperlipidemia the average age patients 65.6 9.3 years patients apheresis average 6.2 7.0 years four 36.4% patients currently statins 7 63.6% history statin intolerance five 11 45.5% patients nonstatin cholesterol lowering medications including 1 9.1% colesevelam welchol 3 27.3% ezetimibe zetia 1 9.1% niacin maximum ldl levels ranged 211 448 mg dl mean sd value 298 80.7 mg dl study group since ehr implemented 2005 possible may underestimating highest lifetime ldl patient of 11 participants 9 completed questionnaire entirety 1 patient provided answers questions disclose risk factors 1 patient complete questionnaire all patients indicated aware likely fh 7 patients indicated immediate family tested fh the patients self reported total 44 cardiac events apheresis 8 cardiac events apheresis of 10 patients completed questionnaire 4 patients currently statins 6 statin intolerant eight patients 72.7% cardiac event documented ehr 43 cardiac events occurring overall table 4 self reported events unable verified via ehr excluded cardiac event rate analysis thirty four cardiac events documented apheresis 8 patients compared 9 events 5 patients apheresis excluding cardiac events unverifiable 14 cardiac events documented preapheresis time period 7 documented postapheresis time period the cardiac event rates calculated 0.23 0.13 0.39 events per person year preapheresis group 0.10 0.041 0.21 events per person year postapheresis group p 0.064 patients observed average 7.6 5.9 years apheresis 6.2 4.7 years apheresis 60.6 total patient years apheresis 67.8 patient years apheresis this study conducted gain information lipid apheresis evaluate effectiveness lowering lipid values addition chart review patient survey attempted gain greater understanding patient population terms traditional risk factors family awareness screening statin cholesterol medication uses desire additional treatment options ultimately cardiac events our study shows apheresis markedly lowers total cholesterol ldl cholesterol triglycerides much lesser degree hdl cholesterol there small statistically significant reduction hdl values apheresis many patients statin intolerant using nonstatin cholesterol medications importantly 10/11 90.9% participants indicated desire learn potential treatment options indicating population may indeed experience fatigue procedure although taken small study population data suggests reduction cardiac event rate apheresis statistically significant data shows strong trend towards event rate reduction this statistical insignificance likely explained study small sample size larger population it also important note risk cardiac events increases age ldl apheresis shown improve endothelium dependent vasodilation 11 12 microvascular flow myocardial perfusion some studies 2 15 16 also shown significant reduction angiographic cad others these studies small primarily nonrandomized trials ldl apheresis atherosclerosis regression study laars ) looked change plaque characteristics patients undergoing apheresis compared drug therapy period two years in period 7 21 patients apheresis cardiac event compared 3 21 medication study found apheresis arrested progression atherosclerosis the fh regression study found ldl apheresis combined simvastatin effective colestipol plus simvastatin reducing ldl cholesterol lipoprotein less effective influencing coronary atherosclerosis another study found 18 patients 3 myocardial infarctions 1 underwent cabg 12 needed coronary angioplasties within two years beginning combination therapy apheresis statins probucol beginning combination therapy 11 experienced mi 5 undergone cabg 13 undergone angioplasty the heparin induced extracorporeal ldl precipitation help study found help suitable reducing ldl concentrations may work reduce burden atherosclerosis myocardial infarctions low coronary intervention rate patients began apheresis due expensive nature apheresis randomized controlled clinical trial needed truly gauge effectiveness apheresis reducing occurrence cardiac events if apheresis deemed effective minimally effective studies suggest types treatment lomitapide mipomersen pcsk9 inhibitors pursued satisfaction generally high survey patients specifically cited satisfaction based results apheresis process many patients complained invasive nature apheresis citing bruises procedure inconvenience reporting treatment every two weeks additionally almost patients interested learning alternative treatments suggesting would prefer alternative treatment could match results provided apheresis this study several limitations since lipid apheresis advanced treatment uncommon genetic disease limited number patients available participate study led small sample size the event rate reduction statistically significant showed strong trend toward cardiac event rate reduction apheresis defining observational period initial time point first documented ehr visit excluded 20 events apheresis 2 events apheresis cardiac event rate calculation the lipid lowering effects apheresis best expressed reductions interval means although lipid apheresis performed every two weeks ldl values measured ever two weeks due clinical practices this inconsistency measurement intervals prevents use advanced measures accurately track effect apheresis ldl measurements finally study focused active apheresis patients therefore include patients stopped apheresis deceased lipid apheresis reliably reduce ldl non hdl cholesterol triglyceride total cholesterol levels fh patients our data suggest lipid apheresis shows strong statistically significant trend towards reduction cardiac events apheresis viable treatment fh patients especially statin intolerant due lipid lowering nature apparent reduction cardiac events however need alternative treatments less invasive provide easier patient access

lipid apheresis is used to treat patients with severe hyperlipidemia by reducing low - density lipoprotein cholesterol ( ldl - c ) . this study examines the effect of apheresis on the lipid panel and cardiac event rates before and after apheresis . an electronic health record screen of ambulatory patients identified 11 active patients undergoing lipid apheresis with 10/11 carrying a diagnosis of fh . baseline demographics , pre- and postapheresis lipid levels , highest recorded ldl - c , cardiac events , current medications , and first apheresis treatment were recorded . patients completed a questionnaire and self - reported risk factors and interest in alternative treatment . there were significant reductions in mean total cholesterol ( 58.4% ) , ldl - c ( 71.9% ) , triglycerides ( 51% ) , high - density lipoprotein ( hdl ) cholesterol ( 9.3% ) , and non - hdl ( 68.2% ) values . thirty - four cardiac events were documented in 8 patients before apheresis , compared with 9 events in 5 patients after apheresis . our survey showed a high prevalence of statin intolerance ( 64% ) , with the majority ( 90% ) of participants indicating an interest in alternative treatment options . our results have shown that lipid apheresis primary effect is a marked reduction in ldl - c cholesterol levels and may reduce the recurrence of cardiac events . apheresis should be compared to the newer alternative treatment modalities in a randomized fashion due to patient interest in alternative options .

agenesis inferior vena cava ivc cause recurrent deep vein thrombosis dvt uncommon a 33-year old male family history thrombophilia experienced multiple recurrent episodes dvt 15-year period unknown cause admitted hospital cellulitis right leg congenital absence ivc could rare risk factor idiopathic dvt especially young individuals venous thromboembolism vte includes deep vein thrombosis dvt pulmonary embolism incidence 1 3 per 1000 individuals per year western populations.1 congenital anomalies inferior vena cava ivc uncommon associated development venous thrombosis lower limbs.2 congenital anomalies ivc reported risk factor dvt especially individuals 30 years old concomitant thrombophilic disorder found individuals.3 report case recurrent dvt 33-year old man agenesis ivc the patient experienced recurring episodes idiopathic dvt right leg 15 years a 33-year old man admitted internal medicine department holy family hospital nazareth israel cellulitis right leg one week prior admission complained pain increased local heat left ankle thumb right leg the patient history previous trauma surgery insect bites dysuria joint symptoms family history thrombophilia he reported rheumatic fever without complications 19 years old treated penicillin b hospitalized 23 years old infected skin ulcers right calf treated parenteral antibiotics c recurrent episodes idiopathic dvt last 15 years he also reported treated warfarin prophylactic enoxaparin therapy dvt years ago since stopped recently treated allopurinol colchicine presumed diagnosis gout he investigated several times primary hypercoagulability state results negative examination outstanding clinical findings swelling ankles mild edema redness increased temperature right ankle calf trophic skin changes skin discoloration ulcers superficial varicose veins lower abdomen figure 1 the clinical laboratory findings erythrocyte sedimentation rate leukocyte platelet counts plasma hemoglobulin plasma protein c plasma protein fibrinogen antithrombin iii levels results kidney liver function tests resistance activated protein c normal polymorphisms genes encode methylenetetrahydrofolate reductase detected factor v leiden prothrombin mutations g20210a absent results clinical immunological studies complement c3 c4 rheumatoid factor negative circulating titers antinuclear antibody antineutrophil cytoplasmic antibody cardiolipin antibody found cultures infected skin ulcers right leg positive methicillin resistant staphylococcus aureus mrsa ultrasound imaging leg veins showed previous dvt right common femoral vein dilated superficial inguinal veins computer tomography contrast abdomen showed agenesis infrarenal segment ivc figure 2 dilated azygos hemiazygos veins figure 3 there also varicose veins abdominal wall right groin associated dilated superficial collateral veins figure 4 transthoracic echocardiography patient heart revealed mild atrial enlargement good systolic function left ventricle pathological valvular flows the patient diagnosed agenesis infrarenal segment ivc dvt right leg without concomitant risk factors vte since attributed agenesis ivc underlying cause recurrent episodes dvts patient started anticoagulant therapy subcutaneous enoxaparin 160 mg day dvt antibiotic therapy intravenous vancomycin 1.5 g day mrsa skin infection referred vascular surgeon specialist patient refused follow internal medicine clinic the outstanding clinical findings swelling left ankle redness trophic skin changes mild improvement skin ulcers despite several phone calls follow up the normal ivc composed 4 segments hepatic suprarenal renal infrarenal since many transformations occur formation ivc such anomalies occur 0.3% otherwise healthy individuals 0.6% 2% patients cardiovascular anomalies.4 ruggeri et al reported 10 years ago 4 cases congenital absence ivc 75 young patients idiopathic dvt 5-year period estimated 5% young patients dvt anomaly ivc.5 venous thrombosis caused presence isolated combined risk factors almost 150 years ago nineteenth century pathologist rudolf virchow described 3 critically important causes venous thrombosis venous damage coagulation defect(s venous stasis.6 individuals congenital anomaly ivc typically asymptomatic anomaly usually detected incidentally radiological abdominal procedures congenital absence ivc infrequently associated thromboembolic events.5 patients suffer congenital anomalies ivc usually develop compensatory circulation azygos veins collateral abdominal veins order keep venous return near normal levels.7 reported cases congenital anomalies ivc cases linked thrombophilia disorders.3,5,7 however true prevalence thrombophilia congenital anomalies ivc unknown screening thrombophilia patients ivc anomaly usually incomplete.3 anticoagulants thrombolytic therapy usually prescribed venous thrombosis duration anticoagulant therapy well established hence anticoagulant therapy indefinite duration probably prescribed unless vascular reconstructive surgery done anomalous ivc such surgery rarely reported long term outcome undetermined.8 congenital anomalies ivc may cause recurrent dvt especially young individuals

background : agenesis of the inferior vena cava ( ivc ) as a cause of recurrent deep vein thrombosis ( dvt ) is uncommon.case:a 33-year - old male with no family history of thrombophilia , who had experienced multiple recurrent episodes of dvt over a 15-year period of unknown cause , was admitted into our hospital because of cellulitis in the right leg . computer tomography with contrast of the abdomen showed an absence of ivc.conclusion:congenital absence of the ivc could be a rare risk factor for idiopathic dvt , especially in young individuals .

exponential rise alzheimer disease ad prevalence rates predicted parallel aging baby boomers creating potentially unsustainable economic burden healthcare system delaying onset progression ad even modestly earlier pharmacological intervention could substantially reduce economic psychosocial impact illness 1 2 unfortunately many ad patients remain undiagnosed go undetected later stages disease insights underlying pathological mechanisms involving beta amyloid plaque deposition within brain led development host antiamyloid agents various stages clinical investigation there scientific consensus pathological events ad initiate decades clinical symptoms become apparent disease modification realized coming decades need improved methods early detection prior overt clinical signs accentuated traditionally neuropsychological measures particularly tap cognitive abilities subsumed hippocampal formation episodic memory shown usefulness identifying cognitively normal elders subsequently develop ad 4 5 decrements semantic memory concept formation shown occur nearly decade development ad performance visual spatial verbal memory measures midlife also shown predict later memory loss however individuals high premorbid intellectual abilities experiencing incipient cognitive decline may go undetected false positives possible individuals low level intellectual abilities also appropriate interpretation extensive neuropsychological testing requires high degree expertise training limits use routine clinical settings advancement molecular imaging tracers bind amyloid pittsburgh compound b pib longer lived probes e.g. fddnp offers non invasive vivo method detect quantify brain amyloid deposition 8 9 however approach presymptomatic detection economically impractical routine use given current costs restrictions medically necessary use similarly biomarkers including a142 phosphorylated tau also implicated ad pathology cerebral spinal fluid csf predict subsequent cognitive decline 10 11 lumbar puncture carries risks inconvenient wide scale use cognitively impaired elderly subjects blood based biomarkers practical applicability routine use likely cost effective csf imaging procedures consequently measurement a140 a142 blood increasingly explored shows potential identifying individuals preclinical stage ad 1214 it reported csf levels subject high diurnal fluctuations extremely high variability reported 12 hours days weeks furthermore serum contains plasma possibly due release bound clotting process hence serum appears suitable use predicting mci ad optimal sensitivity specificity probably achievable combined current diagnostic procedures brief neuropsychological testing study examined usefulness brief neuropsychological tests combination blood a140 a142 predictive test detecting mci ad risk older adults pre symptomatic stage such approach practical clinical use germane designing large scale prevention trials participants included subset subjects enrolled alzheimer disease anti inflammatory prevention trial adapt adapt randomized placebo controlled multicenter primary prevention trial sponsored national institute aging subjects randomly assigned one three groups celecoxib 200 mg b.i.d naproxen sodium 220 mg b.i.d placebo full details data collection measurements study procedures available http://www.jhucct.com/adapt/manall43.pdf described elsewhere inclusion criteria adapt subjects age 70 older enrollment self reported family history ad like dementia normal cognitive performance brief battery neuropsychological tests recruitment adapt began 2002 study completed 2007 in 2005 roskamp institute initiated proteomic ancillary study f. crawford pi involving blood draw subjects the inclusion criteria ancillary study stipulated subject active adapt participant met adapt inclusion exclusion criteria a separate consent also obtained subject participated ancillary study two hundred fifteen subjects roskamp adapt cohort enrolled proteomic ancillary study time blood draw subjects maintained cognitively normal status determined performance annual cognitive assessment battery blood collected semi annual followup visits cognitive assessments performed baseline visit annual visits the time baseline cognitive testing diagnosis mci ad 4.06 years 1.3 sd timeframe baseline cognitive testing blood draw 2.25 years 0.71 sd blood draw diagnosis 1.79 years 1.2 sd the cognitive measures completed baseline annual followup included modified mini mental state examination 3ms hopkins verbal learning test revised hvlt r digit span forward backward wechsler adult intelligence scale revised wais r generative verbal fluency test supermarket items narratives rivermead behavioral memory test rbmt brief visuospatial memory test revised bvmt r the mini mental state examination mmse extracted 3ms alternate forms utilized annually hvlt r rbmt bvmt r subsequent annual visit subjects also completed 30-item geriatric depression scale self rating scale memory functions collateral respondents completed dementia severity rating scale dsrs due significant intercorrelations tests analyses described below are limited baseline cognitive tests sensitive early changes i.e. verbal learning memory associated mci ad tests similar previously shown associated levels normative data cache county study used develop standardized cut scores utilized adapt individuals scored cut scores annual cognitive assessments underwent dementia workup including physical neurological examinations laboratory studies i.e. cbc chemistry count sedimentation rate vitamin b12 folic acid levels thyroid test syphilis serological test neuroimaging i.e. mri ct applicable a comprehensive neuropsychological assessment also administered neuropsychologist part dementia work this battery tests consisted expanded consortium establish registry alzheimer disease cerad battery logical memory ii wechsler memory scale revised benton visual retention test benton generative fluency test animals control oral word association test cowat cfl trail making test symbol digit modalities test smdt shipley vocabulary following completion components dementia work consensus team determined cognitive status using published diagnostic criteria the diagnosis ad made using nincds adrda amnestic mild cognitive impairment mci using petersen criteria all mci patients considered amnestic mci memory impairment maintained normal activities daily living overall well preserved cognition cognitive domains ample evidence indicates amnestic mci patients may transitional stage normal aging ad 85% subjects converting ad 7-year period additional evidence comes imaging study demonstrated pattern brain atrophy amnestic mci patients typical observed ad patients it reasonable combine diagnoses single category thus allowing large enough numbers supply statistical power 215 subjects gave blood ancillary study two developed non ad dementia and of remaining subject pool 208 used analyses 28 subjects met criteria either ad n 10 mci n 18 two years following blood draw the serum content determined per manufacturer instructions using elisa kits human a140 a142 inter assay cv intraassay cv reported 10% invitrogen calif dna extracted whole blood apoe genotyping using pure gene kits gentra systems calif apoe genotyping performed using previously established methods described elsewhere apoe genotypes unavailable 4 individuals included analyses the data set range checked prior analyses dependent independent variables examined missing data outliers violations normalcy assumption differences among groups demographic variables neuropsychological variables serum a140 levels examined using either student test analyses depending type variable measurement time updated cox regression modeling used test whether neuropsychological test scores combination predict conversion mci ad individuals cognitively normal baseline potential confounding variables shown impact risk cognitive decline included age education gender apoe status serum creatinine triglycerides presence apoe 4 allele history vascular disease determined treatment statins antihypertensive medication entered covariates latter variables coded dichotomously previously shown impact levels because previous analyses revealed nonsignificant increase ad risk naproxen cohort also controlled effect logistic regression modeling employed construct receiver operator curves roc examine predictive performance neuropsychological measures baseline visit serum levels diagnoses mci ad roc curve comparisons based area curve auc se associated 95% confidence interval ci we subsequently calculated sensitivity various models using predicted probability subject logistic regression modeling specificity least eighty percent post hoc power calculations using g power software multivariate regression analyses utilized suggest power nearly 100% alpha value 0.05 current sample size total number predictors observed effect size the mean age education sample 76.7 sd 3.9 14.6 sd 2.8 years respectively the majority sample caucasian 98.1% 51.9% male despite cohort self report enriched family history less one third total sample 31.7% carried least one apoe 4 allele frequency similar general population comparisons variables subjects remained cognitively normal declined short follow period reported table 1 although subjects enrollment performed within normal limits based established cut scores ultimately declined generally poorer scores 3ms mmse memory measures the two groups also significantly different serum a142 levels a142/a140 ratios prior diagnoses mci ad only 23% cognitively normal individuals serum a142 lowest quartile compared nearly 50% diagnostic group 44% mci subjects 50% ad subjects time dependent cox regression analyses performed examine relationship cognitive tests prediction subsequent conversion mci ad all neuropsychological analyses adjusted age gender education adjustment study medications required baseline scores cox regression analyses show model using neuropsychological tests predicted mci ad 2 log likelihood 206.51 52.11 df 8 p .001 significant individual neuropsychological measures 3ms 0.25 0.06 wald 17.78 p .001 generative verbal fluency 0.12 0.04 wald 8.09 p < .004 hvlt r scores 0.24 0.11 wald 4.58 p .032 cox regression analysis showed a142 measured lowest two quartiles compared highest quartile significant individual predictor conversion mci ad model 2 log likelihood 197.47 38.41 df 15 p .001 the regression analysis utilizing a142/a140 ratio found similarly significant results 2 log likelihood 204.69 36.10 df 14 p .001 lowest ratios predictive subsequent conversion mci ad final full model adjusting confound study medications included hvlt r fluency 3ms a142 levels a142 quartiles 2 log likelihood 166.25 74.55 df 18 p .001 fluency 3ms a142 lowest two quartiles significant individual predictors mci ad model similar results observed a140 levels a142 quartiles substituted model a142/a140 ratios 2 log likelihood 168.49 72.90 df 17 p .001 baseline values 3ms hvlt r generative verbal fluency scores subtracted obtained 12-month repeat testing determine changes measures differ a142 a142/a140 ratios unadjusted analyses among subjects converted mci ad greatest decline hvlt r observed among individuals lowest quartile a142 1.17 2.33 sd a142/a140 ratios 0.75 2.63 sd individuals highest quartile a142 1.33 1.86 sd a142/a140 ratios improved nearly one point 0.6 1.82 sd however differences statistically significant p .05 3ms scores among subjects converted mci ad a142 lowest quartile declined 1.83 1.28 sd compared highest quartile 4.83 1.35 sd difference statistically significant f 3.42 p .033 mci ad subjects lowest quartile a142/a140 ratios 3ms values remained ultimately unchanged 0.16 1.20 sd while scores improved among highest quartile a142/a140 ratios 4.33 1.20 sd differences also statistically significant f 3.10 p .046 generative verbal fluency test decline noted lowest quartile 4.17 1.40 sd highest quartile 1.17 2.13 sd a142 differences marginally significant f 2.63 p .073 a142/a140 ratios a similar pattern observed difference statistically significant among individuals remained cognitively normal while similar pattern observed lowest quartile a142 a142/a140 ratios larger decline highest quartile hvlt r 0.28 0.27 sd versus 0.14 0.33 sd respectively 3ms 1.02 0.51 sd versus 0.39 0.44 sd however due small magnitude change scores differences statistically significant no change observed generative verbal fluency test data shown examination sensitivity specificity using roc analysis revealed auc neuropsychological testing age education gender covariates 0.83 95% ci 0.750.91 p .001 a142 ( adjusted presence apoe 4 allele vascular risk factors associated medications auc 0.79 95% ci 0.700.88 p .001 neuropsychological testing 3ms hvlt r generative verbal fluency a142 combined auc increased 0.91 95% ci 0.860.95 p .001 adjusted a142/a140 ratios alone .001 combined neuropsychological measures auc 0.91 95%ci 0.870.96 p .001 optimal sensitivities specificity least 80% predicted probabilities shown table 2 highest sensitivity specificity was achieved using combination cognitive scores a142/a140 ratio finding driven a142 the pathogenesis ad initiated clinical symptoms cognitive impairment functional decline become apparent victims a simple pragmatic method identifying older adults increased risk mci ad may benefit targeted prevention therefore importance reducing burden ad the combination brief neuropsychological tests along blood based biomarkers ad represents reasonable approach potential wide scale use our findings provide support notion demonstrate early prediction risk developing mci ad may feasible via combination brief neuropsychological tests biomarkers risk cohort subcohort adapt measures global cognitive function 3ms episodic memory hvlt r trial 4 language fluency serum a142/a140 ratio achieved excellent accuracy 91% furthermore sensitivity specificity least 80% combined measures superior neuropsychological measures serum levels alone we recently shown levels alone predict mci ad levels influenced vascular disease associated medications require adjustment observe full impact predictive modeling we also shown subjects diagnosed ad association measures language tests fluency object naming a140 memory performance associated serum a142 an association serum a140 cognitive measures memory language also reported cognitively normal older adults high baseline a142 a140 stable a142 time shown associated diminishing cognition more recently yaffe colleagues demonstrated low a142/a140 ratios predict cognitive decline 9 years study demonstrate low a142 a142/a140 ratios associated cognitive decline even within one year this extremely valuable clinical perspective ability identify risk individuals within year prior onset significantly improve quality care recruitment strategy prevention trials redirecting individuals may benefit preventive therapies towards suitable clinical intervention this demonstrated recent adapt findings suggest individuals low baseline cognitive scores converted soon trial initiated neither naproxen celecoxib intervention beneficial individuals collectively findings suggest combining cognitive tests blood may useful predicting future mci ad date explored particularly either cognitive tests alone may desired sensitivity specificity prediction future mci ad this current work presented provides evidence combination brief neuropsychological tests blood potential utility predicting mci ad least 2 4 years prior clinical classification mci diagnosis ad in addition findings also demonstrate importance accounting factors apoe vascular risk factors medications using predicting mci ad although present studies reported sensitivity specificity csf a142 predicting mci ad conversion normal cognition large multicenter study shown csf a142 predicts transition mci ad tau alone achieved high sensitivity 83% acceptable specificity 72% it interesting note findings using blood cognitive tests far less invasive method resulted higher sensitivities specificities predicting cognitive decline risk cognitively normal older adults despite limitation blood sampling conducted time point cognitive testing our data provide strong support evaluation approach particularly seen significant fluctuations levels one year period pers our study provides support blood based levels may diagnostic utility combined neuropsychological measures proposed method warrants investigation determine practical applicability specialized clinic setting allied health personal routine primary care clinics

we examined the usefulness of brief neuropsychological tests and serum a as a predictive test for detecting mci / ad in older adults . serum a levels were measured from 208 subjects who were cognitively normal at enrollment and blood draw . twenty - eight of the subjects subsequently developed mci ( n = 18 ) or ad ( n = 10 ) over the follow - up period . baseline measures of global cognition , memory , language fluency , and serum a142 and the ratio of serum a142/a140 were significant predictors for future mci / ad using cox regression with demographic variables , apoe 4 , vascular risk factors , and specific medication as covariates . an optimal sensitivity of 85.2% and specificity of 86.5% for predicting mci / ad was achieved using roc analyses . brief neuropsychological tests and measurements of a142 obtained via blood warrants further study as a practical and cost effective method for wide - scale screening for identifying older adults who may be at - risk for pathological cognitive decline .

we compared serum polychlorinated dibenzo - p - dioxins ( pcdds ) and polychlorinated dibenzofurans ( pcdfs ) among residents of two homes to levels among age- and sex - matched comparison subjects . the residents of the two homes consumed contaminated eggs and beef from animals raised at the homes . the animals had greater soil contact than those raised with conventional commercial husbandry practices . the comparison subjects were from a similar rural area , but did not consume home - produced beef and eggs . serum levels of 2,3,7 , 8-substituted tetra- , penta- , and hexacdds and penta- , hexa- , and heptacdfs were increased between 2- and 6-fold in residents from one home ; contaminated eggs and beef were consumed by residents for 2 - 15 years . elevations were less for those in the other index home , where only home - produced eggs were consumed for 2 years ; a 3-fold elevation of 1,2,3,7,8,9-hexacdd as compared to controls was most apparent . very strong bivariate correlations among all of the 2,3,7 , 8 penta- and hexacdds / cdfs were observed . the elevations observed verify that pcdd / pcdf - contaminated food contributed to the body burden of these compounds . the blood levels among the highest exposed participants are generally higher than those observed in other studies of u.s . contaminated - fish consumers and higher than average adipose tissue levels observed in u.s . urban populations . there are sufficient animal toxicologic and human epidemiologic data to recommend that exposures be reduced . in the study area , pentachlorophenol and pentachlorophenol incineration sources have been identified , and the animal contamination and blood elevations probably reflect these sources . soil reference values and site - specific risk assessments should include estimates of exposures to contamination in home - produced animal products . such estimates can be verified with limited pcdd / pcdf sampling of animals and humans.imagesfigure 1figure 2

wnt/-catenin pathway implicated development progression melanoma wide range cancer types including colorectal cancer breast cancer esophageal carcinoma liver cancer 13 normal conditions increases expression binding certain wnt ligands frizzled receptor mutations specific components -catenin degradation assembly deactivate regulatory mechanism nuclear -catenin stimulates transcription large number tcf/-catenin responsive genes include cyclin d1 c myc 5 6 melanocyte specific gene microphthalmia associated transcription factor mitf thus accumulation nuclear -catenin observed several cancer types considered marker canonical wnt/-catenin pathway deregulation unfavorable prognosis 3 8 previous studies reported association nuclear -catenin accumulation melanoma progression suggested nuclear -catenin marker poor prognosis 1 7 however recent studies shown contrary breast colon cancer metastatic progression melanoma associated decreases nuclear cytoplasmic -catenin expression 9 10 moreover clinical genetic histological studies suggest nuclear cytoplasmic -catenin may used biomarkers good prognosis melanoma 1114 recently hhr6 human homologue yeast rad6 gene principal component postreplication dna repair pathway identified important regulator canonical wnt/-catenin signaling 15 16 hhr6 referred hereafter rad6 stabilizes -catenin polyubiquitin modifications render -catenin resistant 26s proteasomal degradation furthermore rad6 transcriptional target -catenin thus revealing positive feedback loop -catenin mediated activation rad6 gene expression rad6-induced -catenin stabilization rad6 expression low normal breast tissues however increases rad6 protein expression detected hyperplastic ductal carcinoma situ dcis invasive breast carcinomas we previously demonstrated role rad6 breast cancer progression regulatory effect canonical wnt/-catenin pathway since decrease loss nuclear -catenin 9 10 rather increases breast cancer is linked melanoma progression known whether rad6 -catenin work concert promote melanoma pathogenesis furthermore rad6 expression skin investigated data role rad6 pathogenesis benign nevi malignant melanoma melanocytic lesions it important address gap knowledge unmet medical need new effective antimelanoma therapies rad6 -catenin identified therapeutic targets 19 20 study examined rad6 -catenin expressions serial sections nevi primary metastatic melanomas determine potential roles melanoma development metastatic progression our data suggest membranous relocation -catenin upregulation rad6 independent markers melanoma development progression we also offer hypothesis explains role membranous -catenin relocation decreasing cytoplasmic -catenin melanoma development phenomenon linked unfavorable prognosis 9 21 22 cases retrieved files pinkus dermatopathology laboratory pdl private dermatopathology laboratory located monroe mi preserved paraffin embedded tissue specimens collected case assigned accession code excluded patient identifier information nevus primary melanoma cases selected study using random numbers generated uniform random number generator stata mp 13.1 the study groups consisted 30 cases melanocytic nevi 29 cases primary cutaneous melanoma 29 cases metastatic cutaneous melanoma the study includes metastatic cutaneous melanoma samples archived 2010 2012 the number cases nevus primary melanoma subtype determined reflect lesion relative representation cases obtained pdl period atypical nevi diagnosed using criteria originally proposed clark lesion architecture reviewed roth et al primary antibodies used study follows anti--catenin is702 purchased dako glostrup denmark used undiluted form ii anti rad6 ab31917 purchased abcam cambridge used 1 500 dilution humans yeast homologous rad6 gene duplicated proteins encoded two genes hhr6a rad6a hhr6b rad6b chromosomes xq24-q25 5q23-q31 respectively share 95% identical amino acid residues neither ab31917 rad6 antibody commercially available anti rad6 antibody currently able distinguish rad6a rad6b proteins therefore rather referring rad6a rad6b refer protein detected antibody rad6 briefly five micrometer sections deparaffinized xylene rehydrated graded ethanol antigen retrieval sections microwaved citrate buffer ph 6.0 biogenex san ramon ca usa 12 min 95c cooled 30 min prior immunostaining sections incubated 3% hydrogen peroxide 15 min followed incubation primary antibody 60 min an automated immunostainer i6000 biogenex utilized subsequent incubation steps sections incubated multilink biotinylated anti igg 20 min horseradish peroxidase conjugated secondary antibody 20 min followed development 3-amino-9-ethyl carbazole 10 min biogenex all incubation steps performed room temperature sections washed tris buffered saline incubations lung colon cancer tissues included positive controls immunostaining anti--catenin antibody breast cancer tissues included positive controls staining anti rad6 antibody stained sections independently enumerated two coauthors d. r. mehregan m. campbell blinded patient medical records case blinded enumeration performed light microscopy 400x magnification ocular grid consisting simple square lattice 100 test points utilized count number positively negatively stained melanomas nevus cells section per section total number positively negatively stained cells counted three sequential horizontal fields the mean value three fields used estimate relative density cells specimen increase assessment accuracy positively negatively stained melanomas nevus cells visual field when independent readings positively stained cells differed 20% given section evaluators reviewed section together establish consensus reading a specimen considered negative less 4% cells immunostained rad6 -catenin a tumor considered stained high intensity 50% cells specimen expressed rad6 -catenin similar criteria used mineta et al kruskal wallis tests used compare groups basis continuous variables age percent positive cells chi square tests differences proportions used compare groups basis categorical variables gender -catenin localization spearman rank correlation used assess pairwise association age percent rad6 positive -catenin positive cells multinomial logistic regression used assess simultaneous association rad6 age diagnostic group adjustments made multiple comparisons using wilcoxon rank sum tests bonferroni correction pairwise comparisons our analysis included 30 individuals diagnosed nevi 29 primary melanoma 29 metastatic melanoma table 1 these groups differed marginally respect gender p 0.08 significantly age p 0.0001 significant age differences observed individuals nevi either primary melanomas p 0.02 metastatic melanomas p 0.0001 in contrast age difference observed individuals primary metastatic melanomas p 0.27 significant differences age also observed groups defined -catenin localization p 0.007 individuals -catenin localized cytoplasm significantly younger individuals -catenin localization cell membrane p 0.02 marginally younger individuals -catenin localization cytoplasm cell membrane p 0.05 age categorized 50 5060 60 years statistically significant differences rad6 expression groups p 0.0008 although substantial variability table 2 median rad6 greater group people older 60 years compared 5060 years old group p 0.04 50 years old group p 0.001 a 20% discrepancy positively stained cells two evaluators observed fewer 5% cases cases evaluated together establish consensus reading melanoma development progression associated significant changes percentage specimens expressing -catenin -catenin staining observed 97% nevi primary metastatic melanomas also percentages nevi 93% primary melanoma 97% metastatic melanoma 93% expressed -catenin 50% cells differ significantly figures 1 2 3 however significant differences observed percentages nevi 59% primary melanoma 90% metastatic melanoma 56% expressed -catenin 90% cells p 0.02 figure 2 these differences greatly impacted percentage primary melanomas 48% expressed -catenin 100% cells approximately twofold higher percentages nevi 21% metastatic melanoma 26% data shown none nevi melanomas expressed -catenin nucleus figure 1 the percentage tumors expressed membranous -catenin increased dramatically nevi 10% primary metastatic melanomas 83% 93% resp ; concurrently increase percentage tumors expressed cytoplasmic -catenin decreased nevi 90% primary metastatic melanomas 45% 38% resp ; in contrast significant differences observed percentages primary metastatic melanomas expressed -catenin either membrane 83% 93% resp ; p 0.289 cytoplasm 45% 38% resp p 0.633 figure 4 four nevi types junctional intradermal compound atypical expressed -catenin cytoplasm junctional atypical nevi expressed -catenin plasma membrane as opposed nevi types three primary melanoma types examined superficial spreading nodular lentigo maligna differ -catenin localization -catenin localized plasma membrane cytoplasm figure 4 conversely primary melanomas 100% majority metastatic melanomas 96% exhibited greater 50% rad6 expression the increase tumor populations expressing rad6 37% nevi 100% primary metastatic melanomas significant p 0.0001 figures 1 2 3 melanoma progression primary metastatic disease associated changes percentage melanomas expressing rad6 100% primary metastatic melanomas ii percentage melanomas expressing rad6 50% tumor cells 100% 96% primary metastatic melanomas resp the increase proportion tumor populations expressing rad6 50% cells primary melanoma 67% versus metastatic melanoma 79% significant p 0.37 figure 2 this study designed test whether distribution tumor cells positive rad6 subtypes nevi however percentages benign tumors lacked rad6 similar atypical nevi 62% group three nevi types 59% interestingly one 30 nevi atypical nevus 3% expressed rad6 80% cells none primary metastatic melanomas expressed rad6 40% cells figure 2 these results prompted us examine whether rad6 expression serve marker histological diagnosis melanoma using multiple logistic regression model found strength rad6 expression strong predictor melanoma p 0.001 even age group p 0.65 gender p 0.24 included model the model predicts every 1% increase rad6 expression results 9% increase probability lesion melanoma if assume predicted probability 0.5 indicates melanoma model rad6 sensitivity 93% specificity 80% these results encouraging however need validated larger study expression profiles -catenin rad6 differed considerably nevi approximately 93% nevi expressed -catenin 50% cells whereas 27% population nevi expressed rad6 figure 2 -catenin rad6 expressions nevi significantly correlated r 0.06 p 0.77 there 2.7-fold difference percentage primary melanomas 100% expressing rad6 compared nevi 37% virtually difference -catenin expression primary metastatic melanomas 100% accordingly rad6 -catenin expressions primary melanoma correlated r 0.001 p 0.99 significant correlation rad6 -catenin positive cells however association diminished r 0.40 p 0.05 following exclusion two observations disproportionally influential one 50% positive rad6 one 50% positive -catenin this first study characterize rad6 expression cutaneous benign malignant melanocytic tumors study examined association rad6 -catenin expressions benign malignant melanocytic tumors determine whether rad6 works concert -catenin influence melanoma development progression rad6 -catenin positively regulate breast cancer 15 18 however -catenin implicated pathogenesis melanoma cancer types data role rad6 cancer pathogenesis mostly limited breast cancer therefore hypothesized comparison rad6 -catenin expressions nevi melanoma tumors would help determine whether two signals collaborate promote melanoma development progression breast cancer 15 28 accumulation nuclear cytoplasmic -catenin implicated driving development progression several cancer types e.g. colon ovarian cancers 2931 however results show expression levels -catenin contribute melanoma initiation progression since difference -catenin levels found nevi primary melanoma metastatic melanoma 93%97% samples expressed -catenin 50% tumor cells the high expression levels -catenin line crucial role -catenin differentiation proliferation normal melanocytes metastatic melanoma cells also findings agreement previous reports positive -catenin staining nevi 100% primary melanoma 95% 94% higher reported metastatic melanoma 75% 68% 9 21 variation expression -catenin levels metastatic melanomas studies while studied melanoma metastases skin studies either obtained 58% specimens lymph nodes tonsil liver identify anatomical site metastases 9 21 furthermore different anatomical sites may regulate dissimilar antigen expressions metastases originate primary tumor patient 33 34 previous studies shown higher percentages nuclear -catenin nevi melanoma 84% versus 33% 44% versus 15% 9 22 those observations provided basis currently held concept loss nuclear cytoplasmic -catenin suggest poor prognosis decreased overall survival melanoma patients 12 22 light data absence nuclear -catenin nevi melanomas analyzed study surprising usage different anti--catenin antibodies may explain part discrepancy nuclear -catenin expression observed studies however results consistent lack nuclear -catenin reported four studies comprised 57 nevi 55 primary melanomas 20 metastatic melanomas 21 3537 moreover nuclear -catenin found either nevus portion melanoma portion 15 cutaneous lesions absent additional 42 primary melanomas another study 70 primary melanomas nuclear -catenin reported 6.4% melanomas finally study 230 primary metastatic melanomas nuclear -catenin reported 13 cases 5.6% therefore cases excluded analysis taken together absence negligible amount nuclear -catenin detected aforementioned studies well suggests possible extranuclear roles -catenin nevi melanoma this notion supported role cytoplasmic -catenin execute functions require nuclear translocation e.g. activation map kinase p38 nf kb 37 40 a major finding study association melanoma development intracellular redistribution -catenin the percentage cases expressed -catenin cell membrane increased dramatically 10% nevi 83% 93% primary metastatic melanomas respectively concurrently percentage cases expressed cytoplasmic -catenin decreased 90% nevi 45% 39% primary metastatic melanomas respectively figure 4 we hypothesize relocation -catenin cytoplasm cell membrane may serve deactivating mechanism canonical wnt/-catenin signaling resulting reduction cytoplasmic -catenin level may contribute malignant transformation melanocytic nevi the proposed hypothesis supported following observations study bachmann et al also reported association nevus melanoma development relocation -catenin cell membrane nevertheless authors study offer explanation observation ii analysis data kagashita et al showed -catenin decrease cytoplasm increase cell membrane changes -catenin distribution corresponded malignant transition nevi iii wnt4 signal identified mechanism drive -catenin relocation cytoplasm cell membrane iv -catenin relocation cytoplasm cell membrane reported block -catenin signaling human embryonic kidney hek293 cell line of note hypothesis explain despite abundant -catenin expression melanoma 1 7 cytoplasmic -catenin selectively decreased phenomenon associated unfavorable melanoma prognosis 9 21 22 our current efforts directed towards determining increases membranous -catenin observed primary metastatic melanomas result relocation existing molecules cytoplasm deposition newly generated -catenin membranous site rad6 implicated early breast cancer development since increase rad6 levels observed adenosis benign hyperplasias compared normal tissue in contrast findings support rad6 play similar role nevus formation benign breast neoplasia since 63% nevi negative rad6 rad6 also implicated breast cancer progression rad6 levels increase progression ductal carcinoma situ invasive primary carcinoma metastatic cancer 15 28 accordance upregulation rad6 early stages breast cancer development compared benign hyperplasia 15 17 observed striking increase rad6 expression primary melanoma compared nevi while primary melanomas displayed strong rad6 staining 50% tumor cells rad6 negative 63% nevi these findings suggest rad6 may play role malignant transformation nevi breast cancer progression melanoma primary metastatic disease significantly associated changes percentage tumors expressing rad6 rad expression intensity 50% tumor cells stained positively 100% 96% primary melanomas metastatic melanomas respectively these findings suggest rad6 may play sustained role melanoma metastasis melanoma development benign malignant breast tumors rad6 stabilizes -catenin turn -catenin positively upregulates rad6 transcription 1517 however direct positive correlation -catenin rad6 expression appear conserved melanoma expression profiles -catenin rad6 differed considerably nevi approximately 93% nevi expressed -catenin compared 27% nevi expressed rad6 50% cells figure 2 these observations suggest high -catenin expression nevi likely driven regulators rad6 first glance would appear -catenin rad6 expressions correlated primary melanoma proteins coexpressed approximately primary melanomas also findings correspond 80% correlation rad6 -catenin expressions primary breast cancer however unlikely high rad6 expression primary melanoma driven concurrent high -catenin expression rad6 expression low nevi despite presence high cytoplasmic -catenin expression comparable primary melanoma this notion confirmed lack statistical correlation rad6 -catenin expressions primary melanoma -catenin activator rad6 instance rad6 activated nerve growth factor nervous tissue therefore conceivable primary melanoma rad6 expression regulated yet unidentified activators we also demonstrated progression melanoma primary metastatic disease associated correlation -catenin rad6 expressions taken together study support direct positive interaction -catenin rad6 either benign malignant melanocytic tumors we characterized first time rad6 expression cutaneous benign malignant melanocytic tumors we showing striking upregulation rad6 negative expression benign melanocytic tumors 100% primary metastatic melanomas these findings strongly suggest role rad6 development primary melanoma metastatic disease we show contrast rad6 -catenin expressed 50% tumor cells almost nevi melanoma tumors taken together contrast rad6 -catenin positive relationship breast cancer 1517 study support similar positive interaction -catenin rad6 benign malignant melanocytic tumors finally findings suggest role cytoplasmic membrane translocation -catenin development primary melanoma future studies determine whether newly generated -catenin membranous site coincide -catenin translocation cytoplasm

we have previously demonstrated that rad6 and -catenin enhance each other 's expression through a positive feedback loop to promote breast cancer development / progression . while -catenin has been implicated in melanoma pathogenesis , rad6 function has not been investigated . here , we examined the relationship between rad6 and -catenin in melanoma development and progression . eighty - eight cutaneous tumors , 30 nevi , 29 primary melanoma , and 29 metastatic melanomas , were immunostained with anti--catenin and anti - rad6 antibodies . strong expression of rad6 was observed in only 27% of nevi as compared to 100% of primary and 96% of metastatic melanomas . -catenin was strongly expressed in 97% of primary and 93% of metastatic melanomas , and unlike rad6 , in 93% of nevi . none of the tumors expressed nuclear -catenin . -catenin was exclusively localized on the cell membrane of 55% of primary , 62% of metastatic melanomas , and only 10% of nevi . cytoplasmic -catenin was detected in 90% of nevi , 17% of primary , and 8% of metastatic melanoma , whereas 28% of primary and 30% of metastatic melanomas exhibited -catenin at both locations . these data suggest that melanoma development and progression are associated with rad6 upregulation and membranous redistribution of -catenin and that -catenin and rad6 play independent roles in melanoma development .

guanine heterocyclic ring rich chemical reactivity toward oxidants adduct forming species dna 2-deoxyguanosine dg mass chief site base oxidation due low redox potential leading many products characterized mass signatures the principal products characterized one electron oxidants aqueous solutions grouped based site reaction radical intermediate resulting one electron oxidation dg the 2-deoxyribonucleoside products arising initial reactivity c5 dg include four electron oxidation product imidazolone diz m-39 hydrolyzes oxazolone dz m-21 two electron oxidation product 5-carboxamido-5-formamido-2-iminohydantoin d2ih m+34 scheme 1 when initial reaction occurs c8 dg either 2,6-diamino-4-hydroxy-5-formamidopyrimidine fapy dg 18 observed reducing conditions 8-oxo-7,8-dihydroguanine dog m+16 observed oxidizing conditions latter compound key marker monitoring oxidative stress cells scheme 1 the two electron oxidation product dog stable highly susceptible oxidation leading two hydantoin compounds the yield thermodynamically preferred product spiroiminodihydantoin dsp 32 greatest nucleoside reactions ph 6 unencumbered reaction contexts i.e. single stranded dna g quadruplexes yield 5-guanidinohydantoin dgh 6 greatest nucleoside reactions ph 6 sterically demanding duplex contexts scheme 1 the hydantoins also readily formed direct four electron oxidation o2 this list products represents consistently observed many oxidant systems conducted several laboratories however compounds reported lower yield cellular context oxidation reactions dg nucleophilic participants amines phenols cases amines phenols participate reaction products are observed similar backbone structures characterized water serving nucleophile for example dg oxidized presence lysine products retaining dg heterocycle core similar dgh dsp observed the adducts characterized laboratory others show lysine competing water sites covalent bond formation single lysine observed c8 analogous dog either c5 c8 spirocyclic core similar dsp last bis adduct c5 c8 spirocyclic ring structure identified figure 1 the lysine adducts stable allowing quantification characterization last example polyamine spermine adducted dg dog oxidative conditions dg oxidation studies spermine adduct c8 is observed retaining dg heterocyclic core dog oxidations yield adduct c5 undergo acyl migration create spirocycle instead polyamine generate unstable hemiaminal intermediate decomposes leaving ribosylurea lesion adduct formation site moreover facile formation spermine adducts dog oxidation intermediates harnessed quantification dog dna samples in contrast amines phenols i.e. tyrosine redox active amines better able compete dg oxidant reactions the products observed phenols participate dg oxidation variability structures compared amine adducts these model studies aid understanding chemical nature dna protein cross links detrimental cellular processes current work oxidations allowed dg react nh3 conducted full product diastereomer distributions monitored after careful characterization nucleoside reactions similar oxidations conducted single stranded duplex oligodeoxynucleotide odn contexts purified ammonia adducts also studied respect decomposition pathways leading end products previously determined lastly polymerase insertion studies conducted test hypothesis amine adducts might altered base pairing preferences every substitution oxo group base amino group converts hydrogen bond acceptor potential hydrogen bond donor these results provide fundamental understanding stability base pairing properties amine adducts dg result oxidation may occur vivo due high concentration nucleophilic amines vicinity genome adducts observed dg lysine allowed react presence oxidant the unencumbered nucleoside dg 1 mm chosen initial oxidation reactions nh4cl 20 mm provided source nucleophilic nh3 all reactions conducted 75 mm napi buffer ph 7.4 22 c the oxidants chosen include photooxidants riboflavin rose bengal one electron oxidant na2ircl6 reactions conducted triplicate achieve 70% conversion products reaction products scheme 2 analyzed dual hplc method first round hplc analysis utilized reversed phase column identify dog m+16 8-amino dg m+15 products eluted void volume the void volume previous run collected analyzed hypercarb hplc column allowed analysis hydantoins ammonia adducts dz however diz hydrolyzes dz detected hypercarb column thus formation diz inferred quantification dz moreover hypercarb hplc column also allowed separation quantification spirocyclic diastereomeric pairs products the dgh diastereomers interconvertible thus diastereomer ratios reported see supporting information complete experimental details lastly test reaction na2ircl6 conducted half directly analyzed hypercarb hplc column half analyzed dual hplc method outlined the product distributions observed comparative studies within 3% one another the photooxidant riboflavin led largest number different products used obtain suitable amounts material characterization esi ms figure s1 supporting information adducts observed involve participation nh3 product formation included dz 21 dog 16 dgh 6 dsp 32 scheme 2 confirmation structures achieved esi ms ms fragmentation free bases monitoring daughter fragments the esi ms ms experiments conducted hplc purified nucleosides n glycosyl bond cleaved ionization source liberate free bases fragmented cid chamber generate daughter fragments used identification structures the ms ms fragmentation spectra compared literature values two dsp diastereomers figure 2 dz confirm structural assignments figures s2 s3 supporting information the structure dsp established x ray crystallography nmr ammonia adducts observed included two pairs chromatographic peaks diastereomers spirodi(iminohydantoin)-2-deoxyribonucleosides dsi whose names based site nh3 attachment guanine thus 5-dsi 31 8-dsi 31 scheme 2 see reference cited correct dsi iupac nomenclature confirm identities 5- 8-dsi constitutional isomers respective diastereomers esi ms ms free bases conducted figure 2 comparison esi ms ms spectrum 5-dsi dsp gave pair peaks 5-dsi established c5 site nh3 attachment z h 140 96 figure 2 as 8-dsi comparison esi ms ms spectrum obtained dsp 5-dsi identified new masses best explained nh3 attachment c8 z h 141 97 figure 2 basis proposed mechanism scheme 2 product includes bis addition nh3 c5 c8 oxidized guanine yield spirocycle 5,8-dsi m+30 possible however adduct observed reasons elaborated additionally nh3 adducts dgh core observed likely due fact reactions performed ph 7.4 yields dgh minimal lastly yields dog 16 8-amino dg 15 low 1% determined lc esi ms figure s1 supporting information hence quantities reported the nucleosides dog c8 amine adducted dg redox potentials 600 mv parent nucleoside dg causing much susceptible oxidation further one electron oxidized dog observed even lower redox potential parent compound dog means oxidation dog likely 8-amino dg occurs product formation inevitable due 70% conversion product yielded spirocyclic compounds dsp 5-dsi 8-dsi esi ms ms spectra dsp top 5-dsi middle 8-dsi bottom the data provided collected first eluting diastereomer spirocycle hypercarb hplc column data second eluting diastereomer dsp 5-dsi 8-dsi found supporting information figures s2 s4 s5 the heavy lines represent fragment observed thin lines represent portion molecule lost upon fragmentation relative product distributions observed oxidant system determined integration hplc peak areas measured 240 nm followed normalization via molecule unique extinction coefficient 240 nm extinction coefficients 5-dsi 8-dsi known determined experiments reported riboflavin mediated oxidations this result anticipated riboflavin type photooxidant effects oxidation electron transfer dg yielding o2 aerobic reaction conditions oxidation dg one electron proton transfer yields intermediate radical dg couples o2 initially yield diz prone hydration leading dz scheme 2 species quantified the adducts derived nucleophile trapping electrophilic dg oxidation intermediates show nh3 participation products 5-dsi 29% highest yielding nh3 adduct followed nearly 3-fold less 8-dsi 11% the participation h2o trapping nucleophile identified lower yields dsp 11% dgh 4% the nucleophilicity nh3 much greater h2o therefore expected adducts resulting nh3 participation dominated derived h2o relative product distributions observed dg reacted nucleophilic h2o nh3 oxidation reactions the oxidants include photooxidants riboflavin rose bengal well na2ircl6 reactions conducted 1 mm dg 20 mm nh4cl 75 mm napi buffer ph 7.4 22 c ( 1 photoactivation riboflavin 200 achieved 350 nm light 3 h 2 photoactivation rose bengal 100 achieved 350 nm light 3 h 3 oxidation na2ircl6 10 mm achieved bolus addition salt results represent average triplicate trials error 10% reported value the second oxidant studied rose bengal type ii photooxidant o2 furnished 5-dsi major product 62% followed 3-fold lower amount dsp 31% low yields dz 5% dgh 2% observed complete mass balance figure 3 expected oxidant yield 8-dsi based mechanism oxidation oxidation dg o2 proceeds 4 2 cycloaddition imidazole ring followed ring opening yield 8-hoo g eliminates water giving proposed electrophile dog next dog trapped nucleophiles c5 leading dsp h2o 5-dsi nh3 scheme 3 support exclusive nucleophilic attack c5 o2 oxidations derived h2o studies followed mapping labeled site esi ms ms current observation nh3 adducts 5-dsi diastereomers support previously proposed mechanism confirms structural assignments peaks comparisons product distributions photooxidants riboflavin rose bengal show dramatic difference respect major product observed figure 3 riboflavin oxidation dz major product rose bengal oxidation 5-dsi major product observations ascribed oxidant unique mechanism oxidation schemes 2 3 product distributions oxidant included nearly equivalent distributions dsp 50% 5-dsi 42% mass balance completed dgh 8% figure 3 oxidation reaction distribution yield nh3 adducts major products unexpected basis nh3 better nucleophile compared h2o comparison product distributions observed one electron oxidants riboflavin na2ircl6 identified nh3- h2o adducted compounds the current results differ previously reported laboratory lysine adducted dg analogous oxidation reactions previously riboflavin oxidations spirodihydantoins lysine c8 2-fold greater lysine c5 figure 1 na2ircl6 oxidations c8 lysine adduct observed in contrast results riboflavin oxidations presence nh4cl gave c5 adducts 29% c8 adducts 11% na2ircl6 oxidations yield detectable amounts c8 adducts we propose difference current ammonia results compared lysine data attributed difference mechanism product formation c8 adduct nucleoside context the former work laboratory proposed c8 amine adducts result oxidation amine aminyl radical adds c8 carbon dg followed oxidation leading product formation scheme 4 nucleoside dg proposed mechanism best supports observation ammonia adducts c8 upon one electron oxidation dg initial radical cation dg formed acidic pka 3.9 rapidly deprotonates neutral radical dg susceptible nucleophilic attack thus dg reacts o2 yielding diz dz amines h2o formation amine adducts c8 must result difference amine reactivity the key difference lysine ammonia resides standard reduction potentials in general primary amines 1.0 v vs nhe ph 10 lower redox potential ammonia 1.3 v vs nhe ph 9 trend scale ph 7 oxidations conducted thus oxidation lysine aminyl radical adds c8 dg possible na2ircl6 0.9 v vs nhe ph 7 riboflavin 1.7 v vs nhe ph 7 contrast analogous reaction readily occur nh3 ph 7 dg dominant site oxidation due lower redox potential leading products 8-dsi summary one electron oxidant driven oxidations dg presence nh3 lead spirocyclic adducts c5 c8 competition h2o adducts core structure next step set determine decomposition products pathways ammonia adducts proceed hplc used provide diastereomerically pure 5-dsi 8-dsi samples subjected conditions ph 3 0.1% formic acid ph 10 20 mm napi 22 c 30 min 10 h. could decomposition products determined diastereomerically pure starting material also allowed us probe mechanism decomposition specifically 5-dsi first 5- 8-dsi stable ph 10 time frame 5-dsi readily hydrolyzed dsp ph 3 30 min 8-dsi hydrolyzed dsp 10 h. 5-dsi deamination amine group occur two possible mechanisms 1 retro acyl migration occur followed loss nh3 yield electrophilic intermediate dog susceptible h2o attack followed second acyl migration back dsp 2 acid catalyzed deamination occur directly furnish dsp scheme 5 if retro acyl migration proceeds diastereomerically pure sample expected mixture dsp diastereomers would observed direct deamination occurs one dsp diastereomer would predicted upon incubation one diastereomer 5-dsi ph 3 only one diastereomer dsp observed supporting direct deamination mechanism moreover early eluting 5- 8-dsi nh3 adducts decomposed early eluting dsp isomer late eluting adducts deaminated later eluting dsp isomer figure s6 supporting information these results aid establishing absolute configuration 5-dsi 8-dsi diastereomers discussed moreover results also allude explanation bis ammonium adduct observed reactions based data bis ammonium adduct formed could rapidly deaminate yield either 5-dsi 8-dsi although hypothesis could validated utilization hypercarb hplc column analyzing product distributions spirocycles allowed determination diastereomer ratios it previously determined r)-dsp elutes first column s)-dsp elutes second the absolute stereochemistry diastereomers ammonia adducts yet determined the results studies identified r)-dsp s)-dsp yields nearly equal also 5-dsi 8-dsi ammonia adducts nearly equal yields diastereomers observed basis results defining point reaction determine product stereochemistry must sterically impeded order lead small diastereomer preference stated diastereomerically pure ammonia adduct samples determined decompose give single diastereomer dsp therefore basis hplc elution order absolute configuration diastereomers two dsi constitutional isomers determined the first eluting 5-dsi 8-dsi diastereomers decomposed first dsp diastereomer r late eluting diastereomer decomposed late eluting dsp diastereomer therefore 5-dsi r diastereomer elutes first diastereomer elutes second r assignments dsp 5-dsi in contrast r assignments 8-dsi diastereomers opposite dsp thus s)-8-dsi elutes first r)-8-dsi elutes second hypercarb hplc column figure 4 these examples provide fascinating case outlining movement ring substituents affects r stereochemical assignments assignment absolute configurations diastereomers dsp 5-dsi 8-dsi based elution profile hypercarb hplc column ecd spectra the r assignments diastereomers 8-dsi opposite dsp 5-dsi isomers geometric configuration spirocyclic ring due change cahn ingold the diastereotopic ammonia adducts probed electronic circular dichroism spectroscopy ecd previously ecd used tandem vibrational circular dichrosim spectroscopy nmr x ray crystallography establish absolute configuration dsp the ecd spectra r)- s)-dsp isomers gave three lobes mirror images one another expected figure 4 critical assigning absolute configuration dsp low energy lobe isomer gave positive rotation 258 nm r isomer gave negative rotation 259 nm comparison results the 5-dsi diastereomers gave ecd spectra different dsp showed similarity low energy lobe figure 4 for r)-5-dsp lobe 258 nm gave negative rotation s)-5-dsi gave positive rotation 258 nm the higher energy lobes observed ecd 5-dsi diastereomers different measured dsp figure 4 as last comparison 8-dsi diastereomer ecd spectra compared recorded dsp note 8-dsi dsp isomers geometric configuration spirocyclic ring give opposite r assignments due difference cahn the low energy lobe gave negative rotation 262 nm similar r)-dsp r)-8-dsi gave positive rotation similar s)-dsp furthermore 8-dsi diastereomers also gave similar rotations energies analogous dsp diastereomers 238 nm lobe 8-dsi dsp gave similar rotations highest energy lobe absolute energy different i.e. 202 nm 8-dsi 211 nm dsp figure 4 the similarity critical low energy lobe supports absolute configuration assignments made deamination studies monitored hplc future computational studies model ecd spectra help solidify conclusions may address challenges occurred modeling ecd spectra dsp diastereomers the ability deaminate dsi adducts dsp allowed determination extinction coefficients 5- 8-dsi relative dsp values used determine relative yields peak areas identically pure 5-dsi samples measured incubation formic acid change peak area measured used determine relative 240 nm compared value established dsp a similar experiment conducted 8-dsi diastereomers experiments the 240 nm 5-dsi 8-dsi diastereomers determined 3800 3500 lmolcm respectively slightly greater determined dsp diastereomers 3300 lmolcm the next step nucleoside studies explore context dependence nh3 adduct formation single- double stranded odns ssodn dsodn the photooxidant riboflavin chosen studies gave diverse distribution products nucleoside reactions might provide insight context effects studies ssodns selected analysis 18-mers odn-1 odn-2 dsodn context studied via duplex formed two single strands odn-12 oxidation odn systems digested suite nucleases phosphatase nucleosides followed analysis using previously described hplc methods previously laboratory demonstrated digestion method used provides complete degradation dsp containing odns nucleosides assumed dsi adducts equally digested completion the nuclease digestion conditions modified include ammonium salts buffer prevent loss 5-dsi via deamination dsp scheme 5 controls conducted sodium salts buffers detect 5-dsi due deamination dsp nuclease digestion 18 h ph 5.4 scheme 5 a comparison contexts studied dg allowed react nh3 presence photooxidant riboflavin provided figure 5 the first observation data respect dz distributions dramatically decreased proceeding nucleoside odn contexts specifically dz distribution dsodn context 2% 10-fold less ssodn context 20% 20-fold less observed nucleoside context 40% this observation already reported literature proposed result odn context increasing lifetime dg reacts nucleophilic h2o give c8 product dog decreasing lifetime dg reacts o2 yield dz schemes 2 6 respect yields hydantoins dsp relative dgh observed nucleoside context 11% vs 4% respectively versus dsodn context 9% vs 21% respectively again trend follows literature duplex context favors less sterically demanding product dgh the nh3 adducts 5-dsi 8-dsi provided interesting context dependent product distributions the yield 5-dsi greatest nucleoside 29% decreased half odn contexts studied 14% contrast yield 8-dsi smallest nucleoside 11% increased 3-fold ssodn context 39% half products observed dsodn context 8-dsi 54% as previously stated lifetime electrophilic dg longer duplex context superior nucleophilicity nh3 compared h2o greatly increased yield 8-dsi dsodn oxidations scheme 6 furthermore increase 8-dsi yield dsodn oxidations supports product resulting nucleophilic addition nh3 c8 leading 8-dsi nh3 aminyl radical adding c8 yield product these results clearly demonstrate dependence reaction context formation dg oxidation products nh3 adducts a look distribution diastereomers resulting oxidation odn contexts gave nearly equal amounts r diastereomers this observation parallels previous work looking dsp diastereomer formation single stranded duplex contexts coupled together observations support state disorder duplex time nucleophilic attack c5 oxidized dog 8-amino dg likely intermediates leading spirocycles leads nearly equal covalent bond formation si faces electrophiles relative product distributions measured dg allowed react nh3 presence photoexcited riboflavin various contexts reactions conducted 75 mm napi buffer ph 7.4 22 c 20 mm nh4cl nucleoside studies 1 mm dg studied odn contexts 20 ssodn 10 dsodn studied ( 1 photoactivation riboflavin 200 achieved 350 nm light 3 h nucleoside studies 30 min odn studies these conditions achieved 70% conversion product nucleoside reactions 50% odn studies it must first noted bis ammonium adduct could quantified due instability formed adduct likely deaminated either 5-dsi 8-dsi keeping limitation mind the oxidation dg riboflavin initially yields dg rapidly deprotonates dg nucleoside contexts pka 3.9 dominating product forming step reaction in contrast dg dsodn context retains cationic character acidic proton h bonded 2-deoxycytosine base pair therefore product forming steps reaction determined radical cation intermediate shown scheme 2 dg could couple radicals e.g. o2 ultimately yield dz dg reacts nucleophiles e.g. h2o nh3 c8 ultimately yielding spirocyclic product completion four electron oxidation thus yield 8-dsi anticipated greatest duplex context indeed furthermore results support original hypothesis steenken duplex context would favor radical cation nature one electron oxidized dg still focus many current research efforts limitation imposed inability detect bis ammonium adduct understand decomposition pathway any comparison ammonia adduct distributions would based poorly defined assumptions consequently discussion results provided last set studies inspired observation ring dsp mimics h bonding pattern thymidine ring 5-dsi mimics h bonding pattern 2-deoxycytidine figure 6 basis observation polymerase insertion assays opposite dsp vs 5-dsi were conducted determine h bonding schemes applied selection nucleotide insert opposite spirocycles comparison h bonding patterns dsp vs 5-dsi vs dc site specific synthesis dsp 5-dsi achieved synthesizing dog odn solid phase synthesis oxidizing strand without nh4cl present one electron oxidant na2ircl6 furnish desired products upon ion exchange hplc purification the absolute stereochemical assignments dsp isomers established odns 5-dsi assigned work analogous based mechanism deamination discussed see figure s7 supporting information details standing start polymerase studies conducted providing enzyme one type nucleotide per reaction basis previous studies insertion dttp opposite dsp was observed therefore ensure one nucleotide inserted opposite lesion extension past lesions occurs sequence placed 5 spirocycle figure 7 klenow fragment exo- selected polymerase extension reactions polyacrylamide gel electrophoresis page conducted determine amount datp dttp dgtp dctp incorporated opposite dsp 5-dsi diastereomers the polymerase select either pyrimidine insertion opposite two lesions figure s7 supporting information thus data purine insertion opposite lesions provided figure 7 respect insertion opposite dsp diastereomers r)-dsp observed give slight preference insertion datp opposite s)-dsp gave nearly equal insertion datp dgtp comparison dsp results 5-dsi isomers showed s)-5-dsi gives similar amounts datp dgtp insertion r)-5-dsi yields slight preference datp insertion unfortunately results support hypothesis h bonding ring spirocycle key parameter nucleotide selection show stereochemistry may important selecting base pairing partner polymerase sequence studied polymerase dntp insertion studies percent dntp insertions opposite diastereomers dsp 5-dsi ( sequence dsodn construct used polymerase insertion assays b comparison percent purine dntp insertion opposite lesions dsp 5-dsi dna polymerase klenow fragment exo- the present studies mapped pathways quantified products observed dg allowed react nh4cl presence photooxidants riboflavin rose bengal well one electron oxidant na2ircl6 on basis analysis products nucleoside context major products oxidant dependent the major product riboflavin dz rose bengal yielded 5-dsi diastereomers na2ircl6 gave dsp diastereomers major products figure 3 further analyses determined 5-dsi 8-dsi decompose via acid catalyzed deamination pathway leading dsp end product scheme 5 oxidations dg nucleoside ss- dsodn contexts photochemically activated riboflavin demonstrated three major context effects 1 yield dz highest nucleoside studies decreased dramatically dsodn contexts 2 nh3 participated nucleophile 5-dsi obtained highest yield nucleoside studies yield 8-dsi highest dsodn contexts 3 h2o nucleophile nucleoside reactions dsp presented highest yield dsodn contexts dgh obtained highest yield figure 4 furthermore combination mapping decomposition pathways dsi compounds dsp absolute configuration assigned allowed determination absolute configurations diastereomers 5- 8-dsi these studies provide fundamental chemical insight formation amine adducts dg stability further studies insert cautionary note researchers purify odns using ammonium salts conduct oxidation reactions purification ammonia better nucleophile competes water electrophilic intermediates derived dg dog oxidation resulting new mass dg 31 dog 15 respectively a similar observation highlighted oxidations occurring tris buffer generate tris adducts dg oxidations conducted 2-deoxyguanosine dg 1 mm concentration 75 mm napi buffer ph 7.4 22 c reactions 20 mm nh4cl without salt allowed product profile comparisons the oxidants specific reaction conditions achieved follows 1 riboflavin oxidations initiated adding 200 riboflavin exposing samples 350 nm light 3 h. 2 rose bengal oxidations achieved adding 100 rose bengal exposing samples 350 nm 3 h. light source riboflavin rose bengal reactions came sun lamp placed 7 cm reaction eppendorf tubes the tube lids left open allow wavelengths light pass reaction samples ( 3 na2ircl6 oxidations initiated bolus addition oxidizing salt final concentration 10 mm 30 min reaction samples quenched 50 mm edta ph 8) the reaction products distributions determined dual hplc method following previously reported set protocols specific details found supporting information file first rp hplc run allowed analysis dog 8-amino dg observed 1% yield products eluted void volume run the void volume collected dried reinjected hypercarb hplc column analyze diastereomers dgh dsp 5-dsi 8-dsi well product dz monitoring absorbance 240 nm determine product distributions peak areas integrated normalized compound 240 nm values provided esi ms compound hplc purified structural analysis the dgh diastereomers previously characterized nmr dz also previously characterized nmr dsp diastereomers characterized x ray crystallography structural characterization 5-dsi 8-dsi nmr conducted instability compounds toward deaminating dsp lack nonexchangeable protons ring either ammonia adducts makes challenging structural analysis furthermore deamination either 5-dsi 8-dsi dsp occurs nmr tube analysis peaks observed would similar challenging interpret therefore best method obtaining structural data diastereomers 5-dsi 8-dsi via esi ms ms conducted figure 2 provided satisfactory results determine structures characterization molecule follows mixture dgh diastereomers resolvable gave tr 6 min lc esi ms z h calcd 274.3 found 274.1 hrms esi tof z na calcd c9h15n5o5na 296.0971 found 296.0979 uv vis 240 2400 l molcm.(r)-dsp tr 11 min lc esi ms z h calcd 300.3 found 300.3 hrms esi tof z na c10h13n5o6na calcd 322.0764 found 322.0761 esi ms ms z h lit 184 156 141 114 113 99 86 found 184 156 141 114 113 99 86 uv vis 240 3,300 lmolcm cd c 1.24 10 ddh2o nm 259 8.7 236 35.1 211 37.4 ( s)-dsp tr 18 min lc esi ms z h calcd 300.3 found 300.3 hrms esi tof z na c10h13n5o6na calcd 322.0764 found 322.0761 esi ms ms z h lit 184 156 141 114 113 99 86 found 184 156 141 114 113 99 86 uv vis 240 3300 lmol cm cd c 1.30 10 ddh2o nm 258 8.7 234 32.9 212 40.5 ( r)-5dsi tr 9 min lc esi ms z h calcd 299.3 found 299.3 hrms esi tof z na c10h14n6o5na calcd 321.0923 found 321.0920 esi ms ms z h found values 183 166 140 123 113 96 86 uv vis 240 3800 lmolcm cd c 1.50 10 ddh2o nm 258 8.2 242 20.8 216 61.8 ( s)-5dsi tr 12 min lc esi ms z h calcd 299.3 found 299.3 hrms esi tof z na c10h14n6o5na calcd 321.0923 found 321.0916 esi ms ms z h found 183 166 140 123 113 96 86 uv vis 240 3800 lmolcm cd c 1.45 10 ddh2o nm 258 8.2 242 20.1 216 62.2 ( r)-8dsi tr 7 min lc esi ms z h calcd 299.3 expt 299.3 hrms esi tof z na c10h14n6o5na calcd 321.0923 found 321.0924 esi ms ms z h found 183 165 155 138 113 98 86 uv vis 240 3500 lmolcm cd c 1.30 10 ddh2o nm 261 20.0 237 43.2 203 18.6 ( s)-8dsi tr 14 min lc esi ms z h calcd 299.3 expt 299.3 hrms esi tof z na c10h14n6o5na calcd 321.0923 found 321.0926 esi ms ms z h found 183 165 155 138 113 98 86 uv vis 240 3500 lmolcm cd c 1.24 10 ddh2o nm 262 13.7 239 46.0 201 33.1 dz tr 27 min lc esi ms z h calcd 247.3 found 247.3 hrms esi tof z na c8h14n4o5na calcd 269.0862 found 269.0870 esi ms ms z h lit 131 117 found 131 117 uv vis 240 1800 lmolcm the odns hplc purified using ion exchange hplc column purification salts naoac removed dialysis prior oxidation following previously reported methods the riboflavin oxidations conducted similarly reported nucleoside studies following exceptions ssodn oxidations conducted 20 samples dsodn oxidations conducted 10 samples addition reaction times decreased odn reactions 30 min after oxidations odns digested suite nucleases phosphatases nucleoside samples following previously established protocol exception buffers digestion process comprised ammonium salts next digested mixture analyzed hplc method used nucleoside studies the polymerase insertion assays conducted duplex odn samples site specific incorporation dsp 5-dsi template strand the site specific synthesis commenced odns dog phosphoramidite synthesized desired site modification within sequence 5-cgt tax ggc gca act gga aa-3 x dog the modifications synthesized taking 1 nmol dog containing odn placing 100 l reaction buffer 75 mm napi ph 7.4 without 2 mm nh4cl reaction without nh4cl gave dsp diastereomers reaction nh4cl gave 5-dsi diastereomers the individual diastereomers purified using ion exchange hplc column running naoac resolving salt characterized via digestion odn nucleosides followed hplc analysis purification details found supporting information the primer template duplex insertion studies made annealing 125 nm primer 5-tt tcc agt tgc gcc-3 156 nm lesion containing template 5-cgt tax ggc gca act gga aa-3 x r)-dsp s)-dsp r)-5-dsi s)-5-dsi obtain 100 nm duplex klenow fragment exo- buffer 50 mm tris 50 mm nacl 5 mm mgcl2 1 mm dtt ph 8) 25 l reaction 20 l annealed duplex added 1 l klenow fragment exo- 0.2 units/l 0.5 l dntp 500 stock solution 8.5 l klenow buffer obtain 100 nm duplex solution 10 dntp 0.2 u polymerase the reaction incubated 37 c 30 min loading dye 95% dmf plus 0.025% bromophenol blue 0.025% xylene cylanol added samples heated 95 c 20 min quench reaction denature dna the denatured samples loaded 20% page gel electrophoresed 2 h 45 w. upon completion electrophoresis gel placed phosphor screen overnight imaged storage phosphor autoradiography

upon oxidation of the heterocyclic ring in 2-deoxyguanosine ( dg ) , the initial electrophilic intermediate displays a wide range of reactivities with nucleophiles leading to many downstream products . in the present study , the product profiles were mapped when aqueous solutions of dg were allowed to react with nh4cl in the presence of the photooxidants riboflavin and rose bengal as well as the diffusible one - electron oxidant na2ircl6 . product characterization identified the 2-deoxyribonucleosides of spiroiminodihydantoin , 5-guanidinohydantoin , and oxazolone resulting from h2o as the nucleophile . when nh3 was the nucleophile , a set of constitutional isomers that are diastereotopic were also observed , giving characteristic masses of dg + 31 . esi+-ms / ms of these nh3 adducts identified them to be spirocycles with substitution of either the c5 or c8 carbonyl with an amine . the nh3 adducts exhibit acid - catalyzed hydrolysis to spiroiminodihydantoin . quantification of the nh3 and h2o adducts resulting from oxidation of dg in the nucleoside , single - stranded , and duplex oligodeoxynucleotide contexts were monitored allowing mechanisms for product formation to be proposed . these data also provide a cautionary note to those who purify their oligonucleotide samples with ammonium salts before oxidation because this will lead to unwanted side reactions in which ammonia participates in product formation .

review literature extensive medline search revealed first case report use guaifenesin increase sperm motility he reported inability conceive wife 18 months unprotected intercourse a semen analysis performed included spermatozoa count liquefaction morphology motility viscosity volume two months guaifenesin therapy semen analysis repeated demonstrated marked improvement total sperm count motility evidence effectiveness guaifenesin almost entirely anecdotal given mechanism action guaifenesin clear case patient demonstrated large improvement sperm count motility additional studies effects guaifenesin male fertility could yield information medication effect men normal decreased total sperm counts there currently anecdotal reports popular news media stories use guaifenesin particularly brand name product robitussin pfizer inc new york ny use treating male female infertility.14 guaifenesin expectorant medication sold counter usually taken mouth assist expectoration phlegm airways acute respiratory tract infections its mode action treating infertility well understood appears decrease mucus viscosity a 32-year old male patient presented primary care provider infertility evaluation the patient nonsmoker consumes little alcohol known allergies a recent screening exam pulmonary tuberculosis negative patient recently undergone required military service physical exam he reported inability conceive wife 18 months unprotected regular intercourse as part routine infertility evaluation semen analysis performed included spermatozoa count liquefaction morphology motility viscosity volume cpt code 89320 initial results semen analysis demonstrated low sperm count motility table 1 this sample well follow sample obtained masturbation provided lab within 30 minutes collection the patient primary care provider offered treatment guaifenesin 600 mg extended release tablets twice daily the repeat semen analysis demonstrated marked improvement total sperm count motility table 1 the patient made significant lifestyle changes treatment course guaifenesin time writing this case report describes semen analysis laboratory results male patient given guaifenesin guaifenesin mucolytic agent usually taken orally assist expectoration phlegm airways acute respiratory tract infections scientific evidence effectiveness guaifenesin almost entirely anecdotal review medical literature revealed limited data use guaifenesin infertility.5,6 appeared improvement small study without controls female infertility related hostile cervical mucus.5 check regards guaifenesin simplest least effective method improving cervical mucus.7 given proposed mechanism action guaifenesin clear case patient demonstrated large improvement sperm count motility additional study effects guaifenesin male fertility suggests need conduct rigorous placebo controlled clinical trial could yield information medication effects men normal decreased total sperm counts

backgrounda review of the literature and an extensive medline search revealed that this is the first case report of the use of guaifenesin to increase sperm motility.casea 32-year - old male presented for an infertility evaluation . he reported an inability to conceive with his wife after 18 months of unprotected intercourse . a semen analysis was performed that included spermatozoa count , liquefaction , morphology , motility , viscosity and volume . initial results of the semen analysis demonstrated low sperm count and motility . the provider offered treatment with guaifenesin 600 mg extended release tablets twice daily . two months after guaifenesin therapy the semen analysis was repeated that demonstrated marked improvement in both total sperm count and motility.conclusionevidence for the effectiveness of guaifenesin is almost entirely anecdotal . given the mechanism of action of guaifenesin , it is not clear from this case why the patient demonstrated such a large improvement in both sperm count and motility . additional studies of the effects of guaifenesin on male fertility could yield information of the medication s effect on men with normal or decreased total sperm counts .

agriculture one primary economic avenues philippines contributing 20% gross domestic product gdp crops comprise 47.56% total agricultural sector contributed 510 billion pesos p510b country national income benguet province northern portion philippines belonging cordillera administrative region there 27.5 thousand farms covering 30 thousand hectares agricultural land benguet it also largest producer vegetables fruits supplying capital cities philippines the province known salad bowl philippines major crops tubers roots bulbs leafy vegetables stems flowers 2005 benguet top producer brocolli carrots producing 1.2 thousand 13.7 metric tons contributing 87.4% 81.4% respectively national output however growing vegetables considered risk occupation areas developing countries soogarun et al 2003 found significantly low abnormal mean blood cholinesterase levels among vegetable growers thailand health impacts pesticide misuse hand greatly affect farming communities philippines questioning economic advantages use many researchers correlated extent direct indirect pesticide exposure health hazards increased mortality dermal contamination depression cholinesterase level fetal abnormalities spontaneous abortion among pregnant women 36 it discouraging fact though knowledge health risks many filipino families still perceive crop yield outweighs health risks associated pesticide use pesticide poisoning one prevalent health problems philippines study department health doh 19911995 organophosphates accounted highest number poisoning cases organochlorines caused number deaths cheng 1994 studied 2000 benguet vegetable farmers found common complaints allergic reactions skin eyes abdominal pain dizziness chest pain headache nose bleed meanwhile study pesticide poisoning selected hospitals four philippines regions 2001 found cases acute poisoning prevalent chronic cases this study aimed identify pesticide exposure risk factors among vegetable farmers data used baseline data vegetable industry philippines this cross sectional study investigate prevalence pesticide exposure risk factors target population consisted vegetable farmers largest vegetable producing community philippines the inclusion criteria farmers living community least one year time interview practicing farmers work farm community those involved organic farming migrant farmers area less one year excluded there 211 respondents identified municipalities selected study population using cluster sampling the sampling size calculated p .05 211 vegetable farmers 37 farms data gathering done using following 1 questionnaire structured personal interview farm workers farmers done research assistants trained prior data collection details included personal information health history pesticide usage work practices work conditions risk factors associated pesticide exposure health data 2 exposure assessment monitoring work conditions work practices pesticide concentration 3 work analysis farm also done validate work practices related pesticide preparation application recall bias dealt confining health data questionnaire last one year time interview the health data also collected medical doctors simultaneously conducted physical assessment farmers this project study collaborated local agencies coordinating farmers vegetable industry benguet ethical clearance given research information dissemination office proponent institute the study included 127 males 60.2% 84 females 39.8% ages ranging 16 72 mean 45 12 showing relatively adult population seventy one percent 71% married majority working agricultural workers 82% remaining pesticide applicators mixers loaders 18% the respondents living present address average 34.76 years sd 16.72 mean distance 3163 meters sd 36539.13 vegetable plantation farm few farmers reported history smoking 16.2% 7% claimed smoked 2% history chewing tobacco the average number cigarettes tobacco consumed week 12 sticks 1 tobacco respectively the farmers used pesticides farms average 1.9 days per week the mean total application time 3.47 hours mean 3.47 2.09 the mean amount pesticide used application 21.35 l per application mean 21.35 48.17 the farmers also reported average year 2.3 mean 2.3 0.53 cropping seasons mean 3.84 mean 2.3 0.53 months per cropping season table 1 44.5% reported wiped sweat contaminated piece fabric 41.7% entered recently sprayed area 37.4% exposure damaged backpack sprayer 31.8% exposed sprayed wind table 2 however analysis shows frequently use equipment adequate gear fully protect the pattern seen among kinds personal protective equipment ppe exception boots frequently used 77.5% farmers 94% said worked used pesticides lifetime 16.4% population used pesticides households the vegetables commonly grown area potatoes 67.4% cabbage 63.7% carrots 36.8% majority 87% ) the common route pesticide entry study respiratory 68.9% followed dermal ocular entry 60.5% 38% resp sumicidine commonly used pyrethroid contains fenvalerate active ingredient table 3 shows 37% almost 14.7% study population used pesticides active ingredients fenvalerate cypermethrin respectively although pyrethroid frequently used pesticide organophosphate consisted largest amount exposure among farmers 210.02 liters followed pyrethorid 151.4 liters carbamates 32.16 liters entire one year the pesticide exposure farmers measured table 4 dependent variable related amount pesticide used liters frequency use duration use all independent variables except amount years pesticide use categorical variables those used pesticides longer period time higher total pesticide exposure furthermore farmer pesticide applicator mixer loader wiped sweat contaminated piece fabric given instructions training association risk higher pesticide exposure seventy four percent 74% respondents became ill work last 12 months preceding study the common symptoms headache 64.1% muscle pain 61.1% cough 45.5% weakness 42.4% eye pain 39.9% chest pain 37.4% eye redness 33.8% a subsequent study recommended focus adverse health effects farmers association certain risk factors the results study identified pesticide exposure farming practices farmers largest vegetable producing area philippines this also documented countries study coble et al 2005 thompson et al 2003 unsafe practices like entry recently spayed area use damaged backpack sprayer wiping sweat contaminated piece fabric identified study re entering recently sprayed area mentioned study tielemans et al 1999 important determinant dermal exposure specific chemicals captan tolylfluanid a pesticide formulation significant factor human exposure greater risks present among aqueous emulsifiable concentrates impairs protective function chemically protective gloves according wolfe 1993 pesticides may react chemical biotic processes however pesticides may undergo activation processes unexpectedly may broken equally potent mobile toxic compounds posing greater threat nontarget organisms it advised limit decrease frequency duration staying contaminated crops right pesticide application organophosphates carbamates pyrethroid pesticides commonly used type pesticides among farmers study the seen study clarke et al 1997 ghanna organophosphates consisted commonly used pesticides followed carbamates organochlorines the trend seen among farmers sri lanka brazil 15 16 the farmers study used pesticides farms mean application time 3.47 hours mean 3.47 2.09 the mean amount pesticide used application 21.35 liters per application mean 21.35 48.17 the number spray operations per week proven significant association likelihood experiencing neurobehavioral respiratory intestinal symptoms study among indonesian farmers study among north carolina growers agents found study population perceived pesticide diluted reentry intervals observed risk poses becomes diminished sumicidine commonly used pesticides among benguet farmers contains fenvalerate fenvalerate induces numbness itching tingling burning sensations exposed workers developed latent period approximately 30 minutes peaked 8 hours disappeared within 24 hours additional data among chinese workers demonstrated fenvalerate decreased semen quality occupational workers hand active ingredients like cypermethrin mancozeb and skin sensations reported occur among field workers usually lasted hours persist one day exposure cypermethrin for mancozeb prolonged low level exposure mancozeb affected several aspects immune functioning moderate association existed mancozeb neural tube defects most often gloves commonly used personal protective equipment hands exposed areas 23 24 many circumstances contributed nonadherence proper use ppe like extreme heat pesticide application uncomfortable use resources afford new ppe peer related factors increasing age 18 2527 the study also showed certain risk factors associated pesticide exposure entering recently sprayed area spraying wind use damaged backpack sprayer spills back spills mixing pesticides among others aside direct pesticide use different agricultural tasks mentioned may also contribute risk factors pesticide exposure re entering recently sprayed area mentioned study tielemans et al 1999 important determinant dermal exposure specific chemicals captan tolylfluanid there evidence weight loss could possible health effect chronic pesticide poisoning decreased body mean mass accompanied reduced cholinesterase activities among seven farm workers documented also kackar et al 1999 found rats administered orally mancozeb ethylenebisdithiocarbamate dose dependent signs poisoning weight loss mortality developed senthilselvan et al found significant association carbamate exposure prevalence asthma among non asthmatic farmers lower mean lung function variables among asthma this study shown pesticide exposure farmers largest vegetable producing area philippines it vital sequential exposure assessment done order come correlation study pesticide exposure health problems the study showed pesticide use prevalent among farmers benguet largest vegetable producer philippines it also suggested chronic effects pesticide cited certain studies 31 32 carcinogenic effects poor reproductive outcomes neurologic respiratory disorders impairments immune system birth defects also investigated future studies this manuscript adds existing literature pesticide exposure philippines far mainly descriptive nature this paper also identifies risk factors work practices designs containers sprayers may increase pesticide exposure among farmers this also calls local level policy research program intervention among vegetable farmers using pesticides

this was a cross - sectional study that investigated pesticide exposure and its risk factors targeting vegetable farmers selected through cluster sampling . the sampling size calculated with p = .05 was 211 vegetable farmers and 37 farms . the mean usage of pesticide was 21.35 liters . risk factors included damaged backpack sprayer ( 34.7% ) , spills on hands ( 31.8% ) , and spraying against the wind ( 58% ) . the top 3 pesticides used were pyrethroid ( 46.4% ) , organophosphates ( 24.2% ) , and carbamates ( 21.3% ) . those who were exposed to fungicides and insecticides also had higher total pesticide exposure . furthermore , a farmer who was a pesticide applicator , mixer , loader , and who had not been given instructions through training was at risk of having higher pesticide exposure . the most prevalent symptoms were headache ( 64.1% ) , muscle pain ( 61.1% ) , cough ( 45.5% ) , weakness ( 42.4% ) , eye pain ( 39.9% ) , chest pain ( 37.4% ) , and eye redness ( 33.8% ) . the data can be used for the formulation of an integrated program on safety and health in the vegetable industry .

evans using mouse mutant lim homeodomain transcription factor islet1 isl1 demonstrated isl1 positive isl1 population localised secondary heart field shf contributing outflow tract right ventricle atria small extent left ventricle isl1 considered marker shf cells contribute venous arterial poles cardiac tube cells shf contribute arterial pole the shf anterior heat field ahf identified splanchnic mesoderm underlying caudal pharynx provides myocardium outflow tract tube looping 2005 the research group also identified isl1+/c kit negative c kit-)/stem cell antigen-1 negative sca-1- progenitors postnatal heart demonstrating cells persist birth organ specific progenitor cells may isolated purified expanded differentiated mature cardiac myocytes future cardiac applications our research group identified isl1 cells gestation postnatal age demonstrated contemporary expression isl1 c kit interstitial cells ventricular myocardium human foetal postnatal hearts this paper demonstrated confocal analysis isl1 cells also c kit+ c kit+ cells necessarily isl1 isl1 cells subpopulation c kit+ cells it supposed may primordial cardiovascular precursor shf expresses three markers isl1 nkx2.5 fetal liver kinase 1 flk1 generate three lineages cardiac muscle smooth muscle endothelium the shf cooperates first heart field fhf cardiac neural crest cells development vertebrate heart the fhf lineage forms early cardiac tube generates left ventricle shf contributes additional cells maturing heart along cardiac neural crest cells generates outflow tract vessels valves the presence cardiovascular progenitor cells positive isl1 and/or nkx2.5 shf well confirmed recent work published science the authors suggested two distinct populations one shf fhf first population clearly positive isl1 expresses mirna 199a b second distinct markers expresses mirna 200a b progenitor cells shf depend cardiac specific transcription factors isl1 nkx2.5 play key role early stage cardiac progenitor formation their expression regulated wnt beta catenin signalling turn also regulates bmp4 signalling this last signalling pathway activates gata4 srf despite key role isl1 this transcription factor considered indubitable marker subpopulation shf progenitor cells it demonstrated recently isl1 labels shf precursors cardiac neural crest cells mef2c efficient marker shf progenitor cells labelling experiments this paper indirectly suggests review past literature view new data using different marker studies shf progenitor cells moreover considering heart development different species chicken mouse xenopus appears isl1 expressed common cardiac cell population splits fhf shf lineages heart development common progenitor also contributes cells cardiovascular system anversa research group described rat cardiac stem cells first time many research groups claimed discovered new important cardiac progenitor stem cells adult heart .. since 2005 scientific community talked adult c kit+ and/or sca-1 and/or mdr-1 cells embryonic isl1 cells these two populations always considered different entities described separately many research papers reviews although expression isl1 transcription factor cardiac precursor cells also reported adult hearts di nardo described first time concomitant expression three markers i.e. c kit sca-1 isl1 cardiac precursor cell prof di nardo research group described concomitant expression isl1 c kit sca-1 markers adult mouse cardiac progenitor cells 2008 2009 research group confirmed expression three markers adult rat cpcs systematic work published 2011 identification isl1 cells mouse heart postnatal day 1 young adulthood different strains authors found clusters positive cells cardiac ganglia studied strains found clusters isl1 cardiac precursors 129svj balb c strains animals older 4 months recently genead et al demonstrated contemporary expression c kit isl1 markers rat adult hearts normal pregnant infarcted individuals they reported expression markers entire heart right ventricle left ventricle outflow tract peri infarct peri ischemia regions unfortunately study based real time pcr analysis whenever immunocytochemistry shown double staining markers performed evidence supports hypothesis isl1 cells different population sca-1 cpcs the contemporary expression sca-1 isl1 described subpopulation sca-1+/c kit- cells identified isolated adult mouse hearts sca-1 cardiosphere derived cells obtained cardiac explants normal sham operated post myocardial infarct hearts study sca-1+/cd45- cells also positive isl1 increased number acute myocardial infarct considering authors identified isl1 cells adult murine rat hearts weinberger et al used heterozygous isl1-lacz mice sensitive genetic approach investigate presence localisation precursor cells 30 animals different time points birth 10 weeks 18 months they found four different populations isl1 cells clusters isl1 neurons found cardiac parasympathetic ganglia posterior side heart nervous plexus surrounding pulmonary veins ii clusters isl1 smooth muscle cells found muscular layer aortic pulmonary valve proximal part aorta trunk pulmonary artery positive cells present aortic valve leaflets iii clusters isl1 cardiomyocytes found left ventricular outflow tract region iv clusters isl1 sinoatrial node san cells found muscular wall right atrium vena cava superior these results support hypothesis adult heart many cell populations may derive isl1 embryonic precursors smooth muscle cells parasympathetic neurons san cells also even reduced number isl1 cardiomyogenic progenitors may present adult myocardium many papers published cpcs many research groups claimed discovered different populations progenitor cells it strange think cardiac tissue possesses larger number stem progenitor cells compared tissues found body hopeful cpcs may vary number external stimuli age happens adult stem cells the hypothesis myocardium non regenerative tissue valid anymore much evidence supports new idea least one cardiac progenitor cell isl1 c kit+/sca-1 cells considered two different populations 2012 prof sussmann citing recent paper published european journal histochemistry editorial circulation research suggested considering possibility studying population cells positive isl1 c kit instead choosing study one side coin review research paper published 2009 reported concomitant expression isl1 c kit sca-1 population cpcs isolated without sorting selection suggested first time could unique population cells several subpopulations several markers identified could effect different cultivation conditions different laboratories other research groups later described co expression isl1 sca-1 and/or c kit demonstrated samples foetal postnatal human hearts also isl1 subpopulation c kit+ cells anversa among authors study presence c kit+ cardiac stem cells embryonic foetal neonatal mouse hearts they demonstrated cells form cardiomyocytes coronary vessels demonstrated paper abundant isl1 cells moreover stated isl1 cells present outflow tract atria part right ventricle population committed cells derived immature primitive cell we say strong evidence suggesting c kit sca-1 isl1 may markers subpopulations cpcs present embryonic foetal neonatal heart persist birth adulthood the identification real immature cardiac precursor expressing four cell markers c kit sca-1 mdr-1 isl1 identification unique isolation protocol important clinical practice this immature common cardiac precursor may represent perfect candidate cardiac tissue engineering hopefully may driven pharmacologically one phenotype identify standardised protocol is extremely important go studies cardiac tissue regeneration common guidelines needed cardiac stem cell therapy the isolation stem cells cell sorting immunobead selection using surface markers c kit sca-1 mdr-1 important identify standardised protocol isolation however isl1 may useful basic research follow fate cpcs heart development myocardium differentiation moreover extremely important understand predominant precursor population different stages life population used paediatric patient instead adult one if fate immature cardiac precursors may determined pharmacologically possibility regenerate san cells important curing arrhythmia patients ischemia malformations the identification different subpopulations developing heart may fundamental step identifying optimal cell line cell based therapies

cardiac progenitor cells are multipotent stem cells isolated from both embryonic and adult hearts in several species and are able to differentiate at least into smooth muscle cells , endothelial cells and cardiomyocytes . the embryonic origin of these cells has not yet been demonstrated , but it has been suggested that these cells may derive from the first and secondary heart fields and from the neural crest . in the last decade , two different populations of cardiac progenitor or stem cells have been identified and isolated , i.e. , the islet1 positive ( isl1 + ) and c - kit positive ( c - kit+)/stem cell antigen-1 positive ( sca-1 + ) cells . until 2012 , these two populations have been considered two separate entities with different roles and a different origin , but new evidence now suggests a connection between the two populations and that the two populations may represent two subpopulations of a unique pool of cardiac stem cells , derived from a common immature primitive cell . to find a common consensus on this concept is very important in furthering the application of stem cells to cardiac tissue engineering .

primary diffuse leptomeningeal gliomatosis pdlg rare neoplasm short survival time months we report 53-year old male patient presented epileptic seizures gait disturbance paraparesis sensory deficits dermatomes t8 10 magnetic resonance imaging mri revealing numerous spinal cranial gadolinium enhancing nodules meninges histopathology led us diagnose primary diffuse leptomeningeal gliomatosis grade iii astrocytic cells consecutively patient underwent craniospinal radiotherapy 30 gy 11 sequential cycles temozolomide thirteen months later spinal mri revealed tumor progression second line chemotherapy 5 cycles irinotecan bevacizumab prevent clinical deterioration the patient died twenty two months diagnosis longest survival time described thus far respect pdlg consisting astrocytic tumor cells radiochemotherapy including temozolomide established standard therapy brain malignant astrocytomas might valid basic therapeutic strategy pdlg subtype primary diffuse leptomeningeal gliomatosis pdlg diagnosed glioma located subarachnoid space intraparenchymal tumor lesions absent pdlg must distinguished secondary meningeal gliomatosis resulting primary gliomatous cns tumor pdlg especially caused malignant astrocytic cells associated poor survival we describe patient pdlg consisting malignant astrocytic cells underwent combined radio- chemotherapy leading longest survival time described literature thus far a 53-year old man referred dept neurology due generalized epileptic seizure and five months later presented bilateral sensory deficits dermatome levels t8 10 paraparesis gait disturbance cerebrospinal fluid csf analysis revealed high cell count 300/3 cells/l reference range 5/3 cells/l atypical cells could characterized t1-weighted images t1-wi revealed spinal cranial gd enhancing nodules leptomeninges figures 1a e t2-weighted images t2-wi intramedullary edema figure 1c note gd enhanced supra- fratentorial meningeal thickenings brain sagittal t1-w image prior ra diochemotherapy t1-wi reveals lep tomeningeal gd enhancement b t2-wi shows edema myelon levels c7 t1 2 t5 6 due minor tumor extensions adjacent spinal cord c following radiochemotherapy t1-wi displays reduced leptomeningeal gd enhancement t2-wi shows less myelon spinal edema levels e three weeks later intradural biopsy gd enhancing nodule l2 3 level revealed fibrously thickened meninges infiltrated malignant astrocytic tumor cells figures 2a c the tumor categorized primary diffuse leptomeningeal gliomatosis pdlg confirmed reference center brain tumors dsseldorf germany intradural lumbar biopsy displays fibrously thickened lep tomeninges infiltrated pleomorphic neoplastic astrocytic cells the astrocytic tumor cells reveal intensive intracytoplasmic staining anti glial fibrillary astrocytic protein ki67 mib-1 staining reveals high proliferation index 20% c prior radiotherapy craniospinal axis 4 2.5 gy week total dose 30 gy patient underwent 3 cycles temozolomide tmz cycle 1 150 200 mg mtzm d1 5 q28d staging spinal t1-weighted images showed tumor lesion regression l5 spinal t2-wi images demonstrated spinal edema regression compare figures 1c figures 1a b three weeks completion radiotherapy patient received eight additional cycles tmz 200 mg mtzm d1 5 q28d meningeal thickening brain regressed however spinal mri thirteen months starting tmz therapy revealed meningeal tumor progression lesions spinal levels c1 2 c7-t2 t5 8 five cycles second line chemotherapy irinotecan bevacizumab failed halt clinical deterioration the patient died twenty two months diagnosis pdlg exhibited dead encouraging karnovsky performance status 60% the diagnosis pdlg usually established autopsy rarely diagnosed prior death pdlg oligodendroglial well differentiated astrocytic tumor type associated considerably longer median survival time malignant astrocytic tumor type pdlg diagnosed aforementioned case observed histopathology leptomeningeally encapsulated malignant astrocytic cells without primary attachment spinal cord brain parenchyma gd enhancing leptomeningeal thickening base brain spinal level mri various treatment modalities used 14 patients suffering pdlg malignant astrocytic cells reported literature far cf table 1 demonstrating lack standardized treatment regimen pdlg malignant astrocytic cells although number cases small data survival times cf table 2 might suggest radiotherapy temozolomide tmz established treatment newly diagnosed recurrent anaplastic astrocytomas also seem valid pdlg malignant astrocytic cells this concept supported observation radiotherapy alone prolong median survival time five months patients without specific therapy median survival 12 months integration tmz chemotherapy alone may lead prolonged median survival 15 months the importance tmz chemotherapy treatment pdlg supported observation median survival time fell 3 months integration tmz omitted clinico pathological characteristics treatment adult patients suffering pdlg malignant astrocytic cells including case 5-fu 5-fluouracil adr adriamycin auc 5 carboplatine bcnu carmustine brs brainstem bvz bevacizumab c cycle ca cytarabine ccnu lomustine cr cranial cyc cyclophosphamide ddp cisplatin eto etoposide inn topotecan int irinotecan irp raised intracranial pressure intrathecally mcnu ramustine mtx methotrexate sc spinal cord tmz temozolomide top thiotepa vincristine prednison summary literature pdlg malignant astrocytic cells prolonged survival patient may due addition tmz radiation therapy resulted extent median survival time high grade glioma patients in addition hypofractionated radiotherapy regimen used supposed effective conventional fractionated irradiation additionally patient good karnofsky performance status may contributed patient prolonged survival conclusion report partial regression long survival patient pdlg malignant astrocytic type following hypofractionated radiotherapy tmz an immediate radiochemotherapy seems crucial prolonged survival pdlg patients good general condition the authors disclose potential conflict interest including financial personal relationships people organizations within three years beginning submitted work could inappropriately influence perceived influence work

objectiveprimary diffuse leptomeningeal gliomatosis ( pdlg ) is a rare neoplasm with a short survival time of a few months . there is currently no standardized therapeutic approach for pdlg.materials and methodswe report on a 53-year - old male patient who presented with epileptic seizures , gait disturbance , paraparesis and sensory deficits in the dermatomes t8-10.resultsmagnetic resonance imaging ( mri ) revealing numerous spinal and cranial gadolinium - enhancing nodules in the meninges and histopathology led us to diagnose primary diffuse leptomeningeal gliomatosis with who grade iii astrocytic cells . consecutively , the patient underwent craniospinal radiotherapy ( 30 gy ) and 11 sequential cycles of temozolomide . this regimen led to partial tumor regression . thirteen months later , spinal mri revealed tumor progression . second - line chemotherapy with 5 cycles of irinotecan and bevacizumab did not prevent further clinical deterioration . the patient died twenty - two months after diagnosis , being the longest survival time described thus far with respect to pdlg consisting of astrocytic tumor cells.conclusionsradiochemotherapy including temozolomide , as established standard therapy for brain malignant astrocytomas , might be valid as a basic therapeutic strategy for this pdlg subtype .

past years numerous studies described role microalbuminuria mau predictor cardiovascular disease cvd death among subjects type 2 diabetes t2d).13 mau one earliest clinical signs diabetic nephropathy significant risk factor progression proteinuria.1 additionally hypertensive t2d individuals mau increased risk developing end stage renal disease esrd).4 risk factors known associated cvd diabetic nephropathy high blood pressure bp elevated glycosylated hemoglobin a1c).5,6 achieving adequate bp glycemic control gc plays essential role preventing renal cvd events individuals t2d current secondary analysis hispanic health nutritional examination survey hhanes)7 indicated cuban americans higher serum cholesterol systolic bp puerto ricans mexican americans furthermore compared hispanic subgroups cuban americans highest proportion hypertension htn mean serum creatinine levels.8 smith barnett9 examined national center health statistics nchs 1996 1997 concluded cuban americans 35 years age older highest percentage diabetes related deaths compared hispanics although previous studies shown significant differences diversity within hispanics studies conducted cuban american population scarce past decade the prevalence t2d increased especially among cuban americans higher incidence diabetes 8.2% compared 6.6% non hispanic whites.10 high incidence t2d combined increased risk developing diabetes complications warrants examination cuban american population screening mau detect individuals risk renal dysfunction cvd events possibly reduce burden associated diabetes complications therefore purpose study investigate degree coexistence htn poor gc influences likelihood mau among cuban americans t2d it hypothesized individuals t2d htn poor gc increased likelihood test positive mau it hypothesized association stronger controlling confounding variables this cross sectional study conducted cuban americans without t2d data complete sample set cuban americans without t2d used present study recruitment participants conducted alternate phases potential subjects without t2d age matching subjects age groups 1-year period approximately 10,000 letters outlining study mailed subjects aged 30 years older without diabetes letters sent english spanish included invitation flyer interested participants could respond the participants initially recruited random selection every tenth address randomly generated mailing list this company provided mailing list cuban americans identified without t2d miami dade broward counties florida three percent n 300 letters returned due unknown addresses from interested participants initially interviewed phone time study purpose explained age gender responders determined ascertain t2d status only 18 subjects qualify study cuban americans n 2 age younger 30 years n 9 chronic illnesses n 7 subject determined eligible participation requested human nutrition laboratory florida international university fiu participants instructed refrain smoking consuming food beverages except water unusual exercise least 8 hours prior blood collection the purpose protocol study explained subjects written consent either spanish english obtained prior commencement study seven participants reported diabetes reclassified lab results classified t2d according american diabetes association ada standards for data analysis subjects caloric intakes 5000 kcals n 2 missing a1c levels n 2 excluded two participants unable perform a1c analysis total included data subjects t2d n 179 aged 30 years older a sociodemographic questionnaire given participant complete included questions related age gender smoking status medications diabetes htn cholesterol height weight measured using seca balance scale seca corp columbia md usa body mass index bmi calculated weight kg height m. bp measured twice averaged participants sitting position 15-minute rest using random zero sphygmomanometer tycos 5090 02 welch allyn pocket aneroid sphygmomanometer arden nc usa stethoscope littmann cardiology 3 st paul mn usa htn defined follows systolic bp 140 mm hg systolic diastolic bp 90 mm hg using antihypertensive treatment.11 dietary intake measured using validated semiquantitative food frequency questionnaire ffq developed willett et al.12 ffq also validated nath huffman13 exclusively cuban american population participants self reported average consumption specified amounts various foods past year chose frequency responses ranging never six servings per day in addition food items ffq included questions type duration vitamin mineral supplement use alcohol consumption specific details fat salt sugar used cooking condiments macro- micronutrient intake calculated multiplying frequency consumption nutrient value food item obtained harvard university food composition database boston usa venous blood 20 ml collected subject overnight fast least 8 hours certified phlebotomist using standard laboratory techniques blood samples collected vacutainer serum separator tube sst becton dickinson company franklin lakes nj analysis lipids another tube containing ethylenediamine tetraacetic acid analyze a1c after coagulation completed 3045 minutes sst centrifuged 2500 rpm 30 minutes lipid panel assayed enzymatic methods a1c percentages measured whole blood samples roche tina quant method laboratory corporation america miami fl usa labcorp poor gc defined according ada standards a1c 7%).14 fresh single voided first morning urine samples collected participant determine mau semi quantitative assay immunodip diagnostic chemicals limited oxford ct usa immunodip urinary albumin test uses monoclonal antibody human serum albumin detect mau study conducted davidson et al15 designed evaluate clinical performance immunodip dipstick compared reference measure recommended ada detecting mau albumin creatinine ratio 30 ug mg negative > 30 ug mg positive determined laboratory techniques quest hitachi 717 autoanalyzer additionally results immunodip compared quantitatively measured albumin concentrations secondary outcome urinary albumin concentrations considered 18 mg l negative 18 mg l positive screening mau immunodip exhibited sensitivity 96% specificity 80% compared albumin creatinine ratio 30 ug mg immunodip examined quantitatively measured albumin concentrations dipstick yielded sensitivity 95% specificity 94% recommendations national academy clinical biochemistry nacb diagnosis management diabetes indicated useful semiquantitative screening test mau sensitivity 95%.16 immunodip dipstick fulfilled requirements nacb screening tool detect mau study this cut value established manufacturer immunodip diagnostic chemicals ltd corresponded albumin creatinine ratio 30 ug mg values mau detection.15 analyses performed using spss version 17 spss inc chicago il usa t tests chi square tests performed compare means proportion differences subjects without mau unadjusted odds ratios logistic regression analysis conducted investigate extent htn gc associated increased likelihood mau controlled variables included logistic regression analysis age gender bmi known duration diabetes total cholesterol levels diabetes cholesterol medications smoking total kcal protein intake intake potassium phosphorous sodium this cross sectional study conducted cuban americans without t2d data complete sample set cuban americans without t2d used present study recruitment participants conducted alternate phases potential subjects without t2d age matching subjects age groups 1-year period approximately 10,000 letters outlining study mailed subjects aged 30 years older without diabetes letters sent english spanish included invitation flyer interested participants could respond the participants initially recruited random selection every tenth address randomly generated mailing list this company provided mailing list cuban americans identified without t2d miami dade broward counties florida three percent n 300 letters returned due unknown addresses remaining delivered mail 4% n 388 responded interested participants initially interviewed phone time study purpose explained age gender responders determined ascertain t2d status only 18 subjects qualify study cuban americans n 2 age younger 30 years n 9 chronic illnesses n 7 subject determined eligible participation requested human nutrition laboratory florida international university fiu participants instructed refrain smoking consuming food beverages except water unusual exercise least 8 hours prior blood collection the purpose protocol study explained subjects written consent either spanish english obtained prior commencement study seven participants reported diabetes reclassified lab results classified t2d according american diabetes association ada standards for data analysis subjects caloric intakes 5000 kcals n 2 missing a1c levels n 2 excluded two participants in total included data subjects t2d n 179 aged 30 years older a sociodemographic questionnaire given participant complete included questions related age gender smoking status medications diabetes htn cholesterol height weight measured using seca balance scale seca corp columbia md usa body mass index bmi calculated weight kg height m. bp measured twice averaged participants sitting position 15-minute rest using random zero sphygmomanometer tycos 5090 02 welch allyn pocket aneroid sphygmomanometer arden nc usa stethoscope littmann cardiology 3 st paul mn usa htn defined follows systolic bp 140 mm hg systolic diastolic bp 90 mm hg using antihypertensive treatment.11 dietary intake measured using validated semiquantitative food frequency questionnaire ffq developed willett et al.12 ffq also validated nath huffman13 exclusively cuban american population participants self reported average consumption specified amounts various foods past year chose frequency responses ranging never six servings per day in addition food items ffq included questions type duration vitamin mineral supplement use alcohol consumption specific details fat salt sugar used cooking condiments macro- micronutrient intake calculated multiplying frequency consumption nutrient value food item obtained harvard university food composition database boston usa venous blood 20 ml collected subject overnight fast least 8 hours certified phlebotomist using standard laboratory techniques blood samples collected vacutainer serum separator tube sst becton dickinson company franklin lakes nj analysis lipids another tube containing ethylenediamine tetraacetic acid analyze a1c after coagulation completed 3045 minutes sst centrifuged 2500 rpm 30 minutes lipid panel assayed enzymatic methods a1c percentages measured whole blood samples roche tina quant method laboratory corporation america miami fl usa labcorp fresh single voided first morning urine samples collected participant determine mau semi quantitative assay immunodip diagnostic chemicals limited oxford ct usa immunodip urinary albumin test uses monoclonal antibody human serum albumin detect mau study conducted davidson et al15 was designed evaluate clinical performance immunodip dipstick compared reference measure recommended ada detecting mau albumin creatinine ratio 30 ug mg negative 30 ug mg positive determined laboratory techniques quest hitachi 717 autoanalyzer additionally results immunodip compared quantitatively measured albumin concentrations secondary outcome urinary albumin concentrations considered 18 mg l negative 18 mg l positive screening mau immunodip exhibited sensitivity 96% specificity 80% compared albumin creatinine ratio 30 ug mg immunodip examined quantitatively measured albumin concentrations dipstick yielded sensitivity 95% specificity 94% recommendations national academy clinical biochemistry nacb diagnosis management diabetes indicated useful semiquantitative screening test mau sensitivity 95%.16 immunodip dipstick fulfilled requirements nacb screening tool detect mau study this cut value established manufacturer immunodip diagnostic chemicals ltd corresponded albumin creatinine ratio 30 ug mg values mau detection.15 t tests chi square tests performed compare means proportion differences subjects without mau unadjusted odds ratios logistic regression analysis conducted investigate extent htn gc associated increased likelihood mau controlled variables included logistic regression analysis age gender bmi known duration diabetes total cholesterol levels diabetes cholesterol medications smoking total kcal protein intake intake potassium phosphorous sodium mau present 26% n 47 cuban americans t2d there significantly higher percentage subjects mau classified hypertensive p 0.038 taking diabetes medication p 0.039 compared without mau additionally subjects tested positive mau significantly higher a1c levels p 0.002 normoalbuminuria table 1 unadjusted odds ratios indicated subjects poor gc 3.96 times likely positive mau htn compared without htn p 0.014 95% confidence interval ci 1.25 12.5 figure 1 logistic regression analysis showed controlling covariates subjects poor gc 6.76 times likely mau htn compared without htn p 0.004 95% ci 1.83 23.05 table 2 the results study showed htn poor gc major contributors increasing likelihood mau among cuban americans t2d the combination and/or interaction factors time might increase risk progression proteinuria esrd cvd population our findings supported multicenter study conducted europe found likelihood mau increases patients htn poor gc present along coexisting risk factors cvd.17 ravid et al5 reported longitudinal study combination risk factors including abnormal bp plasma cholesterol a1c levels high bmi male gender identifies group individuals poor renal cardiovascular outcomes maintaining adequate the uk prospective diabetes study ukpds),18 longitudinal study 10-year median follow showed exposure time hyperglycemia associated diabetes complications subjects t2d this study also indicated every 1% reduction a1c level risk microvascular complications decreased 37% diabetes related death 21% a study thomaseth et al19 showed hypertensive t2d subjects incipient diabetic nephropathy tight bp control optimal gc delay progression glomerular filtration rate deterioration additionally hypertensive individuals t2d tight bp control experience reduction risk microvascular macrovascular complications.20 mechanism pathways involving mau diabetic nephropathy cvd fully understood they may interrelated endothelial dysfunction inflammation.21 stehouwer et al22 examined relationship endothelial dysfunction inflammation mau risk death prospective study among subjects t2d the results study showed participants mau endothelial dysfunction inflammation increased risk mortality however associations variables risk mortality independent hyperglycemia obesity associated increase markers endothelial dysfunction inflammation activity,22 possibly indicating combinations factors may interrelated increasing risk death the usual course mau progressive however t2d individuals mau develop macroalbuminuria several authors documented remission and/or regression mau subjects t2d.2327 antihypertensive therapy shown reduce slow progression diabetic nephropathy 6-year prospective study remission regression normoalbuminuria observed 50% t2d individuals.23 factors independently linked remission and/or regression mau proper bp gc short duration mau the study chan et al24 5-year mean follow t2d patients mau treated angiotensin converting enzyme ace inhibitor medications showed 13% reduction urinary albumin excretion uae in addition authors pointed main role bp gc play renal function t2d individuals treated angiotensin receptor blockers arbs eg irbesartan valsatran experienced 38% 44% reduction uae 2-year 6-month follow ups respectively.25,26 evidence another prospective study 7.8-year follow indicated 30% participants antihypertensive therapy achieved remission normoalbuminuria.27 additionally odds remission normoalbuminuria increased participants every 1% decrease a1c level furthermore study conducted mogensen et al,28 urinary albumin creatinine ratio decreased 50% 3-month combination treatment arb ace inhibitors hypertensive t2d individuals mau remission and/or regression mau may conserve renal function also reduce risk cvd testing mau recommended ada individuals t2d performed diagnosis diabetes every year afterwards.29 immunodip dipstick rapid easy screening test perform involve equipment and/or skilled personnel exhibits high sensitivity requires random urine sample first morning urine recommended relatively low cost however test quantify urinary albumin values requires confirmation secondary analysis this method used physician office and/or research setting first screening tool detect presence mau clinical significance early screening monitoring mau is possibly improve individuals prognosis microvascular macrovascular complications especially among t2d individuals concomitant conditions first due cross sectional design study single voided urine collected measure mau able determine cause second due relatively small sample size study sample cuban americans t2d representative entire cuban american population living usa nevertheless knowledge first study examined relationship mau htn gc hispanic subgroup increased risk t2d cvd first due cross sectional design study single voided urine collected measure mau able determine cause second due relatively small sample size study sample cuban americans t2d representative entire cuban american population living usa nevertheless knowledge first study examined relationship mau htn gc hispanic subgroup increased risk t2d cvd early detection mau population may provide valuable treatment improve individuals renal cvd outcomes the therapeutic goals strategies mau focus preventing long term complications associated t2d kidney heart diseases further investigations need carried fully understand mechanism absolute cvd risk individual t2d mau coexists comorbidities

purpose : to investigate to what degree the presence of hypertension ( htn ) and poor glycemic control ( gc ) influences the likelihood of having microalbuminuria ( mau ) among cuban americans with type 2 diabetes ( t2d).methods : a cross - sectional study conducted in cuban americans ( n = 179 ) with t2d . participants were recruited from a randomly generated mailing list purchased from knowledge - base marketing , inc . blood pressure ( bp ) was measured twice and averaged using an adult size cuff . glycosylated hemoglobin ( a1c ) levels were measured from whole blood samples with the roche tina - quant method . first morning urine samples were collected from each participant to determine mau by a semiquantitative assay ( immunodip).results : mau was present in 26% of cuban americans with t2d . a significantly higher percentage of subjects with ma had htn ( p = 0.038 ) and elevated a1c ( p = 0.002 ) than those with normoalbuminuria . logistic regression analysis showed that after controlling for covariates , subjects with poor gc were 6.76 times more likely to have mau if they had hypertension compared with those without hypertension ( p = 0.004 ; 95% confidence interval [ ci ] : 1.83 , 23.05).conclusion : the clinical significance of these findings emphasizes the early detection of mau in this hispanic subgroup combined with bp and good gc , which are fundamentals in preventing and treating diabetes complications and improving individuals renal and cardiovascular outcomes .

cancer second leading cause mortality morbidity developed developing countries india cancer prevalence estimated around 2.5 million 0.8 million new cases 0.5 million deaths occurring year there increase incidence breast cancer found gradually overtaking cancer cervix breast self examination bse important screening measure detecting breast cancer there evidence women correctly practice bse monthly likely detect lump early stage development early diagnosis reported influence early treatment yield better survival rate thus present study aimed identifying level knowledge practice bse among degree female students citizen future teach family members neighbors friends community helps people detect breast cancer early stage thus morbidity mortality reduced current study only one participant practicing bse occasionally incorporating bse concept degree education curriculum useful helpful present study aimed assessing level knowledge effectiveness planned teaching program among degree female students bse it patient centred inexpensive noninvasive method screening breast cancer based increased incidence breast cancer unawareness bse among young women researcher felt need provide awareness bse among young women reduced incidence prevalence breast cancer future the objectives study assess level knowledge degree college female students bse.to determine effectiveness planned teaching program among degree college female students bse.to find association pretest knowledge selected demographical variables assess level knowledge degree college female students bse determine effectiveness planned teaching program among degree college female students bse the study attempted test following hypotheses hypotheses tested 0.05 level significance there significant difference pretest post test score knowledge bse among degree college female students.there significant association pretest knowledge score selected demographical variables significant difference pretest post test score knowledge bse among degree college female students the study assumed degree college female students knowledge bse.feel free express attitude toward bse.bse helps early detection breast cancer the degree college female students knowledge bse feel free express attitude toward bse independent variables teaching program bse selected variables age education parent education exposure mass media the present study aimed assessing level knowledge effectiveness planned teaching program among degree female students bse it patient centred inexpensive noninvasive method screening breast cancer based increased incidence breast cancer unawareness bse among young women researcher felt need provide awareness bse among young women reduced incidence prevalence breast cancer future the objectives study assess level knowledge degree college female students bse.to determine effectiveness planned teaching program among degree college female students bse.to find association pretest knowledge selected demographical variables assess level knowledge degree college female students bse determine effectiveness planned teaching program among degree college female students bse the study attempted test following hypotheses hypotheses tested 0.05 level significance significant difference pretest post test score knowledge bse among degree college female students.there significant association pretest knowledge score selected demographical variables significant difference pretest post test score knowledge bse among degree college female students the study assumed degree college female students knowledge bse.feel free express attitude toward bse.bse helps early detection breast cancer the degree college female students knowledge bse feel free express attitude toward bse independent variables teaching program bse selected variables age education parent education exposure mass media a pre experimental one group pretestpost test study conducted among degree female students selected colleges udupi district a cluster sampling technique used select college 40 students selected convenient method streams study demographic proforma consisted age stream study education occupation parents income parents sources information bse a structured questionnaire consisted 25 multiple choice questions mcq developed assess knowledge bse knowledge scores categorized poor 0 8 average 9 16 good 17 25 planned teaching program lesson plan power point presentation given validation contained basic anatomy physiology risk factors breast cancer steps bse validity tools established submitting seven experts 100% agreement items reliability coefficient knowledge questionnaire established split half method using spearman brown prophecy formula data collected administering knowledge questionnaire bse planned teaching program introduced 8 day post test done administering tool the data analyzed using descriptive frequency percentage inferential statistics based objectives hypotheses demographic proforma consisted age stream study education occupation parents income parents sources information bse a structured questionnaire consisted 25 multiple choice questions mcq developed assess knowledge bse knowledge scores categorized poor 0 8 average 9 16 good 17 25 planned teaching program lesson plan power point presentation given validation contained basic anatomy physiology risk factors breast cancer steps bse validity tools established submitting seven experts 100% agreement items reliability coefficient knowledge questionnaire established split half method using spearman brown prophecy formula demographic proforma consisted age stream study education occupation parents income parents sources information bse a structured questionnaire consisted 25 multiple choice questions mcq developed assess knowledge bse knowledge scores categorized poor 0 8 average 9 16 good 17 25 planned teaching program lesson plan power point presentation given validation contained basic anatomy physiology risk factors breast cancer steps bse validity tools established submitting seven experts 100% agreement items reliability coefficient knowledge questionnaire established split half method using spearman brown prophecy formula administrative permission obtained principal selected colleges written consent obtained study participants data collected administering knowledge questionnaire bse planned teaching program introduced 8 day post test done administering tool the data analyzed using descriptive frequency percentage inferential statistics based objectives hypotheses the data presented table 1 shows among 40 samples majority 52.5% samples age group 18 19 years majority 90% studying basic science group sample characteristics 35% heard bse mass media 8.5% participant one participant practiced bse one time time study the description knowledge scores shows 72.5% students average knowledge bse pre test 85% students good knowledge score post test figure 1 table 2 t test computed test effectiveness planned teaching program bse t=12.46 shown table 3 percentage distribution sample based knowledge score frequency percentage knowledge score computation effectiveness planned teaching program computed find association knowledge selected variables shows significant association knowledge selected variables hence null hypotheses accepted research hypotheses rejected shown table 4 a survey conducted among nurses midwives turkey found among 80 samples 52% samples performed bse significant relation found sociodemographic factor bse study conducted chennai s. aruna supported study significant association found demographic variables level knowledge breast cancer bse among working women study conducted among resettlement colony women shows poor knowledge breast cancer risk factors warning signs early detection procedure the world health organization stresses promoting awareness community encouraging early diagnosis breast cancer especially women aged 40 69 years attending primary health care centres hospitals reason offering clinical breast examination there many methods detect breast cancer expensive community breast related matters sensitive issues females unless breast lesions starts bothering may seek medical attention bse cheapest convenient method detect breast cancer early stage in study majority samples acquired good knowledge bse bse plays major role early detection prevention prompt treatment breast cancer giving teaching young girls teach mother siblings incidence breast cancer may reduced it essential task every woman bse protect family the nurse play important role health promotion possible teaches educates client however teaching bse help women alert abnormal changes breasts seek medical advice immediately

introduction : breast cancer accounts for 19 - 34% of all cancer cases among women in india . there is high mortality due to late stage diagnosis as patients usually present at an advanced stage because of lack of awareness and nonexistent breast cancer screening programs . early detection and prompt treatment offer the greatest chance of long - term survival and breast self - examination ( bse ) seems to be a important viable optional substitute for early detection of cancer.objectives:1 ) to assess the level of knowledge of degree college female students on bse . 2 ) to determine the effectiveness of planned teaching program among degree college female students on bse . 3 ) to find the association between pretest knowledge and selected demographic variables.materials and methods : pre - experimental one group pretestpost - test design was carried out among 40 degree female students by using cluster sampling method from selected colleges of udupi district.results:the data analyzed showed that majority ( 52% ) of them was in the age group of 18 - 19 years and 72% of them were had average knowledge on bse in the pretest score . out of 40 participants only one student was performing bse occasionally.conclusions:awareness regarding breast self examination among young generations is useful and it is the most important viable tool for early detection .

der p 1 isolated house dust mite fecal pellets allergon multistep procedure 6 involving immunoaffinity chromatography immobilized anti der p 1 mab clone 4c1 indoor biotechnologies removal contaminating serine proteases immobilized soybean trypsin inhibitor sigma chemical co. finally fast protein liquid chromatography fplc remove low molecular mass contaminants the purity preparation confirmed nh2-terminal sequencing automatic amino acid sequencer applied biosystems inc sds page analysis 15% gel demonstration enzymatic activity completely dependent preactivation cysteine totally inhibited e-64 l trans epoxysuccinyl leucylamido 4-guanidino]butane protein concentration determined using bicinchoninic acid bca microtiter plate assay confirmed spectrophotometrically using empirical absorption coefficient value der p 1 e 280 nm 16.4 use der p 1 preactivated 5 mm cysteine sigma chemical co. regenerate thiol group becomes oxidized purification the catalytic activity der p 1 ascertained continuous rate kinetic assay using fluorogenic peptide substrate n tert butoxy carbonyl boc)-gln ala arg7-amino-4-methyl coumarin amc reference 6 block proteolytic activity cysteine activated der p 1 1,000-fold molar excess e-64 sigma chemical co. used similar molar ratio cysteine protease inhibitor iodoacetamide sigma chemical co. used another sulfhydryl reactive agent the cells 2 10 suspended rpmi gibco life technologies stimulated 3 37c con 5 g ml final concentration presence il-2 100 u ml humidified atmosphere 5% co2 cd25 cleavage performed incubating 10 cells 10 g ml der p 1 preactivated 5 mm cysteine 1 h 37c total volume 200 l serum free aim v medium gibco life technologies the cells resuspended rpmi containing 2% fcs stained 45 min room temperature dark fitc labeled anti mouse cd25 mab clone amt-13 sigma chemical co. fixed 5% formaldehyde the expression cell surface markers namely cd3 cd4 cd8 monitored way using appropriate pe- fitc labeled antibodies clone kt3 beckman coulter clones yts191.1 kt15 serotec ltd five groups 10 female cba j mice given six weekly intraperitoneal injections 10 g proteolytically active der p 1 10 g e-64blocked der p 1 10 g iodoacetamide blocked der p 1 10 g ova proteolytically inactive antigen sigma chemical co. 10 g ova e-64 respectively a tail bleed obtained 1 wk start immunization prebleed total bleed obtained cardiac puncture 1 wk last injection final bleed the proteolytic activity der p 1 inhibition e-64 iodoacetamide immunization mixture ascertained described serum samples initially titrated determine optimal dilution testing antibody isotype subclass the optimal dilutions used 1/10 detecting total ige der p 1specific ige ova specific ige 1/20,000 1/40,000 1/250 detecting der p 1specific igg igg1 igg2b respectively mouse ige clone r35 72 pharmingen capture antibody second biotinylated monoclonal anti der p 1specific ige ova specific ige measured using samples depleted igg protein g column pharmacia der p 1specific igg igg1 igg2b detected microtiter plates coated 4 g ml solution either der p 1 ova developed biotinylated ige clone r35 118 igg1 clone a85 1 pharmingen igg2b clone ab275 binding site alkaline phosphatase conjugated isotype specific antibodies igg sigma chemical co. alkaline phosphatase conjugated extravidine sigma chemical co. used conjunction biotinylated antibodies unpaired student test used compare levels antibody responses different immunization groups p 0.05 considered significant der p 1 isolated house dust mite fecal pellets allergon multistep procedure 6 involving immunoaffinity chromatography immobilized anti der p 1 mab clone 4c1 indoor biotechnologies removal contaminating serine proteases immobilized soybean trypsin inhibitor sigma chemical co. finally fast protein liquid chromatography fplc remove low molecular mass contaminants the purity preparation confirmed nh2-terminal sequencing automatic amino acid sequencer applied biosystems inc sds page analysis 15% gel demonstration enzymatic activity completely dependent preactivation cysteine totally inhibited e-64 l trans epoxysuccinyl leucylamido 4-guanidino]butane protein concentration determined using bicinchoninic acid bca microtiter plate assay confirmed spectrophotometrically using empirical absorption coefficient value der p 1 e 280 nm 16.4 use der p 1 preactivated 5 mm cysteine sigma chemical co. regenerate thiol group becomes oxidized purification the catalytic activity der p 1 ascertained continuous rate kinetic assay using fluorogenic peptide substrate n tert butoxy carbonyl boc)-gln ala arg7-amino-4-methyl coumarin amc reference 6 block proteolytic activity cysteine activated der p 1 1,000-fold molar excess e-64 sigma chemical co. used similar molar ratio cysteine protease inhibitor iodoacetamide sigma chemical co. used another sulfhydryl reactive agent spleen cells obtained c57bl/6j mice using standard procedures cells 2 10 suspended rpmi gibco life technologies stimulated 3 37c con 5 g ml final concentration presence il-2 100 u ml humidified atmosphere 5% co2 cd25 cleavage performed incubating 10 cells 10 g ml der p 1 preactivated 5 mm cysteine 1 h 37c total volume 200 l serum free aim v medium gibco life technologies the cells resuspended rpmi containing 2% fcs stained 45 min room temperature dark fitc labeled anti mouse cd25 mab clone amt-13 sigma chemical co. fixed 5% formaldehyde the expression cell surface markers namely cd3 cd4 cd8 monitored way using appropriate pe- fitc labeled antibodies clone kt3 beckman coulter clones yts191.1 kt15 serotec ltd five groups 10 female cba j mice given six weekly intraperitoneal injections 10 g proteolytically active der p 1 10 g e-64blocked der p 1 10 g iodoacetamide blocked der p 1 10 g ova proteolytically inactive antigen sigma chemical co. 10 g ova e-64 respectively a tail bleed obtained 1 wk start immunization prebleed total bleed obtained cardiac puncture 1 wk last injection final bleed the proteolytic activity der p 1 inhibition e-64 iodoacetamide immunization mixture ascertained described serum samples initially titrated determine optimal dilution testing antibody isotype subclass the optimal dilutions used 1/10 detecting total ige der p 1specific ige ova specific ige 1/20,000 1/40,000 1/250 detecting der p 1specific igg igg1 igg2b respectively mouse ige clone r35 72 pharmingen capture antibody second biotinylated monoclonal anti der p 1specific ige ova specific ige measured using samples depleted igg protein g column pharmacia der p 1specific igg igg1 igg2b detected microtiter plates coated 4 g ml solution either der p 1 ova developed biotinylated ige clone r35 118 igg1 clone a85 1 pharmingen igg2b clone ab275 binding site alkaline phosphatase conjugated isotype specific antibodies igg sigma chemical co. alkaline phosphatase conjugated extravidine sigma chemical co. used conjunction biotinylated antibodies unpaired student test used compare levels antibody responses different immunization groups p 0.05 considered significant der p 1 25-kd cysteine protease whose structure modeled 7 crystal structure papain shows considerable sequence similarities notably residues involved enzyme active site 8 the proteolytic activity der p 1 inhibited e-64 class specific inhibitor microbial origin 9 this inhibition brought cysteine within der p 1 active site forms thioether covalent bond epoxy group e-64 this irreversible process lead significant structural changes evidenced crystallographic studies papain e-64 complex 10 we purified der p 1 fecal pellets using multistep procedure confirmed purity nh2-terminal sequencing sds page analysis demonstration enzymatic activity completely dependent preactivation cysteine inhibited e-64 iodoacetamide fig 1 recently shown der p 1 selectively cleaves human cd25 surfaces peripheral blood cells 4 here we demonstrate der p 1 also selectively cleaves cd25 cultured mouse spleen cells fig 2 surprising given high degree sequence homology exists human 11 mouse 12 cd25 this observation therefore provided justification using animal species testing hypothesis namely proteolytic activity der p 1 major contributor allergenicity intraperitoneal immunization groups 10 cba j mice either proteolytically active inactive e-64blocked der p 1 6-wk period showed statistically significant enhancement total ige p 0.01 der p 1specific ige p 0.02 responses animals immunized proteolytically active der p 1 this effect ige specific der p 1specific igg igg1 igg2b responses increased extent proteolytically active inactive der p 1 fig we sure igg1 response follow ige two isotypes considered coregulated mouse however ige restricted enhancement seen response immunization proteolytically active der p 1 suggest mechanism unique ige isotype switching synthesis furthermore control experiments clearly show ige specific effect observed due e-64 exerting suppressive influence ige production mechanism independent binding der p 1 enzyme active site fig suppression total ige p 0.04 der p 1specific ige p 0.05 productions also obtained proteolytic activity der p 1 blocked iodoacetamide another sulfhydryl reactive agent second ige antibody response ova proteolytically inactive antigen suppressed animals immunized ova plus e-64 our results direct evidence cysteine protease activity der p 1 induces significant increase ige responses such effect clearly consistent ability der p 1 proteolytically cleave mouse cd25 induce th2 response modulating balance il-4 ifn- 13 the recent demonstration mice leishmania mexicana cysteine proteinase deficient mutants potentiate th1 response compared th2 response normally seen response infection wild type parasite 14 also great relevance allergic individuals could potentially achieved administering der p 1 catalytically inactive mutant form hand exploring potential th2 adjuvant property proteolytic activity der p 1 would important implications defining principles modulation th1-mediated pathological conditions our demonstration cysteine protease activity der p 1 enhances total ige production apart increasing der p 1-specific ige suggests allergen may play central role destabilizing microenvironment within target tissues one proallergic thus aids initiation propagation allergic cascade in words proteolytic activity der p 1 may exert ige specific adjuvant effect the vivo relevance proteolytic activity der p 1 highlighted reports demonstrating increases permeability human respiratory epithelium macromolecules 1516 such observations together current findings showing direct effect immune system indicate proteolytic activity der p 1 major contributor allergenicity

the house dust mite dermatophagoides pteronyssinus allergen der p 1 is the most immunodominant allergen involved in the expression of dust mite specific immunoglobulin ( ig)e mediated hypersensitivity . the reason for this potent ige - eliciting property of der p 1 remains unknown , but there is mounting in vitro evidence linking the allergenicity of der p 1 to its cysteine protease activity . here we demonstrate for the first time that immunization of mice with proteolytically active der p 1 results in a significant enhancement in total ige and der p 1specific ige synthesis compared with animals immunized with der p 1 that was irreversibly blocked with the cysteine protease inhibitor e-64 . we conclude that the proteolytic activity of der p 1 is a major contributor to its allergenicity .

given risk paralysis associated cervical transforaminal injection time reconsider transforaminal injections lumbar spine ? arguments discontinuing lumbar injections discussed anesthesia literature raising concern risks epidural steroid injections esis in 47-year old man paraplegia lower extremities developed specifically conus medullaris syndrome underwent esi recurrent pain the patient felt legs going dead paraplegia lower extremities noted an initial magnetic resonance imaging study performed patient transferred emergency department unremarkable however later neurosurgical evaluation showed conus medullaris syndrome second magnetic resonance imaging study showed conus infarct we conducted search pubmed database articles 2002 2011 containing following keywords complications lumbar epidural steroid injection(s cauda equina syndrome conus medullaris infarction spinal cord infarction spinal cord injury paralysis paresis plegia paresthesia anesthesia summarizing case 5 similar cases weigh potential benefits risks esi although one safely assume severe devastating complication rare speculate true incidence remains unknown possibly medicolegal implications we believe rarity complication preclude continued use transforaminal esi rather emphasized discussion patients consent process a 47-year old man undergone l4/l5 laminectomy discectomy 5 years earlier presented recurrent pain left buttock posterior leg after receiving esi local anesthesiology group within cincinnati ohio area patient transferred outpatient pain clinic institution information regarding medical history prior treatment well details procedure limited provided patient accompanying procedure report the patient reported previously received esis left side lower back second injection series 3 correct needle placement left l5-s1 neural foramen verified epidurography immediately injection patient felt legs going dead paraplegia lower extremities noted because concern intrathecal injection resultant motor blockade patient monitored 4 hours when clinical improvement observed transferred nearby community hospital emergency department neurologic examination although initial magnetic resonance imaging mri study performed emergency department unremarkable fig however second mri study evaluate possibility vascular complications obtained 48 hours injection showed conus infarct fig 2 five hours esi 47-year old man magnetic resonance imaging scans performed emergency department unremarkable showing normal appearing conus ) ( b t1-weighted sagittal image repetition time 416.7 echo time 15.0 magnetic resonance images 48 hours procedure showing extensive signal abnormalities within lower thoracic spinal cord conus compatible clinical diagnosis conus infarct ( t1-weighted sagittal image repetition time 675.0 echo time 9.6 b t2-weighted sagittal image repetition time 3640.0 echo time 102.0 ( c short tau inversion recovery stir sagittal image repetition time 4000.0 echo time 58.0 1-month follow patient could walk without assistance slow calculated gait symmetric lower extremity strength dorsiflexion strength 4 5 bilaterally his urinary urge sensation returned occasional episodes fecal incontinence occurred relation bladder overdistention our search pubmed database 20022011 included keywords complications lumbar epidural steroid injection(s cauda equina syndrome conus medullaris infarction spinal cord infarction spinal cord injury paralysis paresis plegia paresthesia anesthesia esi regarded effective conservative means treating low back pain resulting nerve root inflammation recent case reports post procedural conus medullaris syndrome spinal vascular compromise raise question regarding safety our case represents sixth patient conus medullaris syndrome developed sustaining acute spinal cord infarct esi 5 case reports table 1 complication affected patients aged 4271 years previous lumbar surgery underwent transforaminal steroid injection note findings spinal cord injury detectable initial mri study within first 24 hours 1 case injections typically evaluated first aspiration injection contrast nonvascular penetrating injection contrast media verifies safe needle placement however series 761 lumbosacral transforaminal injections performed furman et al reported sensitivity positive flash actual aspiration 44.7% 38 85 patients shown either flash actual aspiration injection specifically showed 11.2% rate vascular injection series evaluating correct placement 316 caudal approach esis implicated aspiration errorprone method verifying needle placement reporting 9.2% incidence vascular violation despite negative findings aspiration blood supplied caudal portion spinal cord anterior spinal artery 2 posterior spinal arteries segmental radiculomedullary arterial branches importantly artery adamkiewicz the location artery adamkiewicz primary blood supply conus medullaris fairly unpredictable it travels nerve foramen near level origin thoracolumbar segmental arteries . showed artery adamkiewicz originated left t9 12 posterior intercostal arteries 75% cases l1 2 lumbar arteries 10% cases 31 cadavers biglioli et al located artery t12 l3 26 cases 83.9% in 2002 review 4000 spinal angiograms lo et al examined variability artery adamkiewicz noting originated l2 1% cases l4 0.075% cases of proposed mechanisms spinal cord medullary infarction may occur one explanation may combined effect undetected direct arterial injection low lying artery adamkiewicz resultant embolic incident injectate houten errico proposed collaterals surrounding cord level artery proximal injection site thus allowed direct passage injected material conus however discussed lo et al considering observation believe unlikely patient low lying artery could injected epidural steroid precise location another plausible explanation inadvertent sacral radicular artery injection carried injection material distally spinal cord reported material injected abdominal aorta level artery adamkiewicz would appear conus collateralization the likely cause injection steroid particulate either artery adamkiewicz collateral radiculomedullary arterial branches prior lumbar surgery may lead compromise normal vascular supply spinal cord thus making susceptible vascular injury subsequent thrombus formation would result embolic infarct spinal cord supplied affected artery florey noted vasoconstriction local effect lasting 5 seconds 10 minutes site injury found fine needle 30-gauge arterial puncture rhesus monkeys induced intense vasospasm typically lasting anywhere 4 hours 4 days many studies examined mechanically induced vasospasm cerebral vasculature may indirectly suggestive similar phenomenon occur spinal cord conus medullaris multiple recommendations made avoid devastating complications paralysis first foremost strict adherence standard widely accepted techniques transforaminal esis these guidelines include use multiplanar fluoroscopy computed tomography guidance together contrast material prevent complications if recovery neurologic function fails occur patient within 2- 3-hour time period esi initial mri study may obtained exclude epidural hematoma repeat mri 24 hours performed well patient well 1 reported case delayed effect observed mri signal changes occurring 24 hours given risk paralysis associated cervical transforaminal injection time reconsider transforaminal injections lumbar spine ? although risk permanent neurologic deficit negligible arguments discontinuing lumbar injections presented anesthesia literature however one considers potential benefit noninvasive treatment modality abandoning injections may premature however speculate 6 cases conus medullaris syndrome esi occurred medicolegal considerations may explain may go unreported least patients clearly informed regarding potential risks esi including paralysis although one safely assume severe devastating complication rare true incidence remains unknown opinion rarity complication time preclude continued use transforaminal esi relief pain select patients included consent process

backgroundgiven the risk of paralysis associated with cervical transforaminal injection , is it time to reconsider transforaminal injections of the lumbar spine ? arguments for discontinuing lumbar injections have been discussed in the anesthesia literature , raising concern about the risks of epidural steroid injections ( esis).methodsin a 47-year - old man , paraplegia of the lower extremities developed , specifically conus medullaris syndrome , after he underwent an esi for recurrent pain . correct needle placement was verified with epidurography . immediately after the injection , the patient felt his legs going dead ; paraplegia of the lower extremities was noted.resultsan initial magnetic resonance imaging study performed after the patient was transferred to the emergency department was unremarkable . however , a later neurosurgical evaluation showed conus medullaris syndrome , and a second magnetic resonance imaging study showed the conus infarct . we conducted a search of the pubmed database of articles from 2002 to 2011 containing the following keywords : complications , lumbar epidural steroid injection(s ) , cauda equina syndrome , conus medullaris infarction , spinal cord infarction , spinal cord injury , paralysis , paresis , plegia , paresthesia , and anesthesia.conclusionssummarizing this case and 5 similar cases , we weigh the potential benefits and risks of esi . although one can safely assume that this severe , devastating complication is rare , we speculate that its true incidence remains unknown , possibly because of medicolegal implications . we believe that the rarity of this complication should not preclude the continued use of transforaminal esi ; rather , it should be emphasized for discussion with patients during the consent process .

because of rampant concern that estrogenic chemicals in the environment may be adversely affecting the health of humans and wildlife , reliable methods for detecting and characterizing estrogenic chemicals are needed . it is important that general agreement be reached on which tests to use and that these tests then be applied to the testing of both man - made and naturally occurring chemicals . as a step toward developing a comprehensive approach to screening chemicals for estrogenic activity , three assays for detecting estrogenicity were conducted on 10 chemicals with known or suspected estrogenic activity . the assays were 1 ) competitive binding with the mouse uterine estrogen receptor , 2 ) transcriptional activation in hela cells transfected with plasmids containing an estrogen receptor and a response element , and 3 ) the uterotropic assay in mice . the chemicals studied were 17 beta - estradiol , diethylstilbestrol , tamoxifen , 4-hydroxytamoxifen , methoxychlor , the methoxychlor metabolite 2,2-bis(p - hydroxyphenyl)-1,1,1-trichloroethane ( hpte ) , endosulfan , nonylphenol , o , p'-ddt , and kepone . these studies were conducted to assess the utility of this three - assay combination in the routine screening of chemicals , or combinations of chemicals , for estrogenic activity . results were consistent among the three assays with respect to what is known about the estrogenic activities of the chemicals tested and their requirements for metabolic activation . by providing information on three levels of hormonal activity ( receptor binding , transcriptional activation , and an in vivo effect in an estrogen - responsive tissue ) , an informative profile of estrogenic activity is obtained with a reasonable investment of resources.imagesp1296-afigure 1.figure 2.figure 3.figure 4.figure 5 .

alzheimer disease ad neurodegenerative disorder clinically characterized progressive mental decline histopathologically defined highly abundant amyloid deposits neurofibrillary tangles brain parenchyma the identification mutations within amyloid precursor protein app presenilin ps genes cause autosomal dominantly inherited ad result increased production amyloid prone forms established beyond doubt processing app production peptides intimately involved disease process led proposal reinforcement alzheimer amyloid cascade hypothesis 1 2 the role amyloid neuronal dysfunction recently extended discovery small soluble oligomers peptide forms termed addls a-derived diffusible ligands protofibrils a*56 36 these oligomers potential intermediates formation amyloid filaments also shown neurotoxic inhibit long term potentiation ltp cellular model memory hippocampal slices 4 7 8 thus amyloid cascade hypothesis includes essential role oligomers neurodegeneration process despite strength amyloid cascade hypothesis incomplete without including essential role amyloid associated inflammatory proteins for example biochemical histological studies first showed addition amyloid deposits also contained inflammation acute phase protein 1-antichymotrypsin act later apolipoprotein e apoe 10 11 hypothesized serve catalysts pathological chaperones amyloid formation 9 11 12 results also indicated alzheimer disease manifestation middle aged syndrome may include inflammatory process act apoe inflammatory and/or acute phase proteins contexts overexpressed affected regions ad brain reviews see 1315 indeed alzheimer first identified inflammatory component alzheimer disease described reactive astrocytes microglia affected brain regions first patient however inflammatory proteins act il-1 hla apoe found overexpressed ad ds brains term inflammation explicitly excluded clinical pathological description ad lack edema lymphocyte infiltration 911 17 18 the significance biochemical results instigated reinforced parallel genetic discoveries implicating role inflammation ad in particular inheritance apoe 4 allele found strongest known risk factor ad besides age one copy increasing ad risk 35-fold two copies 10-fold 1921 because apoe essential genetic therefore presumably biochemical contribution ad pathology cognitive decline critical role ad pathogenic pathway amyloid cascade elucidated order therapeutics based apoe designed recent excellent encyclopedic literature reviews describe many potential roles apoe plays ad 2326 focused review concentrate interaction apoe inflammatory proteins effects interactions implications designing apoe based ad therapies the central question try answer whether increasing decreasing apoe level and/or function serve best reduce ad ds pathology cognitive decline lack clear answer may lead development drugs rather serving ad therapy instead potentially exacerbate disease to determine whether inflammation contributes alzheimer disease rather merely correlative pathological feature ad brain others tested hypothesis act and/or apoe serve amyloid catalysts pathological chaperones numerous vitro vivo studies showed mature amyloid deposition associated cognitive decline strongly stimulated apoe act dose dependent isoform specific manner apoe4 strongest promoter polymerization apoe2 inhibitor paralleling effect two isoforms humans 2738 indeed without one amyloid catalysts expressed brain amyloid deposition profoundly delayed app transgenic mice become filamentous such app+/apoe ko animals also exhibit normal cognition despite levels expression equal apoe expressing app animals elegant work manelli colleagues also showed native lipidated apoe4 transgene replacement astrocytes increases neurotoxicity compared apoe3 e2 indicating apoe4 provides negative gain function finally jones colleagues recently showed apoe4 also promotes conversion enhanced synaptic localization oligomers neurotoxic form alzheimer amyloid peptide 40 41 these recent studies extended prior work showing apoe copurifies biochemical isolation amyloid human brains apoe preferentially interacts peptides -sheet structure 4245 together results show inflammatory proteins particularly apoe integral parts amyloid cascade without cascade would arrested level harmless monomer ad would ensue the view apoe integral pathological part amyloid cascade shaken experiments suggest apoe far amyloid catalyst serves clear brain view apoe protective human apoe4 less protective apoe3 e2 recent discussion see commentary http://www.alzforum.com/ the first experiments suggested apoe role neuroprotector examined pathology cognition app transgenic mice carrying second transgene expressing one another human apoe isoform contrary expectations amyloid deposition mice inhibited human apoe transgene though human apoe protective ultimately mice develop amyloid apoe4-expressing strain accumulating earlier extensive pathology 33 34 48 49 it proposed human apoe might serve inhibit clearance brain compared mouse apoe apoe4 inhibiting clearance other experiments showed indeed clearance species inhibited complexing apoe especially apoe4 46 50 the possibility interaction apoe modulated clearance mechanism appeared supported finding introduction anti antibodies a-binding proteins gelsolin led reduced amyloid load brain rapidly improved cognition little evidence a-binding agents invading brain parenchyma 4154 we also introduced apoe circulation via parabiosis found induced amyloid clearance without entering brain ad model mice thus peripheral sink hypothesis became viable alternative addition amyloid cascade hypothesis apoe potentially playing additional role a-binding peripheral protein most recently approach therapy investigated ad mice based activating liver x receptor lxr also exists cells including microglia 5557 activation lxr results increased expression many proteins including apoe lipidating enzyme atp binding cassette transporter a1 abca1 the results indicate activating lxr ligand gw3965 fda approved antiskin cancer drug bexarotene reduces soluble insoluble improves cognition app tg mice knocking abca1 gene app mice showed tendency reduced amyloid load because apoe expression lipidation stimulated lxr activation results interpreted proof increased apoe levels help microglia clear amyloid indeed earlier cell culture experiments suggested however also shown genetic overexpression abca1 reduces amyloid deposition mice apoe levels unchanged hence lxr stimulation influences levels many proteins problematic definitively link vivo action altered level one particular protein furthermore increased levels abca1 induced bexarotene enhance apoe lipidation change known alter apoe interactions hence important consider lipidation state apoe affects function addition absolute levels apoe trying distinguish weigh value two hypotheses instructive consider testable predictions apoe amyloid catalyst reducing apoe levels function brain result reduced amyloid deposition reduced cognitive decline if hand apoe involved clearance human apoe4 greater inhibitor clearance poorer clearer reducing apoe levels apoe binding increase amyloid deposition cognitive decline all experiments carried far vitro transgenic mice indicate ability form neurotoxic filaments oligomers cause cognitive decline increased presence apoe particularly mouse apoe human apoe4 apoe2 protective contrast complete absence apoe mutant app gene product harmless generating neither amyloid deposits synaptic disfunction cognitive decline one copy apoe intermediate effect discussed the vitro experiments particular indicate apoe likely acts catalytically promote polymerization molar ratio apoe 200/1 appropriate formation neurotoxic products 2730 most recently earlier work showing mice expressing one apoe gene accumulated less amyloid two apoe genes 32 repeated two different laboratories using human apoe knock mice result found lower doses apoe3 apoe4 led reduced amyloid deposition 59 60 the simplest interpretation vitro cell culture transgenic mouse data apoe necessary polymerize neurotoxic oliogomers filaments probably binding thus altering structure toward -sheet easily allowing successive peptides add growing chain the recent finding apoe promotes oligomer formation vivo reinforces interpretation 40 41 whether apoe needed initiate polymerization also prepare peptide addition growing filament yet known even though key predictions polymerization hypothesis apoe serving filament catalyst borne compelling experiments demonstrating human apoe inhibits filament formation mouse background require explanation furthermore data ladu colleagues others shown lipidated apoe presumably prevalent form vivo binds affinity e2 e3 finally elegant thorough experiments castellano colleagues show convincingly expression human apoe4 transgene absence mouse apoe leads longer half life i.e. slower clearance brain interstitial fluid compared e2 e3 the apoe binding studies might interpreted support apoe functioning clearance apoe2 example would bind tightly could thereby promote removal interstitial fluid via lrp receptors 50 6164 however important feature catalyst must bind substrate tightly enough convert transition state structure release reaction completed 65 66 if mutation leads overly tight substrate binding reaction occur thus apoe2 could indeed bind tightly thereby prevent apoe4 binding promoting oligo polymerization also prevent spontaneous polymerization peptide the ability different apoe isoforms bind different strengths also explain human apoe isoforms slow amyloid deposition presence endogenous mouse apoe may bind tightly differently mouse apoe slow catalytic conversion oligomers polymers mouse background the data showing human apoe inhibits clearance also interpreted reflecting apoe role catalyzing oligo polymerization pathologic macromolecular structures often resistant various clearance mechanisms designed monomeric species whether intracellular proteasome degradation cross membrane bbb transfer thus allowing accumulation oligo polymeric structures anticipated physiological clearance mechanisms place handle antibody antigen complexes clearance facilitated conversion larger structures apoe clearly ability catalyze conversion oligomeric polymeric structures reasonable assume structures difficult clear difficulty detected clearance inhibition brain instance apoe4 pulse chase type experiments higher apoe levels blood may aid clearance circulations figure 1 finally ability gw3965 bexarotene reduce soluble insoluble brain tg app mice improve cognition easily understood resulting general activation phagocytic activity microglia previous work showed activation microglia acute intracerebral treatment app mice lps granulocyte macrophage stimulating factor similarly reduce amyloid load improve cognition 6769 long term peripheral treatment lps exacerbated amyloid deposition apoe dependent manner stimulation microglial activity via induction toll like receptor 9 tlr9 also shown greatly reduce amyloid load improve cognition clearly interaction neuroinflammation microglia amyloid load complex fact bexarotene cures ad mice likely despite rather stimulates expression apoe good test hypothesis pathogenesis disease whether successfully predicts pathogenesis inhibited reversed for example small fragments corresponding amino acid sequences act a1 12 apoe a12 28 bind serve decoy peptides prevent binding apoe catalysis neurotoxic species early vitro work recently repeated confirmed laboratories 72 73 the decoy principal extended vivo preparing version a12 28 better plasma 1/2 life nonfibrillogenic nontoxic it shown peptide could peripherally introduced transgenic app mouse effectively entered brain prevented reversed oligomer formation amyloid deposition cognitive decline 7476 similarly amyloid plaques app mice contain mouse act injecting a1 11 one side app mouse brain block act binding site endogenous rapidly reduced amyloid load compared vehicle injected side brain furthermore inflammatory cytokine il-1 overexpressed ad brain induces astrocyte expression act blocking il-1 expression app transgenic mice ibuprofen treatment thereby reducing mouse act expression lowers amyloid formation restores cognition evidently blocking act apoe expression function vitro vivo successfully prevents pathology neurotoxicity apolipoprotein j also binds shown aid passage across blood brain barrier 7983 interestingly knocking either apoj apoe reduces amyloid deposition app transgenic animals yet knocking leads robust amyloid deposition even earlier age arises nonmanipulated app animals this result may reflect ability mouse act promote amyloid formation presence stronger binding apoe apoj proteins mouse act prevented exhibiting catalytic activity role apoe act alzheimer pathogenic pathway potentially general implications one studied classes binding proteins specific anti antibodies form basis passive active immunization therapies alzheimer disease review see the finding apoe act catalyze oligo polymerization begs question whether antibodies might also promote inhibit polymerization indeed found two antibodies 6e10 directed n terminal sequence bound act 13 binds c terminus function differently vitro polymerization assay 6e10 inhibits act catalyzed polymerization 13 inhibits act catalysis much less even promotes polymerization interestingly n terminus also target many attempts ad immunotherapy aim inducing microglial phagocytosis neurotoxic species yet removing microglial binding fc portion 3d6 antibodies a1 5 generate fab'2 fragments reduce antibody ability remove diffuse amyloid app mice evidently a-binding feature required allow antibody remove amyloid a possible explanation result antibody functions blocking interaction mouse act the consequent suppression act catalyzed oligo polymerization could thus tilt dynamic process plaque development toward depolymerization these results illustrate fact a-binding proteins multiple effects polymerization full range activities must considered using potential targets tools therapeutic intervention although oligomers shown highly neurotoxic vitro vivo formation promoted apoe4 mechanism toxicity still elucidated the data reviewed coupled recent findings suggest novel mechanism toxicity encompasses essential role apoe specifically oligomers bind inhibit certain microtubule motors essential function stability mitotic spindle similar motors including kinesin 5 also present mature neurons 88 89 we found recently inhibition mt motor function specific kinesin 5 inhibitor monastrol prevents efficient transport receptors ldlr nmda neurotransmitter receptor p75 neurotrophin receptor cell surface resulting reduced function (; preparation similarly apoe particularly apoe4 shown reduce cell surface levels function nmda ampa apoer2 receptors neurons this latter finding understood potentially reflecting ability apoe4 promote conversion endogenous neuronal oligomers inhibit mt based transport key cellular components receptors functional location sum appears preponderance data consistently interpreted showing brain inflammatory protein apoe plays catalytic role ad ds amyloid cascade consequent cognitive decline binding clearance differences apoe isoforms reflecting differing abilities bind catalyze conversion neurotoxic macromolecular species figure 2 this conclusion vivo demonstration blocking apoe interaction prevents ad mouse model suggests decoy approach translatable human patients serve effective new approach ad therapy other a-binding proteins may similarly manipulated decoy approach reduce oligomerization polymerization neurotoxic species however finding different antibodies inhibit act catalyzed polymerization and promote polymerization argues immunotherapy must approached care avoid use induction antibodies catalyze oligo polymerization instead inducing phagocytosis removal furthermore human mouse intracerebral environments may differ important ways respect pattern activities a-binding proteins may also respond differently intervention inflammation such differences may explain many treatments successful reducing amyloid dependent cognitive decline transgenic mice failed translate human ad patients finally ability oligomers inhibit key microtubule motors prevent transport neurotrophin neurotransmitter receptors cell surface may underlie neuronal toxicity it apparently apoe- especially e4-dependent formation oligomers constitutes key catalytic step ad pathogenic pathway

the amyloid cascade hypothesis remains a robust model of ad neurodegeneration . however , amyloid deposits contain proteins besides a , such as apolipoprotein e ( apoe ) . inheritance of the apoe4 allele is the strongest genetic risk factor for late - onset ad . however , there is no consensus on how different apoe isotypes contribute to ad pathogenesis . it has been hypothesized that apoe and apoe4 in particular is an amyloid catalyst or pathological chaperone . alternatively it has been posited that apoe regulates a clearance , with apoe4 been worse at this function compared to apoe3 . these views seem fundamentally opposed . the former would indicate that removing apoe will reduce ad pathology , while the latter suggests increasing brain apoe levels may be beneficial . here we consider the scientific basis of these different models of apoe function and suggest that these seemingly opposing views can be reconciled . the optimal therapeutic target may be to inhibit the interaction of apoe with a rather than altering apoe levels . such an approach will not have detrimental effects on the many beneficial roles apoe plays in neurobiology . furthermore , other a binding proteins , including act and apo j can inhibit or promote a oligomerization / polymerization depending on conditions and might be manipulated to effect ad treatment .

musculoskeletal tissues show increased bone fragility loss cartilage resilience reduced ligament elasticity loss muscular strength fat redistribution decreasing ability tissues carry normal functions the loss mobility physical independence resulting arthropathies fractures particularly devastating population physically psychologically also terms increased mortality rates the aim article present frequent musculoskeletal disorders elderly including misleading presentations we used following terms combinations elderly aged epidemiology fracture osteoporosis vertebral hip pelvis arthritis neoplasm malignancy myeloma paget gout infection microcrystal radiology articles without english abstracts excluded besides certain relevant rheumatological orthopedic radiological books also used fractures frequent elderly result mainly effects falls osteoporosis low impact falls even standing height common cause injury geriatric patients falling multi factorial problem due extrinsic e.g. environmental housing conditions intrinsic risk factors e.g. impaired mobility loss muscular strength poor visual acuity medication instance corticoids).[46 osteoporosis characterized qualitatively normal quantitatively deficient bone leads bone fragility increased risk fractures the general prevalence osteoporosis women approximately 50% age 85 years men prevalence 20% age ethnic differences also exist mineral bone density higher black women lower asian women white women evidence shows intermediate value due precision widely used quantitative technique dual energy x ray absorptiometry makes possible diagnose osteoporosis early predict risk fracture determine therapeutic intervention monitor response treatment method grades bone loss according standard deviations sd mean young adult value a value less 2.5 times sd young adult mean considered indicate osteoporosis the main radiographic features osteoporosis increased radiolucency cortical thinning mainly spine giving rise well demarcated outline vertebral body described picture framing. besides spine increased biconcavity vertebral end plates protrusion intervertebral disk vertebral body observed however early radiographic changes subtle bone loss approximately 30% must occur detected vertebral compression fractures common osteoporotic fractures greater incidence women 60 years age they observed 25% women 70 years age 40% 80 years after one episode risk subsequent vertebral fracture increases least four fold substantially increased rates first year fractures associated higher mortality significant morbidity even though afforded little clinical attention they often appear multiple fractures anterior wedging may associated significant deformity leading kyphosis they usually well demonstrated radiographs better assessed computed tomography ct magnetic resonance mr imaging necessary the latter imaging modality may indicated case associated neurological symptoms rare event vertebroplasty discussed order better localize recently fractured vertebra vertebral compression fractures elderly may involve several problems first differentiating osteoporotic malignant vertebral collapse vc particularly metastatic vc latter far common malignant tumor affecting skeleton elderly patients multiple relatively symmetrical thoracolumbar vcs associated diffuse increased radiolucency suggestive osteoporosis figure 1a the whole vertebral endplate impacted sometimes association increased decreased radiolucency subjacent trabecular bone band like distribution abnormalities fractured vertebral end plate gas also seen fracture nearly pathognomonic benign nature collapse there cortical osteolysis although fractures identified retropulsion bone fragment conversely following cause concern single vc involvement cervical spine heterogeneous increased decreased radiolucency explained underlying end plate fracture focal collapse ap lateral view bulging vertebral body cortical osteolysis figure 1b doubt better assessment spinal canal soft tissue ct better yet mri performed order differentiate two disorders benign fractures an mri may show band distribution abnormal signal intensities t1 t2 weighted images spared normal bone marrow signal intensity retropulsion posterior bone fragment multiple compression fractures contrary signs convex posterior border vertebral body abnormal signal intensity posterior elements epidural mass focal paraspinal mass suggestive spinal metastasis.[1921 second vertebral fractures missed following moderate trauma fracture may difficult identify osteoporotic radiolucent bone pain attributed another painful condition degenerative changes this observed particular cervical spine particularly c2 may lead secondary neurological complications figure 2 ankylosis may related ankylosing spondylitis diffuse idiopathic skeletal hyperostosis especially affect males estimated frequency 5 15% elderly.[2225 ankylosed spines become increasingly susceptible injury even event low energy impacts prone unstable vertebral fractures increased frequency neurological complications either primary secondary unprotected transfers manipulation these lesions may missed plain films non displaced mildly displaced especially hyperextension whereas well demonstrated ct mr imaging however mri features sometimes misleading mimic infectious spondylitis signal abnormalities disco vertebral junction present caution required elderly patient presents ankylosed spine minor trauma acute pain especially signal abnormalities anterior posterior spine observed figure 3 usual benign vertebral compression multiple levels diffuse radiolucency whole vertebral endplate involvement arrows usual malignant vertebral compression characteristics b single vertebral involvement focal bulging posterior wall arrowheads missed fracture odontoid process vertebral body c2 arrows patient history fall one month transverse fracture thoracic vertebral body arrow posterior arch arrowhead posterior epidural hematoma curved arrow ankylosed spine depicted t1- b t2-weighted sequences other important sites fractures hip pelvis associated increased mortality specific diagnostic problems elderly population they common frequently result lateral falls directly greater trochanter case hip fractures forward backward falls case pelvic fractures most fractures easily diagnosed conventional radiography particularly fractures proximal femur however non displaced fractures may negative equivocal particularly bone osteoporotic if clinical suspicion fracture persists ct better still mr imaging advocated modality show fracture line surrounded bone marrow edema they may occur everywhere particularly common hip pelvis majority located sacrum pubic ramus figure 4 radiographic findings often subtle unremarkable suspected cases mr imaging indicated due superior accuracy compared radiological methods all images carefully analyzed multiple insufficiency fractures frequent figure 5 subchondral fractures particularly difficult identify radiographs thin hypointense line represents fracture surrounded variable degree edema well demonstrated mri figure 6 kind fracture complicated necrosis subchondral bone hypointense t2 weighted images enhanced following gadolinium administration insufficiency fractures arrows located sacrum adjacent edema arrowheads better depicted t1- b t2- weighted sequences respectively multiple fractures white arrows proximal femur b pubic ramus coronal t1-weighted images subchondral fracture femoral head conventional radiography b fat saturated sagittal t2-weighted image white arrow osteoarthritis oa defined group distinct overlapping diseases may different etiologies similar biological morphological clinical outcomes affecting articular cartilage subchondral bone ligaments joint capsule synovial membrane periarticular muscles pathological changes include fibrillation cartilage disruption collagen fibers changes proteoglycan staining chondrocyte proliferation necrosis neovascularization oa common joint disease persons 65 years age radiographic prevalence high approximately 90% women 80% men.[3335 etiology fully understood although several related factors female gender genetics metabolism excessive mechanical stress it frequently leads decreased function loss independence although joints hand commonly affected less likely symptomatic knee hip figure 7 diagnosis oa primarily based clinical history physical examination plain radiographs help confirm diagnosis grade severity condition the cardinal radiographic features oa focal non uniform narrowing joint space areas subjected pressure subchondral cysts subchondral sclerosis osteophytes however severity spondylolisthesis radiographic changes correlate clinical symptoms shoulder oa rotator cuff disease also fairly common elderly associated significant shoulder pain disability related decreased shoulder movement direct signs oa indirect signs large rotator cuff tears seen plain films including superior humeral head migration remodeling acromion greater tuberosity ultrasound another valuable tool easy assessment rotator cuff tendons due good sensitivity specificity figure 8 however surgical treatment considered arthro ct mri may preferred order improve planning the lumbar cervical spine also frequently affected degenerative changes disk spaces facet joints spinous processes sometimes progressive scoliosis although intervertebral disks synovial joints pathological changes similar seen articular cartilage ct mri routinely used evaluation narrowing central canal lateral recesses neural foramina assessment required percutaneous surgical treatment besides mri useful evaluating marrow changes vertebral plate especially inflammatory changes type modic present positive correlation low back pain typical osteoarthritis distal proximal interphalangeal joints b hip joint joint space narrowing arrows subchondral cysts arrowheads osteophytes curved arrows subchondral sclerosis thick arrow ultrasound images long b short axis supraspinatus tendon demonstrating complete tear arrowheads the frequency microcrystal disorders also increases age mainly true gout calcium pyrophosphate dihydrate deposition cpdd arthropathy gout common inflammatory arthritis elderly characterized disturbance purine metabolism deposits joints cartilage kidneys the first metatarsophalangeal joint common site involvement gouty arthritis figure 9 joint involved the typical radiographic features include eccentric nodular soft tissue masses particularly suggestive tophus dense close erosions also suggestive located distance joint associated elevated bony margin preservation joint space exuberant bony proliferation lack periarticular osteoporosis when clinical biological radiographic findings uncertain ultrasound may particularly helpful technique may demonstrate tophi figure 10 erosions plain films synovitis clinical examination suggestive hyperechoic aggregates synovium joint fluid may aspirated double contour sign irregular hyperechoic band superficial margin articular cartilage related crystal deposition).[4244 calcium pyrophosphate dihydrate deposition cpdd disease characterized articular periarticular tissue deposits hyaline cartilage fibrocartilage soft tissue structures even spine figure 11 unlike gout increase serum urates leads supersaturation deposits joints cpdd calcium deposits usually appear cartilage absence serum abnormality even though deposits may seen asymptomatic patients may associated development severe arthropathies acute pain related migration crystals synovial fluid mimicking septic arthritis gout first mtp joint conventional radiography excentric dense nodular soft tissue mass arrows large erosions arrowhead lack periarticular osteoporosis exuberant bony proliferation curved arrow gout involvement mtp shows tophus arrow hyperechogenic microcrystal deposits arrowheads thickened synovium curved arrows another patient tophus deposition dorsal midfoot b demonstrates microcrystal deposits arrowhead acoustic shadows thick arrows calcium pyrophosphate dihydrate deposition disease demonstrated deposits microcrystals menisci arrow articular cartilage arrowhead periarticular soft tissue curved arrow elderly patients prone infection increased incidence predisposing disorders diabetes mellitus peripheral vascular disease poor dentition immunosuppression surgical procedures population dental extractions open heart surgery prosthetic joint replacement the infectious agents affecting elderly patients similar found younger population although elderly evidence shows increased incidence infection nosocomial organisms due institutionalization hospitalization these infections relatively benign course case cellulitis serious consequences necrotizing fasciitis in patients 80 years age knee shoulder hip frequently affected joints another peculiarity elderly uncommon adults acute hematogenous osteomyelitis mainly affects spine attention moreover paid diagnosis tuberculosis early manifestations subtle advanced disease mimics infections granulomatous diseases malignancy tuberculosis may affect spine 50% cases potential neurological consequences joint causing deformity figure 12 it noted elderly men may present bone lesions manifestation reactivation disease pathognomonic imaging signs musculoskeletal tuberculosis the conclusive means reaching diagnosis biopsy culture chest radiographs skin tests may positive elderly regards imaging techniques magnetic resonance imaging modality choice musculoskeletal infection best delineates extension soft tissue infections computed tomography ultrasound radiography nuclear medicine studies considered ancillary circumstances ultrasound can useful allows aspiration fluid collected joints soft tissue evaluation structures adjacent orthopedic hardware assessment small peripheral joints besides case debilitated elderly patients mobile ultrasound device easily moved close beds ( conventional radiography mild osteoporosis extensive soft tissue swelling large marginal erosion arrowhead b doppler ultrasound synovitis arrows bone erosion arrowhead well depicted paget disease bone disorder characterized increase osteoclast mediated bone resorption accompanied osteoblast mediated formation new bone inferior quality the frequency condition decreasing still exists 1 5% persons 50 years age varying according geographic areas.[5356 radiographic signs include advancing wedge bone resorption accentuation coarsening bone trabeculae along lines stress cortical thickening enlargement bone figure 13 result secondary osteoarthritis insufficiency fractures bowing bones even spinal cord nerve root compression observed minority cases sarcomatous degeneration may develop mainly humerus pelvis proximal femur frequency believed range 0.9 2% paget disease affecting iliac bone demonstrated coarsening bone trabeculae cortical thickening arrows tumors tumors revealed bone pain pathological fractures disability discovered incidental finding primary bone tumors elderly patients common due risk metastases newly discovered bone lesion one developing within known pre existing lesion must assumed malignant proven otherwise metastases bone metastases common complication malignant disease especially breast prostate lung although often multiple solitary metastasis still common primary neoplasm plain films relatively insensitive detection bone metastases especially subtle lesions mr imaging superior ct detection malignant marrow infiltration better contrast resolution visualizing soft tissue spinal cord lesions even advances mri especially bone marrow screening bone scintigraphy continues used effective method initial evaluation whole body bone metastases sarcomas elderly population many sarcomas secondary pre existing disorder bone paget disease lesions treated radiation chondrosarcoma must also kept mind especially isolated osteolytic lesions pelvis seen common primary sarcoma bone adults the cartilaginous nature lesion may suggested presence calcifications lobulated hyperintense lesion mri figure 14 chondrosarcoma pelvis conventional radiography appears isolated osteolytic lesion arrows b coronal t2-weighted image demonstrates lobulated hyperintense lesion arrowheads myeloma myeloma characteristic disease elderly population peak incidence eighth decade results unregulated progressive proliferation neoplastic monoclonal plasma cells accumulate bone marrow leading anemia marrow failure osteolytic lesions may present plain films differentiating osteoporotic vertebral compression fractures associated myeloma common diagnostic dilemma bone loss may first sign revealing latter disease indeed widespread osteoporosis due cytokine mediated osteoclast activation common patients myeloma this possible association must kept mind particularly features present including unexplained back bone pain we used following terms combinations elderly aged epidemiology fracture osteoporosis vertebral hip pelvis arthritis neoplasm malignancy myeloma paget gout infection microcrystal radiology articles without english abstracts excluded besides certain relevant rheumatological orthopedic radiological books also used fractures frequent elderly result mainly effects falls osteoporosis low impact falls even standing height common cause injury geriatric patients falling multi factorial problem due extrinsic e.g. environmental housing conditions intrinsic risk factors e.g. impaired mobility loss muscular strength poor visual acuity medication instance corticoids).[46 osteoporosis characterized qualitatively normal quantitatively deficient bone leads bone fragility increased risk fractures the general prevalence osteoporosis women approximately 50% age 85 years men prevalence 20% age ethnic differences also exist mineral bone density higher black women lower asian women white women evidence shows intermediate value due precision widely used quantitative technique dual energy x ray absorptiometry makes possible diagnose osteoporosis early predict risk fracture determine therapeutic intervention monitor response treatment method grades bone loss according standard deviations sd mean young adult value a value less 2.5 times sd young adult mean considered indicate osteoporosis the main radiographic features osteoporosis increased radiolucency cortical thinning mainly spine giving rise well demarcated outline vertebral body described picture framing. besides spine increased biconcavity vertebral end plates protrusion intervertebral disk vertebral body observed however early radiographic changes subtle bone loss approximately 30% must occur detected vertebral compression fractures common osteoporotic fractures greater incidence women 60 years age they observed 25% women 70 years age 40% 80 years after one episode risk subsequent vertebral fracture increases least four fold substantially increased rates first year these fractures associated higher mortality significant morbidity even though afforded little clinical attention they often appear multiple fractures anterior wedging may associated significant deformity leading kyphosis they usually well demonstrated radiographs better assessed computed tomography ct magnetic resonance mr imaging necessary the latter imaging modality may indicated case associated neurological symptoms rare event vertebroplasty discussed order better localize recently fractured vertebra vertebral compression fractures elderly may involve several problems first differentiating osteoporotic malignant vertebral collapse vc particularly metastatic vc latter far common malignant tumor affecting skeleton elderly patients multiple relatively symmetrical thoracolumbar vcs associated diffuse increased radiolucency suggestive osteoporosis figure 1a the whole vertebral endplate impacted sometimes association increased decreased radiolucency subjacent trabecular bone band like distribution abnormalities fractured vertebral end plate gas also seen fracture nearly pathognomonic benign nature collapse there cortical osteolysis although fractures identified retropulsion bone fragment conversely following cause concern single vc involvement cervical spine heterogeneous increased decreased radiolucency explained underlying end plate fracture focal collapse ap lateral view bulging vertebral body cortical osteolysis figure 1b doubt better assessment spinal canal soft tissue ct better yet mri performed order differentiate two disorders benign fractures mri may show band distribution abnormal signal intensities t1 t2 weighted images spared normal bone marrow signal intensity retropulsion posterior bone fragment multiple compression fractures contrary signs convex posterior border vertebral body abnormal signal intensity posterior elements epidural mass focal paraspinal mass suggestive spinal metastasis.[1921 second vertebral fractures missed following moderate trauma fracture may difficult identify osteoporotic radiolucent bone pain attributed another painful condition degenerative changes this observed particular cervical spine particularly c2 may lead secondary neurological complications figure 2 ankylosis may related ankylosing spondylitis diffuse idiopathic skeletal hyperostosis especially affect males estimated frequency 5 15% elderly.[2225 ankylosed spines become increasingly susceptible injury even event low energy impacts prone unstable vertebral fractures increased frequency neurological complications either primary secondary unprotected transfers manipulation these lesions may missed plain films non displaced mildly displaced especially hyperextension whereas well demonstrated ct mr imaging however mri features sometimes misleading mimic infectious spondylitis signal abnormalities disco vertebral junction present caution required elderly patient presents ankylosed spine minor trauma acute pain especially signal abnormalities anterior posterior spine observed figure 3 usual benign vertebral compression multiple levels diffuse radiolucency whole vertebral endplate involvement arrows usual malignant vertebral compression characteristics b single vertebral involvement focal bulging posterior wall arrowheads missed fracture odontoid process vertebral body c2 arrows patient history fall one month transverse fracture thoracic vertebral body arrow posterior arch arrowhead posterior epidural hematoma curved arrow ankylosed spine depicted t1- b t2-weighted sequences other important sites fractures hip pelvis associated increased mortality specific diagnostic problems elderly population they common frequently result lateral falls directly greater trochanter case hip fractures forward backward falls case pelvic fractures most fractures easily diagnosed conventional radiography particularly fractures proximal femur however non displaced fractures may negative equivocal particularly bone osteoporotic if clinical suspicion fracture persists ct better still mr imaging advocated modality show fracture line surrounded bone marrow edema they may occur everywhere particularly common hip pelvis majority located sacrum pubic ramus figure 4 radiographic findings often subtle unremarkable suspected cases mr imaging indicated due superior accuracy compared radiological methods all images carefully analyzed multiple insufficiency fractures frequent figure 5 subchondral fractures particularly difficult identify radiographs thin hypointense line represents fracture surrounded variable degree edema well demonstrated mri figure 6 kind fracture complicated necrosis subchondral bone hypointense t2 weighted images enhanced following gadolinium administration insufficiency fractures arrows located sacrum adjacent edema arrowheads better depicted t1- b t2- weighted sequences respectively multiple fractures white arrows proximal femur b pubic ramus coronal t1-weighted images subchondral fracture femoral head conventional radiography b fat saturated sagittal t2-weighted image white arrow osteoarthritis oa defined group distinct overlapping diseases may different etiologies similar biological morphological clinical outcomes affecting articular cartilage subchondral bone ligaments joint capsule synovial membrane periarticular muscles pathological changes include fibrillation cartilage disruption collagen fibers changes proteoglycan staining chondrocyte proliferation necrosis neovascularization oa common joint disease persons 65 years age radiographic prevalence high approximately 90% women 80% men.[3335 etiology fully understood although several related factors female gender genetics metabolism excessive mechanical stress although joints hand commonly affected less likely symptomatic knee hip figure 7 diagnosis oa primarily based clinical history physical examination plain radiographs help confirm diagnosis grade severity condition the cardinal radiographic features oa focal non uniform narrowing joint space areas subjected pressure subchondral cysts subchondral sclerosis osteophytes however severity spondylolisthesis radiographic changes correlate clinical symptoms shoulder oa rotator cuff disease also fairly common elderly associated significant shoulder pain disability related decreased shoulder movement direct signs oa indirect signs large rotator cuff tears seen plain films including superior humeral head migration remodeling acromion greater tuberosity ultrasound another valuable tool easy assessment rotator cuff tendons due good sensitivity specificity figure 8 however surgical treatment considered arthro ct mri may preferred order improve planning the lumbar cervical spine also frequently affected degenerative changes disk spaces facet joints spinous processes sometimes progressive scoliosis although intervertebral disks synovial joints pathological changes similar seen articular cartilage ct mri routinely used evaluation narrowing central canal lateral recesses neural foramina assessment required percutaneous surgical treatment besides mri useful evaluating marrow changes vertebral plate especially inflammatory changes type modic present positive correlation low back pain typical osteoarthritis distal proximal interphalangeal joints b hip joint joint space narrowing arrows subchondral cysts arrowheads osteophytes curved arrows subchondral sclerosis thick arrow ultrasound images long b short axis supraspinatus tendon demonstrating complete tear arrowheads the frequency microcrystal disorders also increases age mainly true gout calcium pyrophosphate dihydrate deposition cpdd arthropathy gout common inflammatory arthritis elderly characterized disturbance purine metabolism deposits joints cartilage kidneys the first metatarsophalangeal joint common site involvement gouty arthritis figure 9 joint involved the typical radiographic features include eccentric nodular soft tissue masses particularly suggestive tophus dense close erosions also suggestive located distance joint associated elevated bony margin preservation joint space exuberant bony proliferation lack periarticular osteoporosis when clinical biological radiographic findings uncertain ultrasound may particularly helpful technique may demonstrate tophi figure 10 erosions plain films synovitis clinical examination suggestive hyperechoic aggregates synovium joint fluid may aspirated double contour sign irregular hyperechoic band superficial margin articular cartilage related crystal deposition).[4244 calcium pyrophosphate dihydrate deposition cpdd disease characterized articular periarticular tissue deposits hyaline cartilage fibrocartilage soft tissue structures even spine figure 11 unlike gout in increase serum urates leads supersaturation deposits joints cpdd calcium deposits usually appear cartilage absence serum abnormality even though deposits may seen asymptomatic patients may associated development severe arthropathies acute pain related migration crystals synovial fluid mimicking septic arthritis gout first mtp joint conventional radiography excentric dense nodular soft tissue mass arrows large erosions arrowhead lack periarticular osteoporosis exuberant bony proliferation curved arrow gout involvement mtp shows tophus arrow hyperechogenic microcrystal deposits arrowheads thickened synovium curved arrows another patient tophus deposition dorsal midfoot b demonstrates microcrystal deposits arrowhead acoustic shadows thick arrows calcium pyrophosphate dihydrate deposition disease demonstrated deposits microcrystals menisci arrow articular cartilage arrowhead periarticular soft tissue curved arrow elderly patients prone infection increased incidence predisposing disorders diabetes mellitus peripheral vascular disease poor dentition immunosuppression surgical procedures population dental extractions open heart surgery prosthetic joint replacement the infectious agents affecting elderly patients similar found younger population although elderly evidence shows increased incidence infection nosocomial organisms due institutionalization hospitalization these infections relatively benign course case cellulitis serious consequences necrotizing fasciitis patients 80 years age another peculiarity elderly uncommon adults acute hematogenous osteomyelitis mainly affects spine attention moreover paid diagnosis tuberculosis early manifestations subtle advanced disease mimics infections granulomatous diseases malignancy tuberculosis may affect spine 50% cases potential neurological consequences joint causing deformity figure 12 it noted elderly men may present bone lesions manifestation reactivation disease pathognomonic imaging signs musculoskeletal tuberculosis the conclusive means reaching diagnosis biopsy culture chest radiographs skin tests may positive elderly regards imaging techniques magnetic resonance imaging modality choice musculoskeletal infection best delineates extension soft tissue infections computed tomography ultrasound radiography nuclear medicine studies considered ancillary circumstances ultrasound can useful allows aspiration fluid collected joints soft tissue evaluation structures adjacent orthopedic hardware assessment small peripheral joints besides case debilitated elderly patients mobile ultrasound device easily moved close beds ( conventional radiography mild osteoporosis extensive soft tissue swelling large marginal erosion arrowhead b doppler ultrasound synovitis arrows bone erosion arrowhead well depicted paget disease bone disorder characterized increase osteoclast mediated bone resorption accompanied osteoblast mediated formation new bone inferior quality the frequency condition decreasing still exists 1 5% persons 50 years age varying according geographic areas.[5356 radiographic signs include advancing wedge bone resorption accentuation coarsening bone trabeculae along lines stress cortical thickening enlargement bone figure 13 result secondary osteoarthritis insufficiency fractures bowing bones even spinal cord nerve root compression observed minority cases sarcomatous degeneration may develop mainly humerus pelvis proximal femur frequency believed range 0.9 2% paget disease affecting iliac bone demonstrated coarsening bone trabeculae cortical thickening arrows tumors tumors revealed bone pain pathological fractures disability discovered incidental finding primary bone tumors elderly patients common due risk metastases newly discovered bone lesion one developing within known pre existing lesion must assumed malignant proven otherwise metastases bone metastases common complication malignant disease especially breast prostate lung although often multiple solitary metastasis still common primary neoplasm plain films relatively insensitive detection bone metastases especially subtle lesions mr imaging superior ct detection malignant marrow infiltration better contrast resolution visualizing soft tissue spinal cord lesions even advances mri especially bone marrow screening bone scintigraphy continues used effective method initial evaluation whole body bone metastases sarcomas elderly population many sarcomas secondary pre existing disorder bone paget disease lesions treated radiation chondrosarcoma must also kept mind especially isolated osteolytic lesions pelvis seen common primary sarcoma bone adults the cartilaginous nature lesion may suggested presence calcifications lobulated hyperintense lesion mri figure 14 chondrosarcoma pelvis conventional radiography appears isolated osteolytic lesion arrows b coronal t2-weighted image demonstrates lobulated hyperintense lesion arrowheads myeloma myeloma characteristic disease elderly population peak incidence eighth decade results unregulated progressive proliferation neoplastic monoclonal plasma cells accumulate bone marrow leading anemia marrow failure osteolytic lesions may present plain films differentiating osteoporotic vertebral compression fractures associated myeloma common diagnostic dilemma bone loss may first sign revealing latter disease indeed widespread osteoporosis due cytokine mediated osteoclast activation common patients myeloma this possible association must kept mind particularly features present including unexplained back bone pain special attention required population early diagnosis avoid delay treatment associated increased morbidity mortality besides better understanding musculoskeletal diseases lead implementation effective preventive measures thus reducing public health expenditure improving quality life elderly

musculoskeletal disorders are among the most common problems affecting the elderly . the resulting loss of mobility and physical independence can be particularly devastating in this population . the aim of this article is to present some of the most frequent musculoskeletal disorders of the elderly , such as fractures , osteoporosis , osteoarthritis , microcrystal disorders , infections , and tumors .

migraine leading neurological cause seeking medical care associated significant disability sufferer the greatest impact migraineurs headaches days condition defined chronic migraine cm cm defined least 15 days headache per month least eight days fulfill migraine criteria and/or treated specific migraine medications absence diagnosis medication overuse headache patients cm often history episodic migraine began adolescence early adulthood reporting process transformation marked headaches become frequent years among migraineurs defining risk factors cm progression episodic migraine cm identified risk factors include medication overuse obesity sleep problems psychiatric comorbidity 712 studies community tertiary settings demonstrated association migraine several psychiatric conditions 8 9 however the frequency psychiatric disorders setting compared single study furthermore differences methods studies based community tertiary centers prevent appropriate comparison population studies fail conduct face face assessments clinic based studies carry potential selection bias studies focusing best methods address gap interest one strategy compare data obtained community specialty care methods collection virtually identical scope study we compared demographic data psychiatric comorbidity sample individuals cm community another tertiary care clinic light fact patients suffering migraine comorbid psychiatric disorders greater health care service users hypothesized frequency psychiatric disorders notably depression higher patients followed tertiary care community data gathered capela nova city state minas gerais brazil according 2000 brazilian census population 2,066 inhabitants 1,631 age 10 years the present study part observational cross sectional population based study conducted two phases 14 15 initially community health workers family health program directly interviewed inhabitants aged 10 years older headache symptoms previous year the family health program works family health care teams composed one physician one nurse one auxiliary nurse four six community health workers assigned specific geographical areas defined populations 6001,000 families activities provided family health care teams take place primary care facilities patients homes community first phase study screening phase trained community health workers screened occurrence headaches using following question headache episode last 12 months those screened positive asked headache frequency past month reporting 15 days headache offered person assessment neurologists expertise headache medicine three neurologists independently examined participants headaches diagnosed according second edition international classification headache disorders subsequently individuals aged 18 years older cm assessed psychiatric comorbidities psychiatric assessment performed experienced psychiatrist using mini international neuropsychiatric interview mini the investigators involved community based assessment used procedures diagnose consecutive patients attended university based headache center first half 2006 this center located belo horizonte headache clinic state minas gerais brazil the study followed guidance regulatory norms brazilian national health council resolution 196/1996 accordance helsinki declaration the protocol forms reviewed approved local ethics research committee data transferred epi info 2000 study coordinator analyzed using spss 12.0 the relative frequencies psychiatric comorbidities stratified headache type confidence intervals calculated discrete data compared groups using chi square test fisher test anticipated values small continuous non parametric variables mann community data gathered capela nova city state minas gerais brazil according 2000 brazilian census population 2,066 inhabitants 1,631 age 10 years the present study part observational cross sectional population based study conducted two phases 14 15 initially community health workers family health program directly interviewed inhabitants aged 10 years older headache symptoms previous year the family health program works family health care teams composed one physician one nurse one auxiliary nurse four six community health workers assigned specific geographical areas defined populations 6001,000 families activities provided family health care teams take place primary care facilities patients homes community first phase study screening phase trained community health workers screened occurrence headaches using following question headache episode last 12 months those screened positive asked headache frequency past month reporting 15 days headache offered person assessment neurologists expertise headache medicine three neurologists independently examined participants headaches diagnosed according second edition international classification headache disorders subsequently individuals aged 18 years older cm assessed psychiatric comorbidities psychiatric assessment performed experienced psychiatrist using mini international neuropsychiatric interview mini the investigators involved community based assessment used procedures diagnose consecutive patients attended university based headache center first half 2006 this center located belo horizonte headache clinic state minas gerais brazil the study followed guidance regulatory norms brazilian national health council resolution 196/1996 accordance helsinki declaration the protocol forms reviewed approved local ethics research committee data transferred epi info 2000 study coordinator analyzed using spss 12.0 the relative frequencies psychiatric comorbidities stratified headache type confidence intervals calculated discrete data compared groups using chi square test fisher test anticipated values small continuous non parametric variables mann in community 1,605 interviewed inhabitants 57 3.6 headaches least 15 days least three consecutive months 43 75.4 cm 41 consented assessed psychiatrist 95.3 participation rate headache center 43 patients cm n 453 9.5 consented participating psychiatric assessment sociodemographic profiles similar groups exception mean number years formal education lower community relative headache center table 1).table 1demographic characteristics individuals chronic migraine community clinic based samplecommunity n 41)headache center n 43)p valuegender men7 17.1 2 4.7 0.09 women34 82.9 41 95.3 education years study 826 78.8 5 11.6 0.001 9115 15.2 15 34.9 122 6.1 23 53.5 age mean sd)41.2 17.2)35.7 12.6)0.19 range13731863 chi square fisher mann whitney demographic characteristics individuals chronic migraine community clinic based sample chi square fisher mann whitney among individuals community 65.9 cases diagnosed current psychiatric disorder relative 83.7 headache center p 0.06 the relative frequencies specific diagnoses remarkably high groups despite statistically different headache center prevalent disorders simple phobia 41.9 generalized anxiety disorder 34.9 major depression 32.6 community the disorders also common ones generalized anxiety disorder 39.0 phobias 29.3 major depression 29.3 bipolar disorder seen community diagnosed two cases headache center the frequency antidepressants use similar headache center 51.2 community 44.4 p 0.51 table 2 summarizes data.table 2current psychiatric comorbidities individuals chronic migraine community clinic based sampleheadache center n 43)community n 41)p valueany diagnosis36 83.7 27 65.9 0.06*one two psychiatric diagnoses21 48.8 16 39.0 0.36three psychiatric diagnoses15 34.9 11 26.9 0.42major depression14 32.6 12 29.3 0.74*dysthymia9 20.9 9 22.0 0.99**bipolar disorder2 ( 4.7 0 0 0.23**generalized anxiety disorder15 34.9 16 39.0 0.69*specific phobia18 41.9 12 29.3 0.23*obsessive compulsive disorder9 20.9 10 24.4 0.70*somatization7 16.3 3 7.3 0.31**eating disorders2 4.7 1 2.5 0.99*alcohol abuse0 0.0 2 4.9 0.23 chi square fisher current psychiatric comorbidities individuals chronic migraine community clinic based sample chi square fisher to best knowledge first study compare frequency psychiatric comorbidity cm community tertiary care clinic samples the frequency psychiatric disorders cm elevated settings tending higher tertiary care sample while psychiatric comorbidity episodic migraine well established literature psychiatric disorders less studied cm only studies addressed psychiatric comorbidities cm population based samples finding increased levels depression anxiety disorders even comparison episodic migraine patients 11 20 one limitation studies use self report questionnaires rather clinical interview ascertaining psychiatric diagnosis present study we found third patients setting depression a similar rate described american migraine prevalence prevention ampp study population based survey based mailed questionnaires study depression assessed self report physician diagnosis patient health questionnaire phq-9)depression module one interesting result ampp study cm patients twice likely depression assessed phq-9 comparison episodic migraine patients 30.2 17.2 respectively 95 ci 2.0 1.67 2.40 p 0.001 cm patients also approximately twice likely report anxiety 30.2 vs. 18.8 respectively 95 ci 1.8 1.51 2.15 p 0.001 the international burden migraine study ibms also found higher levels anxiety depression cm compared episodic migraine regarding anxiety syndromes generalized anxiety disorder phobias seem comorbid migraine spectrum 2024 interestingly frequency obsessive compulsive disorder significantly high 20 25 cm patients comparison prevalence general population 2 only previous studies pointed association obsessive compulsive disorder migraine may associated underlying serotonin system dysfunction bipolar disorder also comorbid migraine migraineurs without aura 2.4 times likely bipolar disorder type 1 ratio increases 7.3 diagnosis migraine aura 13 22 bipolar disorder type 2 we failed detect association likely small size samples drug abuse traditionally associated migraine 22 24 recent study reported illicit drug abuse may frequent migraine patients depression post traumatic stress disorder demographic profiles similar groups vast majority individuals cm women it must highlighted assessed community small city patients headache center mainly came large urban center nonetheless studies migraine enrolled subjects different demographic features also found striking similarities regarding risk psychiatric comorbidities pointing shared biological factors plausible mechanism comorbidity 22 24 specific genotypes coding d2 dopaminergic receptors dysfunction tyramine conjugation changes metabolism serotonin catecholamines estrogen levels considered explain comorbidities 2730 it worth mentioning however comprehensively systematically assessed almost patients cm entire population small city we assess differential disability associated headache psychiatric disorders individuals finally findings adjusted confounding factors parameters headache severity intensity duration associated symptoms obesity sleep disorders use psychotropic medication household income we partly justify latter limitations arguing demands patients resources conducting missing assessments could jeopardize community assessment since interviews conducted participant households conclusion present study suggests psychiatric comorbidity cm elevated community clinical settings tending common cm patients headache center

although the association between episodic migraine and psychiatric comorbidities is well documented , few studies have focused on the comorbidity with chronic migraine ( cm ) and discrepancies exist between population - based and clinic - based data . the objective of this study is to compare demographic and psychiatric comorbidity correlates between cm samples drawn from the community and tertiary care . all inhabitants from a city borough were interviewed for the presence of headaches occurring 15 or more days per month . cm was diagnosed after subjects had been interviewed and examined by a headache doctor . participants were also assessed with a structured interview by a psychiatrist , who assigned diagnoses based on the dsm - iv . the same investigators assessed all patients consecutively seen in a university - based outpatient headache center over a 4-month period . the samples consist of 41 individuals from the community and 43 from the headache center . sociodemographic profiles were similar between groups with the exception of the mean number of years of formal education . among individuals from the community , psychiatric diagnoses were present in 65.9 % of cases , relative to 83.7 % in those from the headache center ( p = 0.06 ) . phobias ( 41.9 vs. 29.3 % ) and depression ( 32.6 vs. 29.3 % ) were more frequent in patients from the headache center , but this difference did not reach statistical significance . thus the frequency of psychiatric disorders in patients with cm was elevated in both settings , being higher in the specialty care clinic .

m1dg 3-(2-deoxy--d erythro pentofuranosyl)-pyrimido[1,2-]purine-10(3h)-one one many endogenous exocyclic lesions derived reaction dna bifunctional electrophiles generated lipid protein dna peroxidation being endogenous constituent human rodent genomes m1dg mutagenic bacterial mammalian cells leads mispairing replicated vitro multiple different dna polymerases we previously developed monoclonal antibody m1dg incorporated antibody analytical schemes using immunoaffinity purification m1dg followed mass spectrometric detection these studies indicated adult humans excrete m1dg rate 12 fmol kgd urine subsequent investigations metabolism elimination m1dg revealed administration m1dg rodents doses 8 mg kg 6 pg kg leads rapid disappearance plasma due oxidation formation single stable metabolite 6-oxo m1dg 3-(2-deoxy--d erythro pentofuranosyl)-pyrimido[1,2-]purine-6,10(3h,5h)-dione humans rats xanthine oxidase appears responsible oxidation aldehyde oxidase also plays role m1dg metabolism humans because 6-oxo m1dg sole metabolite m1dg rats appears ideal surrogate m1dg vivo biomarker oxidative stress all studies m1dg metabolism vivo conducted exogenously administered deoxynucleoside thus known 6-oxo m1dg actually present unadulterated intact animals order address question developed highly specific monoclonal antibody mab 6-oxo m1dg covalently linked antibody sepharose beads the resultant antibody sepharose matrix gel used immunoaffinity purification 6-oxo m1dg urine feces followed lc ms ms quantification stable isotope labeled internal standard n5]-6-oxo m1dg utilizing method report first time 6-oxo m1dg endogenously produced rodents excreted urine feces na2co3 nahco3 nacl water acetonitrile mariculture keyhole limpet hemocyanin mcklh hcl acetic acid methanol obtained thermo fisher scientific waltham usa abts diammonium salt thimerosal kh2po4 na2hpo4 kcl 30% h2o2 tween 20 bovine serum albumin bsa dimethylformamide dmf dimethylsulfoxide dmso k2co3 sodium periodate sodium methoxide nabh4 hypoxanthine xanthosine xanthine ethyl cis-3-iodoacrylate ethyl cis-3-bromoacrylate aminopterin ethanolamine cyanogen bromide activated sepharose beads diethylene glycol 2-deoxyguanosine sodium hydroxide formic acid sodium azide glycine citric acid obtained sigma aldrich st louis mo usa horseradish peroxidase conjugated goat antimouse igg h l 0.8 mg ml igg fc purchased jackson immunoresearch west grove pa usa phosphate buffered saline pbs purchased invitrogen carlsbad ca usa the synthesis 6-oxo m1guo based previously described synthetic scheme modifications guanosine dissolved minimum amount dmf dmso mixture 1:1 v v k2co3 1.5 equiv added solution reaction mixture held 6065 c 18 h. ethyl cis-3-iodoacrylate 0.25 equiv per h 5 h added reaction mixture the residue dissolved minimum amount methanol sodium methoxide 1.5 equiv added dropwise 0.5 solution 6-oxo m1guo purified biotage sp1 flash chromatography system biotage uppsala sweden using following gradient 1% 5% acetonitrile 30 column volumes followed 5% 15% gradient 10 column volumes separation achieved 12 c18 column purified compound showed single sharp peak reverse phase hplc h nmr 600 mhz dmso d6 8.65 1h h8 j 7.8 hz 8.29 1h h2 6.24 1h h7 j 8.4 hz 5.82 1h h1 5.48 1h h2oh 5.20 1h h3oh 5.03 1h h5oh 4.49 1h h2 4.15 1h h3 3.91 1h h4 3.633.55 2h h5 h nmr may seen figure supporting information 6-oxo m1dg stable isotope labeled analogue n5]-6-oxo m1dg synthesized previously described briefly anhydrous dg 1.6 g 6 mmol anhydrous k2co3 0.93 g 6.75 mmol dissolved anhydrous dmf 18 ml one milliliter 0.55 solution ethyl cis-3-bromoacrylate anhydrous dmf added reaction every 15 min 4 h. reaction stirred additional 2 h cooled filtered the filtrate evaporated high vacuum residue dissolved water 4 ml 5% acetic acid 4 ml the product purified reversed phase c18 medium pressure liquid chromatography biotage sp1 apparatus biotage using prepacked 25 75 mm biotage flash 25 cartridge kp c18-hs flash 25 c18 samplet sample loading a pure final product 6-oxo m1dg 0.92 g 50.6% obtained n5]-6-oxo m1dg synthesized substituting n5]-dg dg cambridge isotope laboratories andover usa employing scheme described the h nmr 6-oxo m1dg stably labeled analogue matched spectrum previously reported compound mass spectrometric analysis 6-oxo m1dg showed h peak z 320 analysis n5]-6-oxo m1dg showed h peak z 325 the z 325 corresponds 6-oxo m1dg value plus 5 additional mass units 5 n atoms incorporated n5]-dg starting material a z 320 peak observed n5]-6-oxo m1dg indicating unlabeled 6-oxo m1dg present internal standard 6-oxo m1guo 12 mg dissolved 750 l 100 mm aqueous sodium periodate protein 20 mg bsa mcklh reconstituted 700 l pbs preadjusted ph 9.5 5% k2co3 6-oxo m1guo solution protein after 1 h 45 l 1 diethylene glycol solution added mixture quench excess oxidizing agent followed 700 l 0.45 nabh4 aqueous after another 12 h ph mixture adjusted 7.0 1.0 formic acid the mixture kept ph 1 h. ph increased 8.5 careful addition 1 aqueous ammonium hydroxide solution this mixture dialyzed pbs buffer twice 24 h. sample lyophilized stored 4 c scheme 1 shows conjugation reaction 6-oxo m1guo lysine residue carrier protein figure b supporting information depicts scheme preparation conjugated protein four balb cj mice four j mice jackson laboratory bar harbor usa injected subcutaneously 50 g 6-oxo m1guo klh freund complete adjuvant primary boost four wk initial immunization mice boosted subcutaneously first boost dose conjugate substitution incomplete adjuvant also used subsequent boosts two wk first boost mice tail bled antibody titers assessed direct competitive elisa described a second boost administered 4 wk subsequent first 2 wk sera extracted subjected elisa evaluation a third boost administered 25 wk boost two sera collected screened approximately 2 wk later basis cumulative elisa data single balb cj mouse balb cj r showing selective concentrated anti-6-oxo m1dg titer chosen fourth final boost given intraperitoneally lacking adjuvant prepare splenocyte extraction four days final boost mouse sacrificed cervical dislocation spleen harvested splenocytes isolated subjected polyethylene glycol mediated fusion sp/20 ns1 murine myeloma cells obtained university virginia university nebraska medical univeristy school dentistry respectively allowed recover 24 h liquid culture the products fusion evenly distributed 24 96-well plates 12 plates corresponding fusions sp/20 cells splenocytes 12 plates corresponding fusions ns1 cells splenocytes cells grown iscove modified dulbecco medium 20% fetal bovine serum invitrogen hybridomas selected growing presence aminopterin 5 10 sigma ht supplement 1:100 dilution invitrogen 14 days media aminopterin replenishment every 3 days supernatant removed screened antigen specific antibodies elisa 6-oxo m1dguo bsa conjugate used antigen described positive hybridoma supernatants rescreened presence xanthine 6-oxo m1dg xanthine employed competitor identify antibodies specific 6-oxo m1dg clones exhibiting anti-6-oxo m1dg activity specificity addition positive growth productivity selected plated 24-well plates these five clones chosen based activity specificity growth productivity determined direct competitive elisa analysis described subsequently subjected two rounds subcloning the clones subsequently cryopreserved vanderbilt institutional care use committee protocol m-07 109 the vanderbilt antibody protein resource core permitted use freund complete adjuvant manner described the following solutions prepared follows use described carbonate bicarbonate coating buffer ph 9.6 prepared na2co3 1.59 g l thimerosal 0.10 g l b pbs tween ph 7.4 prepared nacl 8.00 g l tween 20 1.00 ml l thimerosal 0.10 g / l c bsa 5.0 g mixed pbs tween 500 ml 1 nm abts solution 70 mm citrate phosphate buffer ph 4.2 prepared citric acid 5.64 elisa quality microtiter plates thermo fisher scientific 96-well immulon 2hb flat bottom microtiter plates 384-well 4hb flat bottom plates coated 50 75 100 l 10 g ml solution 6-oxo m1guo bsa antigen carbonate bicarbonate coating buffer incubated 4 c overnight plates washed three times 100 l pbs tween b using bio tek elx405 automatic microplate washer winooski vt usa incubated 100 l pbs tween b 30 min 37 c aliquots murine serum dilutions hybridoma supernatants purified antibody depending stage antibody development process incubated coated wells without addition varying concentrations 6-oxo m1dg structural analogues figure 1 final volume 100 l pbs 60 min 37 c wells included 6-oxo m1dg structural analogues serum dilution used 1:5000 pbs tween b compounds depicted figure 1 preincubated dilute murine serum 45 min prior serum addition step this allowed nonspecific antibodies bind structural analogues theoretically leaving behind 6-oxo m1dg specific antibodies initial analysis revealed xanthine recognized nearly well 6-oxo m1dg led use structural analogue competition studies 6-oxo m1dg m1dg structural analogues used competitive antigens elisa analysis murine sera hybridomal supernatant purified antibodies the plates washed three times pbs tween b aliquots diluted horseradish peroxidase conjugated goat antimouse igg fc region specific igg h l secondary antibody diluted 1:5000 pbs tween bsa added plates incubated 37 c 60 min 60 min plates washed three times 100 l freshly prepared abts solution 1.8 l h2o2 per 1 ml abts immediately added well determine peroxidase activity the absorbance 414 nm measured 15 30 min well using bio tek powerwave ht 340 plate reader gen5 software selected clones scaled inoculated one liter bioreactors wilson wolf manufacturing new brighton mn usa grown 34 wk purification mab bioreactor supernatants achieved affinity chromatography protein g sepharose ge healthcare piscataway nj usa followed final desalting step pbs purified mab isotyped subsequently quantified sds page electrophoresis followed infrared coomassie staining purified anti-6-oxo m1dg mab loaded onto pd-10 columns ge healthcare equilibrated 25 ml coupling buffer 0.1 nahco3 0.5 nacl ph 8.0 water cyanogen bromide activated sepharose beads 3.75 g prepared conjugation rapid swelling 1 mm hcl followed filtering rinsing 400 ml 1 mm hcl 10 ml coupling buffer the sepharose beads transferred antibody solution gently rotated 4 c 20 h. mixture filtered washed 500 ml coupling buffer residue divided four parts each quarter placed 14 ml ethanolamine solution 1.0 ph 8.0 gently rotated overnight 4 c the sepharose beads filtered washed low ph acetate buffer 0.1 acetic acid 0.1 naoh 0.5 nacl followed 0.1 tris hcl buffer 0.5 nacl ph 8.0 each wash used 75 ml buffer wash cycle repeated two times the resulting residue suspended 20 ml 0.1 tris buffer 0.5 nacl 0.2% nan3 ph 8.0 final product gel stored 4 c the gel used recover 6-oxo m1dg n5]- 6-oxo m1dg various fluids following general procedure an aliquot gel prepared use rinsing following solutions 50 ml 0.1 glycine ph 2.7 20 ml h20 50 ml methanol 50 ml pbs this cleaning procedure necessary remove 6-oxo m1dg bound mab preparation the ph fluid analyzed adjusted 7.08.0 acetic acid ammonium hydroxide an aliquot washed reconditioned gel added sample suspension mixed gently 14 h. sample gel suspension filtered precleaned empty polypropylene spe cartridge fitted polypropylene frit sigma aldrich the filtered gel washed 10 ml pbs analytes eluted 2 ml methanol the eluant dried n2 gas capped stored 20 c the sample reconstituted 9:1 water methanol v v immediately prior lc ms ms analysis urine feces collected 24 h intervals stored 20 c following collection urine samples analyzed thawing adding 200500 fmol n5]-6-oxo m1dg centrifuging samples 4000 g 25 min 4 c an aliquot supernatant diluted 1015-fold pbs ph final solution adjusted 7.5 0.5 either acetic acid sodium hydroxide the gel prepared described introduced ph adjustment suspension rotated gently end end 14 h. suspension filtered analyte eluted gel described the weighed sample transferred clean vessel 40 ml pbs 200500 fmol n5]-6-oxo m1dg added dispersion sample accomplished rotating end end 23 h followed sonication 35 min the suspension filtered mesh screen collected solid material rinsed 10 ml pbs the supernatant transferred clean vessel diluted roughly 5 times pbs antibody gel prepared described added the suspension rotated gently end end 14 h filtered analyte eluted gel described final lc ms ms analysis gel purified samples accomplished thermo surveyor autosampler ms pump line thermo quantum triple quadrupole mass spectrometer thermo fisher scientific the mass spectrometer equipped electrospray source operated positive ion mode 6-oxo m1dg internal standard n5]-6-oxo m1dg detected via selected reaction monitoring srm following transitions respectively z 320 204 325 209 cases transition corresponds cleavage glycosidic bond loss deoxyribose moiety positive charge remaining base the analytes chromatographed following reverse phase gradient system 2% b 15% b 5 min 15% b 80% b 1.5 min followed 1 min hold 80% b. component water component b methanol acetonitrile 3:1 component contained 0.1% acetic acid v v the column used phenomenex c18 phenomenex torrence ca usa 10.0 0.2 cm 3 held 3540 c the column equilibrated initial conditions 3 min prior injection 6-oxo m1dg quantitated stable isotope dilution n5]-6-oxo m1dg lc ms ms data acquired processed xcalibur software thermo fisher scientific the overall scheme antibody generation isolation process depicted figure 2 eight mice four balb cj four j injected 6-oxo m1 g conjugated klh described materials methods section 6 10 35 wk initial innoculation mice tail bled direct competitive elisa analyses sera performed figure 2 step 1 all three bleeds 8 mice showed robust responses 6-oxo m1g bsa antigen indicating immune systems mice producing significant amounts antibodies 6-oxo m1 g portion innoculant competitive elisa screenings executed assess antibody specificity 6-oxo m1dg series structural analogues figure 1 serving competing antigens eight mice inoculated adduct protein conjugate followed tail bleeding testing presence 6-oxo m1dg antibodies using direct elisa analysis step 1 splenocytes single mouse balb cj r fused myeloma cells plated twenty four 96-well plates screened using direct competitive elisa analyses step 2 screen five parental cell lines chosen subcloning screening step 4 on basis final screenings cell line 6c9ba4c12 chosen scale antibody purification step 5 figure 3 depicts competitive elisa analysis 35-week serum mouse balb cj r. analysis employed 6-oxo m1dg competing antigen robust concentration dependent decrease optical density observed indicating presence anti-6-oxo m1dg antibodies sera mouse the results similar analyses sera 8 inoculated mice seen supporting information figure c. supporting information figure displays results competitive elisa analyses 35-week serum 8 inoculated mice m1dg employed competing antigen increasing amounts m1dg result decrease optical density indicating m1dg bind anti-6-oxo m1dg antibodie(s present sera 6-oxo m1dg antibodies present serum mouse balb cj r. serum mouse balb cj r subjected competitive elisa analysis 6-oxo m1dg used competitor the displayed results represent average spectroscopic readings 15 30 min postaddition abts substrate basis elisa analysis murine sera a single mouse balb cj r chosen hybridoma production splenocytes balb cj r fused sp/20 ns1 myeloma cells figure 2 step 2 1670 hybridomas formed 2304 fusions wells elisa analysis revealed 1670 hybridomas 180 showed production anti-6-oxo m1dg antibodies these grown 24-well plates figure 2 step 3 supernatants subjected elisa screenings on basis screening data five hybridomas selected subcloning screenings figure 2 step 4 figure 4 shows representative elisa analysis supernatants two subclones b e2 parental hybridoma cell line 6c9 xanthine 6-oxo m1dg employed competing antigens the presence unbound 6-oxo m1dg decreases optical density b e2 supernatants indicating presence anti-6-oxo m1dg antibodies subclone e2 xanthine similar effect demonstrating e2 mab specific 6-oxo m1dg however xanthine effect optical density subclone b supernatant suggesting mab subclone b specific 6-oxo m1dg on basis data subclone b subjected subcloning e2 supporting information figure e illustrates cell line 6c9ba4 subclone hybridoma 6c9b retained activity 6-oxo m1dg react xanthine the specificity antibodies produced two hybridoma cell lines b e2 subcloned parental hybridoma cell line 6c9 assessed using competitive elisa analysis the displayed results represent average spectroscopic readings subclones e2 b 15 30 min postaddition abts substrate basis review cumulative elisa data a final daughter cell line selected parental hybridoma line daughter cell lines cryopreserved the elisa data indicated antibodies cell line 6c9ba4c12 displayed promising expression specificity thus cell line subjected large scale expression antibody purification figure 5 shows elisa responses mab purified 6c9ba4c12 presence 6-oxo m1dg structural analogues only 6-oxo m1dg attenuated optical density indicating specificity purified mab 6-oxo m1dg close structural analogues purified antibodies hybridomal subclone 6c9ba4c12 screened specificity 6-oxo m1dg presence structural analogues using competitive elisa analyses purified anti-6-oxo m1dg mab covalently linked sepharose beads described the purification analysis protocol outlined materials methods used quantify aliquots 10 mm potassium phosphate ph 8.0 spiked varying amounts 6-oxo m1dg 0.25 2.5 25 pmol 1.0 pmol internal standard n5]-6-oxo m1dg n 3 concentration 6-oxo m1dg as shown table 1 experimentally determined amount 6-oxo m1dg within 12% known amount level the average percent recovery 6-oxo m1dg ranged 94% 74% internal standard recovered average rate 79% thus gel able bind 6-oxo m1dg aqueous solution released analyte presence methanol the amount detected accuracy recovery values shown mean s.d the limit detection lod described lc ms ms system established approximately 10 fmol 6-oxo m1dg column supporting information figure f top analyzing series increasingly dilute 6-oxo m1dg solutions given lod percent recovery observed urine fecal samples approximately 30% limit quantification assay estimated 50 fmol per sample additionally lc ms ms system provided linear response 6-oxo m1dg solutions 5000-fold concentration range single n5]-6-oxo m1dg concentration supporting information f bottom these results indicate gel provided sufficient level recovery analyte internal standard well sufficient capacity expected levels 6-oxo m1dg present rat urine feces they also demonstrate lc ms ms analysis purified sample provided sensitive accurate quantification urine feces collected male sprague dawley rats 3 days analyzed described materials methods section 6-oxo m1dg detected urine one subject animal 3 rate 188 fmol kgd however 6-oxo m1dg eliminated feces animals rate 3501893 fmol kgd thus appears fecal elimination main route 6-oxo m1dg excreted body values given mean amount observed fmol kgd s.d ( n 35 feces 2 urine amounts 6-oxo m1dg low assay provided sufficient signal noise ratio permit accurate quantification the upper trace z 320 204 shows analyte bottom trace z 325 209 represents n5]-6-oxo m1dg internal standard the inset figure 6 internal standard alone recovery pbs there peak 6-oxo m1dg trace inset illustrative fact isotopic impurity internal standard could contribute 6-oxo m1dg signal a representative lc ms ms chromatogram 6-oxo m1dg internal standard n5]-6-oxo m1dg isolated rat feces displayed m1dg endogenous dna adduct detectable genomic dna humans rodents its presence associated peroxidative damage cellular constituents particularly polyunsaturated fatty acids dna although many studies shown lipid peroxidation product malondialdehyde react vitro deoxyguanosine form m1dg recent studies e. coli defined polyunsaturated fatty acid content membrane phospholipids indicate major source m1dg rather dna peroxidation products base propenals appear account nearly m1dg generated bacteria exposed peroxynitrite onoo thus although m1dg appears reliable marker oxidative damage cells primarily reflects oxidative damage dna m1dg repaired nucleotide excision repair excreted urine rather low levels humans 12 3.8 fmol kgd a major contributor low levels m1dg oxidative metabolism 6-oxo m1dg this suggests 6-oxo m1dg may superior m1dg noninvasive marker oxidative damage present manuscript describe generation monoclonal antibody exhibits sensitive specific binding 6-oxo m1dg use quantitative assay suitable analysis urine feces assay sepharose bound mab used isolate 6-oxo m1dg urine feces the purified sample subjected lc ms ms analysis 6-oxo m1dg quantified via stable isotope dilution synthetic internal standard n5]-6-oxo m1dg introduced sample prior antibody purification the antibody gel shows excellent recovery 6-oxo m1dg buffer solutions the analyte recovered 74% greater 10 mm potassium phosphate 100-fold range 6-oxo m1dg 0.25 pmol 25.0 pmol the internal standard recovered 79% 1.0 pmol solutions spiked buffer solutions quantified accurately 12% these data demonstrate 100 l antibody gel able bind least 26 pmol 6-oxo m1dg solution lc ms ms detection purified sample quantitative the recovery n5]-6-oxo m1dg saline solutions greater 78% recovery urine feces 29% this suggests matrix effect nucleosides deoxynucleosides and/or endogenous congeners compete 6-oxo m1dg antibody binding sites although minimal cross reactivity antibody individual members panel exocyclic adducts purine oxidation products figures 1 5 possible high levels low avidity nucleosides urine feces compete low levels endogenous 6-oxo m1dg binding sites mab 6-oxo m1dg detected feces three different sprague dawley rats detected urine one rats table 2 the fecal levels 6-oxo m1dg 3501893 fmol kgday significantly higher urinary levels 188 fmol kgday this consistent previous findings demonstrate m1dg excreted mainly urine whereas 6-oxo m1dg excreted mainly feces 6-oxo m1dg present endogenously rats suggests metabolic precursor m1dg also produced endogenously rats metabolized 6-oxo m1dg this idea consistent finding m1dg present rodent human genomic dna studies laboratory demonstrating 6-oxo m1dg sole metabolite m1dg it may argued endogenous 6-oxo m1dg generated nucleoside pool rather arising direct damage dna however seems unlikely one considers base propenals principal precursors m1dg base propenal formation triggered abstraction hydrogen c-4 position deoxyribosyl unit double stranded dna the base propenal produced reacts deoxyguanosine residue duplex dna form m1dg comparison the yields base propenals much lower deoxynucleosides oxidized instead duplex dna furthermore m1dg formation reaction base propenals free deoxyguanosine bimolecular process if base propenals formed duplex dna generated close proximity deoxyguanosine residues dna duplex maximize probability reaction deoxyguanosine residue one compounds may ingested excreted metabolized it possible control possibility reported experimental regime future studies animals fed nucleic acid free diets required test hypothesis the ability measure excreted 6-oxo m1dg potential clinical relevance assessing levels oxidative dna damage humans since basal levels deoxynucleoside adducts low provide high sensitivity increases triggered oxidative damage given analytical method described herein applicable feces urine possibility exists preclinical clinical studies conducted noninvasive fashion

oxidative stress triggers dna and lipid peroxidation , leading to the formation of electrophiles that react with dna to form adducts . a product of this pathway , ( 3-(2-deoxy--d - erythro - pentofuranosyl)-pyrimido[1,2-]purine-10(3h)-one ) , or m1dg , is mutagenic in bacterial and mammalian cells and is repaired by the nucleotide excision repair pathway . in vivo , m1dg is oxidized to a primary metabolite , ( 3-(2-deoxy--d - erythro - pentofuranosyl)-pyrimido[1,2-]purine-6,10(3h,5h)-dione , or 6-oxo - m1dg , which is excreted in urine , bile , and feces . we have developed a specific monoclonal antibody against 6-oxo - m1dg and have incorporated this antibody into a procedure for the immunoaffinity isolation of 6-oxo - m1dg from biological matrices . the purified analyte is quantified by lc - ms / ms using a stable isotope - labeled analogue ( [ 15n5]-6-oxo - m1dg ) as an internal standard . healthy male sprague dawley rats excreted 6-oxo - m1dg at a rate of 3501893 fmol / kgd in feces . this is the first report of the presence of the major metabolite of m1dg in rodents without exogenous introduction of m1dg .

60-year old woman height 162 cm weight 61 kg visited pain clinic tactile allodynia electric shock like pain left dorsal scapular area around t3 dermatome diagnosed phn 1 month previously attack herpes zoster 1 year ago the 100-mm visual analogue scale vas allodynia electric shock like pain rated 70 80 mm scale 0 pain 100 worst pain imaginable the interlaminar epidural block performed t3 4 space paramedian approach 5 ml 0.2% ropivacaine 20 mg triamcinolone acetate pregabalin morphine doses 150 mg 10 mg respectively twice day amitriptyline dose 10 mg sleep topical lidocaine patches prescribed dosages drugs adjusted depending side effects follow period epidural blocks repeated twice 1-week interval continuous intravenous infusion ketamine 60 mg performed period 1 hour twice week careful monitoring after 1 month elapsed electric shock like pain reduced vas score 30/100 allodynia diminished vas score 70/100 after 4 months elapsed decided administer magnesium sulfate via intravenous route and it done continuous intravenous infusion 1,000 mg magnesium sulfate 50 ml normal saline 1 hour infusion serum magnesium levels checked magnesium therapy felt good pain vas allodynia reduced 40 50 1-week follow satisfied treatment reported reduction allodynia dorsal scapular area 50% vas 25 30/100 however serum magnesium level increased normal range 2.3 meq l 2.9 although serum level reveals adverse effect decided stop intravenous infusion magnesium sulfate accurate safe delivery magnesium target site applied magnesium using transforaminal epidural injection technique patient informed consent left t3 tfemi identification t3 nerve root sheath epidural space performed using contrast media fig 1 100 mg magnesium sulphate 1 ml 0.2% ropivacaine total volume 2 ml carefully injected tfemi repeated twice 1-week interval total three times degree pain decreased gradually follow period one week last procedure vas score allodynia decreased 15/100 medications except pregabalin discontinued the vas 10/100 throughout 1-month follow pregabalin also tapered to knowledge previous report described magnesium administration transforaminal epidural route patients neuropathic pain here report phn patient treatment resulted effective pain relief previous studies demonstrated anti allodynic effects nmda receptor antagonists neuropathic pain disorders among currently available nmda receptor antagonists ketamine widely used one treatment neuropathic pain however ketamine always effective psychomimetic side effects frequent magnesium antagonize nmda receptor channels blocking calcium influx voltage gated manner intravenous administration magnesium efficacious management various conditions associated neuropathic pain including phn demirkaya colleagues revealed 1 g i.v mg sulfate effective treatment migraine attacks collins colleagues reported 70 mg kg magnesium sulphate infusions 4 hours 5 days reduced pain patients complex regional pain syndrome whether intravenous administration magnesium achieve sufficient concentration cerebrospinal fluid block nmda receptors unclear studies reported limited efficacy magnesium administered via intravenous route furthermore even dose intravenously administered magnesium sufficient present toxicity patients still risk magnesium overdose neuraxial administration magnesium label use safety technique human subjects still undetermined however animal studies showed intrathecally administered magnesium free neurotoxicity recent studies demonstrated safety magnesium administration via epidural intrathecal route humans in fact exact site action epidurally administered magnesium i.e. spinal supraspinal remains unclear however comparison previous reports regarding intravenous magnesium administration suggested low dose epidural magnesium used patient unlikely result systemic effects conclusion tfemi showed favourable result treatment intractable allodynia associated phn this study performed single case investigations required determine efficacy tfemi management allodynia patients phn

although postherpetic neuralgia ( phn ) is a common chronic pain syndrome , the pathophysiology of this disorder is not well known and management is often very difficult . n - methyl - d - aspartate ( nmda ) receptor antagonists are known to be effective in phn , and magnesium , a physiological blocker of nmda receptors , is widely used to treat various chronic pain disorders . here , we present a case of the phn refractory to conventional treatment , which was treated successfully with transforaminal epidural injection of magnesium sulphate at the affected dermatome .

central retinal vein occlusion crvo common sight threatening vascular disease prevalence rates ranging 0.1%1 0.5%2 older adult population crvo characterized occlusion central retinal vein consecutive damming venous blood flow the occlusion may occur level posterior lamina cribrosa.3 despite prevalence pathogenesis crvo completely understood a combination vascular anatomic inflammatory factors may contribute pathophysiology.4 current treatment options include intravitreal injections steroids5 anti vascular endothelial growth factor anti vegf agents.68 fluorescein angiographic fa assessment important tool adequate evaluation disease severity proper classification two types crvo ischemic nonischemic ischemic crvo associated significant upregulation vegf poor prognosis visual acuity higher incidence secondary neovascular glaucoma nvg ranging 20% 60% compared nonischemic crvo risk developing nvg.9 given significant differences various outcomes risk profiles crucial differentiate ischemic nonischemic crvo conventional fa images retinal circulation within posterior pole however known conventional fa devices able capture areas interest regarding intraocular metabolism vegf peripheral retina earlier findings suggested association peripheral retinal ischemia increased production vegf.10,11 currently two ultrawide field systems commercially available perform fa image peripheral retina one method uses wide field contact lens system ocular staurenghi 230 slo retina lens ocular instruments inc bellevue wa usa heidelberg retina angiograph hra heidelberg engineering gmbh dossenheim germany).12,13 second available system uses optos scanning laser ophthalmoscope optos plc dunfermline uk special non contact lens based system provides visualization peripheral retina.1416 shown ultrawide field fa uwfa useful assessment several retinal pathologies17 including retinal vein occlusions,18 diabetes,19,20 uveitis,21 retinal vasculitis,22 choroidal masses,23,24 retinal detachment,25 retinopathy prematurity.26 aim study evaluate possible association peripheral retinal nonperfusion obtained uwfa number intravitreal ranibizumab injections needed patients crvo this prospective interventional study performed june 1 2012 february 1 2014 the institutional review board ludwig maximilians university munich approved study design patients care adhered tenets world medical association declaration helsinki all patients gave written informed consent participation study fa inclusion criteria diagnosis crvo revealed retinal hemorrhages dilated retinal veins four quadrants fundus active center involving macular edema central subfield thickness 250 detected spectral domain optical coherence tomography sd oct heidelberg engineering heidelberg germany patients without macular edema previous focal panretinal photocoagulation degenerative disorders posterior pole and/or retinal periphery excluded additional intravitreal injections administered presence active center involving macular edema central subfield thickness 250 determined sd oct all patients underwent comprehensive ophthalmologic examination included best corrected visual acuity bcva measurement slit lamp biomicroscopy applanation tonometry indirect ophthalmoscopy sd oct injections follow visit uwfa using optos 200t imaging system obtained case first injection all included patients received three intravitreal injections 0.50 mg ranibizumab lucentis genentech inc south san francisco ca usa novartis pharma ag basel switzerland every four weeks examined monthly follow oct scans macula they received additional intravitreal injections macular edema detected sd oct scans follow visits sd oct volume scans 2015 19 horizontal sections art 9 sd oct heidelberg engineering heidelberg germany macula obtained study eye measure central subfield thickness cst using heidelberg sd oct software significant macular ischemia ruled uwfa fa images acquired approximately one minute arteriovenous phase 45 minutes late venous phase intravenous injection using optos 200t scanning laser ophthalmoscope optos plc standard intravenous infusion 5 ml sodium fluorescein 10% one experienced technician included cases fa images compressed high quality jpeg files figures 1 2 analyzed retinal nonperfusion two experienced ophthalmologists kaa fs the far peripheral retina defined area ampullae vortex veins ora serrata the wide field color images wide field fa images used identify vortex vein ampullae located near ocular equator.27 based another published work defined retinal nonperfusion least five disc areas hypofluorescence28 representing retinal nonperfusion capillary dropout areas microvascular pathology multiple microaneurysms significant perivascular leakage uwfa five disc areas also mean size peripheral retinal nonperfusion patients crvo effect upper lower eyelid eyelashes far periphery horizontal plane alone nasal temporal retina analyzed collected parameters included demographic information previous ocular history number dates intravitreal injections central subfield thickness peripheral retinal ischemia central intraretinal fluid visual acuity intraocular pressure throughout study period well occurrence complications data collected analyzed using spss software version 20.0 ibm corporation armonk ny usa spearman rho test used correlation analysis p value 0.05 considered statistically significant this prospective interventional study performed june 1 2012 february 1 2014 the institutional review board ludwig maximilians university munich approved study design patients care adhered tenets world medical association declaration helsinki all patients gave written informed consent participation study fa inclusion criteria diagnosis crvo revealed retinal hemorrhages dilated retinal veins four quadrants fundus active center involving macular edema central subfield thickness 250 detected spectral domain optical coherence tomography sd oct heidelberg engineering heidelberg germany patients without macular edema previous focal panretinal photocoagulation degenerative disorders posterior pole and/or retinal periphery excluded additional intravitreal injections administered presence active center involving macular edema central subfield thickness 250 determined sd oct all patients underwent comprehensive ophthalmologic examination included best corrected visual acuity bcva measurement slit lamp biomicroscopy applanation tonometry indirect ophthalmoscopy sd oct injections follow visit uwfa using optos 200t imaging system obtained case first injection all included patients received three intravitreal injections 0.50 mg ranibizumab lucentis genentech inc south san francisco ca usa novartis pharma ag basel switzerland every four weeks examined monthly follow oct scans macula they received additional intravitreal injections macular edema detected sd oct scans follow visits sd oct volume scans 2015 19 horizontal sections art 9 sd oct heidelberg engineering heidelberg germany macula obtained study eye measure central subfield thickness cst using heidelberg sd oct software significant macular ischemia ruled uwfa fa images acquired approximately one minute arteriovenous phase 45 minutes late venous phase intravenous injection using optos 200t scanning laser ophthalmoscope optos plc standard intravenous infusion 5 ml sodium fluorescein 10% one experienced technician included cases fa images compressed high quality jpeg files figures 1 2 analyzed retinal nonperfusion two experienced ophthalmologists kaa fs the far peripheral retina defined area ampullae vortex veins ora serrata the wide field color images wide field fa images used identify vortex vein ampullae located near ocular equator.27 based another published work defined retinal nonperfusion least five disc areas hypofluorescence28 representing retinal nonperfusion capillary dropout areas microvascular pathology multiple microaneurysms significant perivascular leakage uwfa five disc areas also mean size peripheral retinal nonperfusion patients crvo effect upper lower eyelid eyelashes far periphery horizontal plane alone nasal temporal retina analyzed collected parameters included demographic information previous ocular history number dates intravitreal injections central subfield thickness peripheral retinal ischemia central intraretinal fluid visual acuity intraocular pressure throughout study period well occurrence complications data collected analyzed using spss software version 20.0 ibm corporation armonk ny usa graded variable tested normal distribution spearman rho test used correlation analysis p value 0.05 considered statistically significant fifty four eyes fifty four consecutive patients treatment nave crvo enrolled study twenty eight patients 52% male twenty three eyes 42.6% located right side seven patients 12.9% known glaucoma 36 patients 66.6% systemic hypertension 22 patients 40.7% pseudophakic all patients center involving macular edema confirmed macular leakage seen fa retinal thickening sd oct images tables 1 2 show baseline final bcva cst shown tables significant improvements visual acuity within groups whereas changes cst significant twenty four eyes 44% showing less five disc areas retinal nonperfusion group 1 received mean number 4.122.73 intravitreal ranibizumab injections thirty eyes 56% showed five disc areas group 2 retinal nonperfusion uwfa received mean number 9.323.84 intravitreal ranibizumab injections p<0.001 mann whitney u test there significant positive correlation size peripheral retinal nonperfusion measured terms disc areas number injections group there also significant correlation size retinal nonperfusion final bcva group there significant correlation size retinal nonperfusion final cst group we observe eye neovascularization disc neovascularization elsewhere observation period therefore panretinal photocoagulation performed study furthermore cases injection related adverse events like retinal detachment endophthalmitis encountered venous occlusive disease retina second common retinal vascular disorder diabetic retinopathy.29 typically affects patients 40 80 years age.30 usually decrease visual acuity result macular edema lead permanent visual loss even legal blindness severe cases applying uwfa found significant correlation total number intravitreal ranibizumab injections size nonperfusion peripheral retina crvo patients peripheral retinal nonperfusion received intravitreal injections treatment macular edema patients without peripheral retinal nonperfusion we hypothesized nonperfused peripheral retina could source increased intraocular vegf levels consecutive macular edema this observation could explain requirement frequent intravitreal anti vegf injections crvo patients macular edema peripheral retinal nonperfusion this finding important evaluation peripheral retina using uwfa may prognostic factor allows ophthalmologists estimate requirement fewer intravitreal injections based peripheral retinal perfusion status looking perfusion peripheral retina patients precise evaluation estimated treatment costs within defined health care system may feasible including better evaluation injection related complications endophthalmitis complications interestingly lack observed neovascularizations patients even extended areas peripheral retinal nonperfusion might attributed good patient compliance strict follow visits every 4 weeks immediate treatment case detected macular edema the results study differ published spaide31 singer et al.32 spaide evaluated 22 patients treated ranibizumab crvo found area peripheral nonperfusion correlated number injections the follow time study longer sample size smaller singer et al32 evaluated 32 patients retinal vein occlusion refractory macular edema using sd oct uwfa those patients retreated intravitreal injections anti vegf dexamethasone intravitreal implant significant difference number anti vegf 1.8 vs 1.6 p=0.438 dexamethasone implant 1.4 vs 1.6 p=0.364 treatments given 10% 10% nonperfusion groups difference regarding time recurrence 3.4 vs 4.3 months p=0.440 singer et al series 13 crvo patients previously failed contiguous therapy intravitreal ranibizumab dexamethasone implant in contrast enrolled previously untreated treatment nave patients furthermore number cases higher abovementioned studies we previously reported peripheral retinal nonperfusion correlates significantly intravitreal ranibizumab injections patients brvo macular edema.33 rehak et al34 evaluated 22 crvo patients randomized clinical trial suggested selective laser photocoagulation peripheral areas nonperfusion may improve visual outcome decrease number needed ranibizumab reinjections crvo patients there published articles regarding size peripheral retinal nonperfusion using uwfa we calculated mean size peripheral retinal nonperfusion enrolled patients five disc areas patients divided two groups according cut point however authors totally agree approach established step due lack evidence moreover several problems interpretation fluorescein angiograms the grading ultrawide field angiograms uniform eyelash artifacts influence entire amount interpretable fundus graders also change clarity images may cause intergrader variability another drawback study design performed uwfa patient one single time point thus able demonstrate potential dynamic angiographic changes nonperfusion areas follow time in conclusion uwfa precise tool detection quantification retinal nonperfusion correlated number needed intravitreal ranibizumab injections patients crvo retinal nonperfusion could considered prognostic factor precise patient management

purposeto evaluate the association between the size of peripheral retinal nonperfusion and the number of intravitreal ranibizumab injections in patients with treatment - nave central retinal vein occlusion ( crvo).methodsfifty - four patients with treatment - nave crvo and macular edema were included . each patient underwent a full ophthalmologic examination including optical coherence tomography imaging and ultrawide - field fluorescein angiography . monthly intravitreal ranibizumab injections were applied according to the recommendations of the german ophthalmologic society . two ophthalmologists quantified the areas of peripheral retinal nonperfusion ( group 1= less than five disc areas , group 2= more than five disc areas ) . correlation analyses between the size of nonperfusion with best - corrected visual acuity , central subfield thickness , and the number of intravitreal injections were performed.resultsbest-corrected visual acuity improved significantly after intravitreal injections ( p<0.001 , both groups ) . final central subfield thickness after treatment did not significantly differ between both groups ( p=0.92 , p=0.96 , respectively ) . mean number of injections in group 1 and group 2 was 4.122.73 and 9.323.84 , respectively ( p<0.001 ) . there was a significant positive correlation between areas of nonperfusion and the number of injections in each group . ( r=0.97 , p<0.001 ; r=0.94 , p<0.001 , respectively).conclusionperipheral retinal nonperfusion in patients with crvo correlates significantly with the number of needed intravitreal ranibizumab injections . ultrawide - field fluorescein angiography is a useful tool for detection of peripheral retinal ischemia , which may have direct implications in the diagnosis , follow - up , and treatment of these patients .

small bowel obstruction sbo one feared complications gastric bypass chronic acute range nuisance patient life threatening emergency sbos related adhesions occur laparoscopic roux en gastric bypass lgb ih formation secondary reconstruction small intestine also concern bariatric surgeons multiple defects mesentery bowel occur may lead ih antecolic bypass defect associated roux limb passing transverse colon the reported incidence sbo lgb varies widely perhaps technique used operation also varies widely placement roux limb regarding closure nonclosure mesenteric defects the disparity reports leads confusion regarding true incidence even causes sbo lgb in addition closure mesenteric defects questioned substantial body literature the objective study examine incidence characteristics sbo antecolic antegastric bypass nonclosure mesenteric defect jejunojejunal jj anastomosis following health insurance portability accountability act guidelines author performed retrospective chart review series consecutive lgbs performed 3-year period recorded prospectively maintained database the follow patients included office visits 1 week 1 month 3 months 6 months yearly all procedures performed surgeon using antecolic antegastric technique case mesenteric defect closed any patients presenting signs symptoms sbo emergently taken operating room the policy bariatric program always explore aggressively patient suspicion sbo whether based physical examination radiographic studies history patients sbo usually taken operating room emergency department those underwent revisional bariatric surgery conversion open operation primary surgery excluded revisional procedures included adhesions may formed previous bariatric surgery could confounded results all patients given informed consent prior surgery deidentified data used study purposes the gastric pouch sized 20 ml orogastric balloon 4 5 staple loads seamguard w. l. gore flagstaff arizona staple line reinforcement slr echelon 60-mm stapler ethicon endo surgery cincinnati ohio the small bowel divided 40 cm ligament treitz mesentery minimal division the division mesentery staple load divided small bowel the roux limb measured 100 120 cm depending body mass index bmi patient the gastrojejunal anastomosis hand sewn 2 layers absorbable sutures 34 french bougie the jejunojejunostomy formed single firing stapler enteroenterostomy closed stapler cases an intraoperative endoscopy used check gastrojejunal anastomosis drains used male patients higher technical difficulty higher rates mortality morbidity patients bmi 50 reasons selected cases there one conversion open operation incomplete malrotation mortality the gastric pouch sized 20 ml orogastric balloon 4 5 staple loads seamguard w. l. gore flagstaff arizona staple line reinforcement slr echelon 60-mm stapler ethicon endo surgery cincinnati ohio the small bowel divided 40 cm ligament treitz mesentery minimal division the division mesentery staple load divided small bowel the roux limb measured 100 120 cm depending body mass index bmi patient the gastrojejunal anastomosis hand sewn 2 layers absorbable sutures 34 french bougie the jejunojejunostomy formed single firing stapler enteroenterostomy closed stapler cases an intraoperative endoscopy used check gastrojejunal anastomosis drains used male patients higher technical difficulty higher rates mortality morbidity patients bmi 50 reasons selected cases there one conversion open operation incomplete malrotation mortality there 249 primary lgbs performed study period january 1 2011 december 31 2013 sbo 4 cases caused ih incidence 1.6% adhesions 11 73% figure 1 cases ih the common locations jj roux limb n 5 followed forming jj abdominal wall n 3 1 jj colon jj common channel figure 2 cases adhesions treated laparoscopic lysis the average time sbo 8.1 months range 121 initial surgery sbo common lgb easily managed easily lead disaster recognized treated promptly the surgical literature many articles discuss ih formation area contention closure versus nonclosure mesenteric defects most authors seem agree retrocolic gastric bypass performed mesocolic defect must closed lead 0% rate ih formation although number climb high 15% elms et al showed almost 2 400 patients underwent antecolic antegastric bypass ih formed 1.1% primarily mesenteric defect cases defects closed cho et al 0.2% ih formation rate 1 400 patients underwent antecolic antegastric bypasses mesenteric closure division mesentery rodriguez et al also reported minimal division mesentery could lead decrease ih formation they showed closure defect wide opening mesentery 14.4% ih rate defect closed mesentery widely opened ih rate dropped 1.1% abasbassi et al showed lower ih formation rate division mesentery also closure mesentery this cumulative experience could indicate way decrease ih formation perform minimal division mesentery obeid et al used mixed techniques retro- antecolic bypasses closure defects without 679 patients antecolic roux limb majority defects closed retrocolic group almost 4% closure mesenteric defect 8.4% nonclosure 3.8% antecolic 8.5% retrocolic bypasses this wide range techniques makes overall analysis literature difficult 2010 jsls hope colleagues examined incidence ih formation documented closure mesenteric defects permanent sutures used close defects 15 18 patients series presented open defects causing ih these outcomes indicate closure defects may permanent surgeons would like believe indeed situation catalyst paper lgbs closing defects ih formation rate seemed climbing we noticed mesenteric defects open reoperation switched nonclosure as demonstrated published papers subject reported wide range ih incidence 0% 15.5% another complicating factor may many papers published area surgical programs training fellows association postsurgical complications performance operations fellows known study author specifically examined incidence cause sbo antecolic antegastric bypasses case either mesenteric antecolic defect closed the interesting finding overall incidence sbo 6% 1.6% total caused ih formation jj mesenteric defect this outcome compares favorably ih formation rate reported authors close defects also incidence sbo caused adhesions higher current study others elms et al reported 47.6% sbos series secondary adhesions mostly jj compared rate 73% the opposing end adhesion multiple locations staple line jj always one end perhaps intense inflammatory reaction generates a hand sewn technique could used close common enterotomy might reduce incidence sbo slightly cut end biliopancreatic limb still exposed staple line the strength study homogeneity technique used single surgeon series however strength also chief weakness results may reproducible others the number sbos also small enough raise possibility type ii error the author lives geographically isolated part country surgeons willing care bariatric patients likely sbos would treated bariatric surgeon another limitation study small series short follow although years 2011 2013 examined average time sbo 8.1 months possible sbo rate climb patients time passes patients likely lost follow another confounding factor slr used early series jj later operations there may association slr adhesion formation connection clear the common location adhesions jj slr used half sbos caused solely adhesions jj occurred use slr abandoned probably enough cases tell use slr increases sbo the usual weaknesses retrospective study apply paper studies ih formation surgeons remember mainstay treatment sbo lgb operation an isolated roux limb obstruction decompressed vomiting placement ngt involves risk perforation the surgeon move patient quickly operating room sbo diagnosed even suspected bowel ischemia lead extensive bowel resection nutritional debility even death these operations often performed laparoscopically laparotomy also safe effective the incidence sbo caused ih nonclosure mesenteric defect similar series defect closed regardless cause sbo operation remains definitive treatment delayed gastric bypass patient

background and objectives : there is a wide variation of reported incidence of small bowel obstruction ( sbo ) after laparoscopic roux - en - y gastric bypass ( lgb ) . there is also wide variation in technique , not only in placement of the roux limb , but also regarding closure or nonclosure of the mesenteric defects . the objective of this study was to examine the incidence and characteristics of sbo after antecolic antegastric bypass with nonclosure of the mesenteric defect of the jejunojejunal anastomosis.methods:this is a retrospective review of a series of consecutive lgbs over a 3-year period . all procedures were performed by the same surgeon using the same technique . in no case was the mesenteric defect closed . a prospectively maintained database was used for data collection . patients who returned with an sbo were the study group , and those who underwent revisional bariatric surgery or conversion to open operation were excluded.results:there were 249 primary lgbs performed during the study period ; 15 of the operations were followed by sbo , for an incidence of 6.0% . four cases were caused by an internal hernia ( ih ) , for an incidence of 1.6% , and 11 were caused by adhesions , which accounted for 73% of the sbos.conclusions:sbo after lgb is a relatively common complication . the incidence of sbo from ih with nonclosure of the mesenteric defect is similar to that in other series where the defect is closed . regardless of the cause of the sbo , operative treatment of the patient who has a gastric bypass remains the definitive standard and should not be delayed .

following section describes treatment procedure patients deep infection following tka using modified static spacers the original prosthesis removed followed intensive irrigation wide debridement infected soft tissue 36 fr diameter straight thoracic catheter mallinckrodt medical athlone ireland steinmann pin measuring 3.0 mm diameter 22 cm length vancomycin 2 g added gentamicin bone cement depuy warsaw usa late liquid stage cement the steinmann pin inserted tube prepared cement delivered tube procedure the tube removed cement rod using surgical knife finally cement rod measuring 9 mm diameter 22 cm length formed fig an entry hole created center distal femur proximal tibia insertion cement rod the rod inserted femur tibia hole insertion important place center cement rod imaginary joint line the proximal medullary canal tibia filled antibiotic impregnated cement surface proximal tibia surgical assistant maintained proper anatomic alignment joint space the space cement distal femur proximal tibia filled antibiotic impregnated cement finally suprapatellar pouch medial lateral gutter space filled antibiotic impregnated cement reduce soft tissue adhesion fig cylinder splint immobilization required three days operation fixed angle knee brace used toe touching ambulation allowed reimplantation surgery from april november 2007 authors performed static technique four patients using novel antibiotic impregnated cement rod treatment infected tka culture staphylococcus three cases bacteria one case follow laboratory studies including erythrocyte sedimentation rate c reactive protein culture study via knee aspiration frozen biopsy second stage operation 5 polymorpho leukocytes high power field performed confirm successful eradication infection the second stage reimplantation performed criteria validation infection control met fig the second stage reimplantation performed using rectus snipping approach 90 flexion obtained intra operatively four patients no infection evident two half years follow the range motion knee joints respectively improved 50 80 95 100 knee society scores 70 86 65 84 respectively last follow evaluation fehring et al.8 emphasized importance resting joint septic joint conditions others also reported static spacer technique provides stability mobile spacer technique patients severe bone loss.5,8 main advantage technique maintenance normally aligned lower limb interval period this maintains knee stability combination early muscle strengthening exercises including quadriceps setting exercise enables patient comfortably dress manage intervening period the cement rod static spacer provide stable gap femur tibia thereby minimizing soft tissue contracture shortening lower limb in addition symmetric maintenance soft tissue medial lateral gutters requires additional soft tissue balancing second stage reimplantation the additional cost metal nail however difficulty infection control due biofilm formation around metal nail troublesome addition metal nail removed easily second stage reimplantation due hardness soft tissue adhesion femoral tibial medullary canals hand an antibiotic impregnated cement rod enjoys advantages inexpensive antibiotic delivery marrow spaces easy removal using hercules cutter in addition static spacer anchored cement rod prevent spacer migration bone erosion this feature believed generate less cement wear debris conventional static spacer mobile articulating spacer technique conduct antibiotic impregnated cement rod technique antibiotic impregnated cement applied proximal tibia distal femur joint gap space suprapatellar pouch gutters stepwise manner this technique enables easy removal cement reduced soft tissue adhesion second stage reimplantation

the two - stage exchange arthroplasty ( one- or two - stage ) is believed to be the gold standard for the management of infections following total knee arthroplasty . we herein report a novel two - stage exchange arthroplasty technique using an antibiotic - impregnated cement intramedullary nail , which can be easily prepared during surgery using a straight thoracic tube and a steinmann pin , and may provide additional stability to the knee to maintain normal mechanical axis . in addition , there is less pain between the period of prosthesis removal and subsequent reimplantation . less soft tissue contracture , less scar adhesion , easy removal of the cement intramedullary nail , and successful infection control are the advantages of this technique .

mental fatigue common disabling long time condition following stroke it estimated 3070% stroke survivors complain fatigue 17 even almost recovered stroke without neurological neuropsychological impairments the person suffers mental fatigue able perform mental effort short periods notably take longer normal regain energy exhausted accompanying symptoms irritability sensitivity stress concentration difficulties emotional instability may impair social interactions 811 however attention paid poststroke fatigue last 10 years fatigue generally held separate phenomenon 46 1214 few investigations carried evaluate fatigue cognitive functions following stroke leegard reported fatigue frequent following stroke find related impaired cognitive functions van zandvoort coauthors investigated lacunar infarct reported frequent difficulties relating fatigue decreased cognitive performance demanding conditions intention increase knowledge mental fatigue cognitive difficulties related stroke examined well rehabilitated stroke participants suffered long term mental fatigue least one year prior examination the subjects examined subjective self reporting mental fatigue depression anxiety symptoms neuropsychological tests aimed evaluating information processing speed attention working memory twenty four participants recovered neurological symptoms suffering pathological mental fatigue least one year following stroke 24 healthy controls included study the study persons recruited advertisement local daily newspaper neurological clinic local university hospital later included intervention studies the stroke subjects healthy work stroke meaning known diseases hypertonia present among participants the type stroke obtained medical records self reports see table 1 the control participants recruited local community history brain injury stroke psychiatric neurological disorder drug abuse fully able work they performed cognitive tests focused information processing speed attention working memory the self assessment mental fatigue multidimensional questionnaire containing 15 questions adapted rdholm et al the self reported questionnaire covers common symptoms occurring brain injury stroke neurological disorders affecting brain 11 17 the self assessment scale mental fatigue related items evaluated 14 questions adequate internal consistency cronbach alpha 0.94 the questions concern fatigue general lack initiative mental fatigue mental recovery concentration difficulties memory problems slowness thinking sensitivity stress increased tendency become emotional irritability sensitivity light noise decreased increased duration sleep well 24-hour variations this cprs scale used self assessment depression anxiety the neuropsychological tests included digit symbol coding wais iii measuring information processing speed digit span wais iii measuring attention working memory verbal fluency test fas trail making test tmt b measuring visual scanning divided attention motor speed order evaluate higher demands dual tasks a series two new trail making tests constructed three four factors respectively months added part c months days week chronological order part d. latter order letters digits switched a new computer test constructed department including single complex subtest the single test included speed mouse click four squares located corner bigger square 6 6 cm computer screen performed clockwise order a mouse click outside square recorded miss new click necessary order able go test the complex sub test also included mouse clicking procedure time subject asked count many instances specific digit zero nine randomly chosen could see after 30 seconds subject asked report many specific digit seen it possible measure difference speed single complex task variability time errors made counting digits complex test necessary attend square digits a comparison groups done test analysis covariance ancova the mann whitney u test used analyzing separate items included self assessment scales pearson correlation linear regression used analysis connections variables spss 16.0 windows the control group significantly years education stroke group test p 0.001 age almost significantly different comparing two groups p 0.055 table 1 accordingly ancova controlling variance education age conducted variables analysed the significant gender difference found control females faster digit symbol coding test ancova also controlling sex conducted variable a significant difference found groups total sum scores mental fatigue the mean value stroke group 18.4 95% confidence interval 16.420.5 the mean value control group 4.0 95% confidence interval 2.95.0 see figure 1 the total score cprs scale taken depression anxiety subscale also rated significantly higher stroke group compared controls see table 2 figure 1 significant effect mental fatigue remained adjustment depression p 0.001 all separate items self assessment scale mental fatigue rated significantly higher stroke group compared controls the cprs gave following findings without taking account overlapping items items relating sadness emotional involvement pessimistic thoughts zest life rated significantly higher stroke group adjusted multiple comparisons shown figure 2 among stroke subjects 74% reported clear 24-hour variation morning frequently reported best time day afternoon evening worst the participants stroke group significantly slower test measuring information processing speed primarily digit symbol coding also reading speed number mouse clicks computer test the stroke group also significantly slower made errors tmt demanding tmt tests they also significantly slower tmt b produced fewer words verbal fluency test the result simple mouse click sub test found significantly faster controls compared stroke subjects computer test placed simultaneous demand speed attention working memory resulted fairly good speed stroke subjects detected difference speed compared controls contrary stroke subjects made significantly errors compared controls table 2 figure 3 the cognitive tests significant results p 0.05 see table 2 included linear regression model using enter method digit symbol coding p 0.004 scores number errors computer test p 0.018 significant predictors mental fatigue scores significant predictors mental fatigue digit symbol coding number errors computer test also correlated significantly mental fatigue sum scores r 0.59 r 0.46 the total scores cprs depression anxiety significantly higher level compared controls the madrs provides separate scale format cprs self assessment scale depression except items graded different way cprs scale depression highest level three separate cprs item levels alternatives madrs scale double separate item highest level 6 according madrs score 12 20 regarded mild depression 21 indicates probable true depression the mean level eight stroke subjects corresponds 16 madrs indicating overall mild level depression there highly significant difference groups self assessment mental fatigue mean value 18 reported almost recovered stroke group mean value four control group the self assessment scale cut value fatigue experience shows value 15 indicates clear problem mental fatigue 9 23 clear difference 24-hour variation also showed specific exhaustion mental fatigue subjects experience active time day it noticed stroke victims included due presence mental fatigue one year following stroke the data presented study include indication frequency mental fatigue different types stroke however individual basis according madrs eight participants depressed seven indicated mild depression nine probable true depression among controls two participants scored mild depression level remainder scored level the total sum scores depression scales may deceptive person complaining concentration difficulties fatigue depressed mood lack interest enjoyment daily activities study three items overlapping mental fatigue depression items rated higher level corresponding specific items depression sub scale see figure 2 depression mental fatigue occur sometimes occur simultaneously shown study accordingly suggest mental fatigue depression independent phenomena following stroke this also conforms findings studies 46 12 13 distressing exhaustion along bad memory concentration difficulties able perform simultaneous tasks phenomena many subjectively complain following stroke it important include cognitive tests examinations order better understand difficulties connected mental fatigue purpose recommending treatment strategies study physically well recovered stroke subjects medical problems except long term mental fatigue also showed decreased information processing speed made errors demanding cognitive tasks compared control subjects processing speed also fundamental important considering cognitive functions higher order few studies carried cover fatigue cognitive performance following stroke however studies shown connection fatigue decreased cognitive performance demanding conditions cognitive impairments detected despite frequent fatigue demanding sensitive tests including processing speed complex attention may possible detect cognitive impairments accompanying mental fatigue this important mental fatigue cognitive deficits obstacle almost recovered stroke subjects way return work previous activities every day life today complex high demands placed simultaneous rapid decisions conclusion mental fatigue disabling many people following almost recovered stroke suggested related cognitive impairments primarily information processing speed attention mental fatigue also treated separate phenomenon differentiated confused depression today specific guidelines exist treatment mental fatigue research urgently needed common yet distressing symptom

mental fatigue is for many a distressing and long - term problem after stroke . this mental fatigue will make it more difficult for the person to return to work and previous activities . the intention with this study is to investigate mental fatigue in relation to depression and cognitive functions . we examined 24 well - rehabilitated stroke subjects , who suffered from mental fatigue one year or more after a stroke , and 24 healthy controls . subjects were examined using self - assessment scales for mental fatigue , depression and anxiety , and cognitive tests . the results showed a highly increased rating for mental fatigue for the stroke group ( p < 0.001 ) . these participants also had a significantly higher rating on the depression ( p < 0.001 ) and anxiety ( p < 0.001 ) scales . furthermore , they had a slower information processing speed ( p < 0.001 ) and made more errors in a demanding attention and speed test ( p < 0.05 ) . among the cognitive tests , processing speed and errors made in an attention and speed test were significant predictors for mental fatigue . we suggest mental fatigue following a stroke to be related to cognitive impairments , primarily information processing speed . mental fatigue should also be treated as a separate phenomenon and should be differentiated from , and not confused with , depression , even if overlapping symptoms exist .

cigarette smoke cs associated development inflammation related diseases chronic obstructive pulmonary disease vascular diseases including atherosclerosis stroke several studies revealed cs major contributor vascular diseases accelerates development atherosclerotic plaques the relationship cs increased incidence atherosclerosis reported 57 may consequence direct endothelial damage increased proliferation smooth muscle atherosclerotic lesions and/or decreased vasodilation endothelial damage also suggested initial cause development vascular diseases previous study shown inhibition oxidative stress exerts protection human endothelial cells could effective strategy treatment vascular diseases a number studies support reactive oxygen species ros causing oxidative stress may play essential role mediating endothelial cell death oxidative stress major factor vascular diseases hypertension stroke atherosclerosis korean red ginseng krg popular traditional herbal medicine widely used treat several diseases cancer vascular diseases recent research shows ginseng may therapeutic potential treatment alzheimer disease diabetes cancer cardiovascular diseases antioxidant antithrombotic antihyperlipidemic anticancer effects 1215 endothelial cells krg simulates production vivo vitro suggesting krg antihypertensive effects krg also promotes angiogenesis activation signaling pathway indicating krg implicated potential angiogenic therapies improving tissue repair wound healing cardiovascular diseases in addition previous study suggested krg exerts cytoprotective effect induction heme oxygenase ho)-1 expression suggesting possible therapeutic mechanism krg cardiovascular diseases it well known chronic inflammation contributes pathogenesis many human diseases atherosclerosis accumulating evidence suggests krg involved regulation inflammatory responses suggesting anti inflammatory effect krg cyclooxygenase cox catalyzes conversion arachidonic acid prostaglandins play vital roles multiple physiological pathophysiological processes including inflammation in particular cox-2 normally undetectable tissues induced response numerous stimuli vascular diseases may part caused cox-2 upregulation sites inflammation vascular injury cox-2 plays important role inflammation therefore inhibition cox-2 expression may participate treatment inflammation related diseases vascular diseases the objective study investigate vascular protective effect krg acrolein stimulated human umbilical vein endothelial cells huvecs therefore examined involvement cox-2 expression via p38 mitogen activated protein kinase mapk intracellular ros apoptosis acrolein stimulated huvecs krg powder obtained korea ginseng corporation daejeon korea m199 medium fetal bovine serum krg powder soaked water 1:25 w w 3 h boiled 40 min following centrifugation 1,900 g 60 min supernatants ginseng extract centrifuged 10,000 g 30 min lyophilized the general composition product offered korea ginseng corporation follows moisture 36% solid volume 64% ash 2.5% total fat 0.05% total crude saponin 70 mg g total ginsenosides 20 mg g huvecs maintained m199 medium supplemented 10% fetal bovine serum 1% penicillin streptomycin 10 ng ml human fibroblast growth factor 18 mu ml heparin huvecs grown 80% confluence maintained fresh medium described subcultured every 2 3 d. cells used within nine passages experiments we applied 20 40 g whole cell lysate proteins lane analyzed western blotting western blotting performed using primary antibodies follows anti cox-2 p38 mapk phopho p38 cyclic amp responsive element binding protein creb phospho creb cell signaling danvers usa anti glyceraldehyde 3-phosphate dehydrogenase abfrontier seoul korea horseradish peroxidase conjugated anti igg antibodies used secondary antibody detect mentioned protein bands enhanced chemiluminescence westsave abfrontier the rna pellets washed 70% ethanol dried completely dissolved diethylpyrocarbonate inhibit rnase total rna quantified using nd-100 spectrometer nanodrop technologies wilmington de usa polymerase chain reaction pcr performed using synthesized cdna template using specific primers cox-2 -actin loading control the primer sequence human cox-2 5-gacagtccaccaacttacaat-3 forward 5-catctctccatcaattatctgat-3 reverse the amplified products resolved 1% agarose gel electrophoresis stained ethidium bromide photographed ultraviolet light huvecs cultured glass culture chamber slide falcon plastics london ontario canada processed immunofluorescence analysis the amount prostaglandin pg)e2 culture medium measured using pge2 eia kit according manufacturer protocol cayman chemical company ann arbor mi usa samples well standards applied 96-well plate precoated goat anti mouse igg incubated pge2 acetylcholinesterase tracer pge2 antiserum all wells emptied rinsed five times incubated ellman reagent 60 min dark gentle rocking produce 5-thio-2-nitrobenzoic acid strong absorbance 405 nm plate read 405 nm enzyme linked immunosorbent assay reader el 800 bio tek winooski vt usa we calculated results using standard curve expressed picograms per milliliter intracellular ros acrolein stimulated huvecs analyzed using fluorescent dye 2,7-dichlorofluorescein diacetate dcf da presence oxidants after 18 h incubation 25 acrolein presence absence krg cells stained 10 dcf da fluorescence analyzed facs vantage flow cytometer becton dickinson san jose ca usa fluorescence microscopy eclipse 50i nikon japan clarify whether krg mediated inhibition acrolein induced cox-2 expression plays significant role cytoprotection oxidative stress acrolein stimulated cells pretreated krg 1 mg ml untreated cell death measured situ terminal transferase dutp nick end labeling tunel assay measure dna fragmentation commercially available situ death detection kit roche diagnostics mannheim germany ) huvecs cultured glass culture chamber slide fixed 30 min 10% neutral buffered formalin solution room temperature a tunel assay system used according manufacturer instructions examination fluorescence microscope excitation 488 nm emission 525 nm fluorescein isothiocyanate fitc bd pharmingen san diego ca usa propidium iodide pi staining necrotic apoptotic cells cells washed pbs resuspended 100 l binding buffer containing 5 l annexin v fitc 1 g ml pi incubated 10 min room temperature dark positioning quadrants annexin v pi dot plots performed previously described data expressed mean standard deviation statistical analysis performed using one way analysis variance graphpad prism version 4 graphpad software san diego ca usa followed bonferroni multiple comparison test a previous study found acrolein cs induces cox-2 expression human endothelial cells krg inhibited acrolein induced cox-2 protein expression concentration dependent manner fig after pretreatment acrolein stimulated cells krg cells fixed cox-2 localization huvecs observed immunofluorescence staining anti cox-2 antibody followed fluorescence tagged secondary antibody immunofluorescence analysis showed acrolein induced cox-2 protein levels inhibited huvecs treatment krg fig the induction cox-2 expression known responsible pge2 release culture medium cells stimulated acrolein acrolein increased pge2 secretion dramatically reduced krg fig 2 this result indicates krg leads reduction cox-2 protein expression subsequently pge2 biosynthesis acrolein stimulated huvecs thus examined effect krg ros production acrolein stimulated cells the shift right curve due increased fluorescence indicates increase intracellular levels ros the results indicate ros generation cells treated acrolein increased compared untreated cells whereas krg inhibited acrolein induced ros generation fig these results indicate krg may play role inhibition cox-2 expression via reduction acrolein generated ros acrolein stimulated huvecs thus determine upstream signaling pathway involved krg mediated cox-2 inhibition measured activation p38 creb detecting increased phospho p38 phospho creb levels acrolein stimulated cells found phosphorylation p38 creb strongly reduced krg acrolein stimulated cells fig 4 these results demonstrate role p38 creb signaling inhibition acrolein mediated cox-2 induction fluorescence activated cell sorting showed number apoptotic cells increased following treatment acrolein pretreatment krg reduced number apoptotic cells fig to confirm result evaluated presence dead cells tunel staining widely used detecting dna fragmentations situ the tunel assay indicates cell death including apoptosis detection appearance intensely stained nuclei indicates incorporation labeled dutp 3-end fragmented dna derived apoptotic nuclei illustrated fig 5b acrolein treatment significantly increased proportion tunel positive cells restored krg pretreatment these results revealed vascular protective effect krg mediated inhibition cox-2 expression acrolein stimulated huvecs in study explored inhibition inflammatory mediator cox-2 krg water extract huvecs we found krg inhibited mrna protein level cox-2 cytoprotective effect acrolein stimulated huvecs there increasing evidence ,-unsaturated aldehydes cs including acrolein crotonaldehyde play important pathophysiological role vascular diseases atherosclerosis alzheimer disease exposure ,-unsaturated aldehydes critical inflammatory response via activation proinflammatory signaling pathway redox sensitive transcription factors furthermore ,-unsaturated aldehydes increase oxidative stress plays crucial role pathogenesis vascular diseases via direct injury endothelium cox-2 key enzyme prostaglandin biosynthesis inducible enzyme rapidly induced inflammatory reactions numerous studies reported involvement cs vascular diseases cox-2 endothelial synthase activity chronic inflammation plays important role vascular diseases therefore cox-2 may participate development inflammation related diseases including vascular diseases ginseng used general tonic 2000 years east asia become famous herbal medicine treatment various diseases including vascular disorders krg reported effective pharmacological activities including antioxidant anticarcinogenic ameliorative effects blood circulation recently diverse effects several constituents krg including ginsenoside endothelial cells extensively studied hien et al demonstrated anti inflammatory antiatherosclerotic activities ginsenoside rg3 human endothelial cells decrease cell adhesion molecules proinflammatory cytokines moreover cytoprotective effect ginsenoside rb1 endothelial cell damage mediated oxidized low density lipoprotein reported several constituents red ginseng reported regulate proliferation migration protect oxidative stress mediated damage human endothelial cells there evidence demonstrating presence major ginsenosides including rb1 rg1 krg water extract thus components could also contribute diverse retinue protective actions krg a previous study showed induction ho-1 expression may exert protective effects krg treated human endothelial cells however reports revealing mechanism underlying krg inhibited cox-2 expression acrolein ,-unsaturated aldehydes cs stimulated huvecs we established major signaling pathway cox-2 i.e. p38 mapk creb intracellular ros generation involved inhibition cox-2 expression acrolein stimulated huvecs krg mentioned above therefore inhibition cox-2 expression following krg water extract treatment may associated strong protective effect acrolein stimulated huvecs conclusion we propose krg water extract may exert cytoprotective effect inhibition cox-2 induction reduction cox-2 acrolein stimulated huvecs mediated p38 mapk

cigarette smoke is considered a major risk factor for vascular diseases . there are many toxic compounds in cigarette smoke , including acrolein and other ,-unsaturated aldehydes , which are regarded as mediators of inflammation and vascular dysfunction . furthermore , recent studies have revealed that acrolein , an ,-unsaturated aldehyde in cigarette smoke , induces inflammatory mediator expression , which is known to be related to vascular diseases . in this study , we investigated whether korean red ginseng ( krg ) water extract suppressed acrolein - induced cyclooxygenase ( cox)-2 expression in human umbilical vein endothelial cells ( huvecs ) . acrolein - induced cox-2 expression was accompanied by increased levels of phosphorylated p38 in huvecs and krg inhibited cox-2 expression in huvecs . these results suggest that krg suppresses acrolein - induced cox-2 expression via inhibition of the p38 mitogen - activated protein kinase signaling pathway . in addition , krg exhibited an inhibitory effect on acrolein - induced apoptosis , as demonstrated by annexin v propidium iodide staining and terminal deoxynucleotidyl transferase - mediated dutp nick end - labeling assay . consistent with these results , krg may exert a vasculoprotective effect through inhibition of cox-2 expression in acrolein - stimulated human endothelial cells .

4cl4-coumarate coa ligasecas9crispr associated protein 9crisprclustered regularly interspaced short palindromic repeatsctcondensed tanningrnaguide rnammillionpamprotospacer adjacent motifpol iiirna polymerase iiirnairna interferencernaseribonucleasesnpsingle nucleotide polymorphisms g ligninsyringyl guaiacyl lignin ratiotrnatransfer rna 4-coumarate coa ligase crispr associated protein 9 clustered regularly interspaced short palindromic repeats protospacer adjacent motif single nucleotide polymorphism syringyl guaiacyl lignin ratio since first report programmable gene editing potential crispr cas9 technology revolutionizing facets biology medicine agriculture jinek et al 2012 with efficiency simplicity crispr cas9 quickly displaced predecessors e.g. zinc finger transcription activator like effector nucleases method choice genome editing carroll 2014 agricultural applications traditionally depended gene silencing rna modification crispr cas9 game changer the previous methods antisense rna interference rnai leave much desired degree specificity stability gene silencing always predictable this necessitates screening characterization large number transgenic lines desired trait by contrast crispr cas9 guided disrupt reading frame thereby protein function target gene dna editing 2012 monoallelic biallelic mutations reported bortesi fischer 2015 biallelic editing null mutations readily obtained primary transformants though varying efficiencies brooks et al 2014 zhang et al 2014 zhou et al 2014 2015 interestingly efficient consistent crispr cas9 editing reported hybrid populus tremula x alba clone 717 1b4 717 biallelic mutations detected independent transgenic lines examined zhou et al 2015 for woody perennials forest trees fruit nut trees woody ornamentals highly heterologous genomes long generation times crispr cas9 affords facile means accelerate genetic improvement the first application crispr cas9 genome editing populus targeted 4-coumarate coa ligase 4cl gene family involved phenylpropanoid metabolism zhou et al 2015 one genes 4cl1 potri.001g036900 extensively characterized involvement lignin biosynthesis down regulation 4cl1 orthologs leads reduced lignin content altered lignin structure number species boerjan et al thus crispr cas9 editing 4cl1 served proof concept study allowing assessment efficacy perturbing lignin biosynthesis relative previous methods we generated 36 independent transgenic lines amplicon sequencing randomly selected events confirmed biallelic mutations cases zhou et al 2015 as frequently reported crispr cas9 genome editing small indels especially 1-bp modifications predominant patterns predicted disrupt reading frame consistent prediction lignin content reduced 23% concomitant decrease g lignin ratio 30% transgenic plants zhou et al 2015 wood discoloration known side effect lignin modification frequently observed transgenic plants suppressed lignin gene expression however coloration patterns reported cases lack uniformity observed crispr cas9 mutants example antisense downregulation 4cl1 populus resulted patchy wood discoloration 5 14 transgenic lines voelker et al wood discoloration patterns transgenic populus regulated expression cinnamoyl coa reductase highly variable among vegetatively propagated plants van acker et al 2014 presumably due unstable nature sense- antisense mediated post transcriptional gene silencing rnai mediated gene suppression considered effective alternative improved trait stability li et al 2008 for instance rnai silencing 4-coumaroyl coa 3-hydroxylase transgenic populus resulted lignin reductions among 9 independent events ranged change 1560% coleman et al similarly rnai silencing 4cl pinus led wood discoloration 2 12 viable transgenic lines wagner et al 2009 by contrast homogeneity wood discoloration within across independent crispr cas9-edited populus mutant lines consistent null 4cl1 resembles naturally occurring brown midrib mutants maize sorghum sattler et al 2010 the results serve testament superiority crispr cas9 previous gene silencing methods ( 2015 permission second gene 4cl2 potri.019g049500 phylogenetically distinct lignin associated 4cls chen et al 2014 has long suggested participate flavonoid biosynthesis based solely preferential expression epidermis roots harding et al 2002 crispr cas9 mutation 4cl2 therefore expected yield functional evidence substantiate role 4cl1 case biallelic mutations observed independent transgenic lines surveyed amplicon sequencing zhou et al the metabolic consequence examined roots flavonoid derived condensed tannins cts known accumulate high levels 20% dry weight experimental poplar genotype chen et al 2014 crispr cas9 mutations 4cl2 resulted significantly reduced levels condensed tannins roots providing reverse genetics evidence support class ii 4cl function flavonoid biosynthesis after initial publication successful crispr cas9 editing reported populus tomentosa fan et al 2015 that study targeted phytoene desaturase pds gene mutagenesis multiplexing 4 grnas observed 50% frequency albino phenotypes the lower mutation rates compared study may attributed gene redundancy sequence heterozygosity accounted grna design see discussion regardless selected albino transgenic lines sequence confirmed harbor biallelic mutations fan et al 2015 providing additional support superior phenotypic uniformity crispr cas9 mutants a major concern genome editing specificity dna modification target cleavage due non specific crispr cas9 activity may cause unintended mutations this especially true plant genomes characterized recurring episodes whole genome segmental tandem duplications we assessed crispr cas9 specificity populus analyzing target versus target activities among duplicated genes the grna 4cl1 designed discriminate paralogous 4cl5 potri.003g188500 3 mismatches target sequence one mismatch protospacer adjacent motif pam zhou et al 2015 by designing consensus primers flanking target site able sequence 4cl1 4cl5 amplicons simultaneously assess specificity crispr cas9 a custom program ageseq analysis genome editing sequencing developed facilitate variant detection xue tsai 2015 no target cleavage 4cl5 locus detected 4cl1-edited lines suggesting crispr cas9 editing populus highly specific zhou et al 2015 negative experiment mismatches 4cl5-grna designed based p. trichocarpa reference genome phytozome v3 corresponding sequence p. tremula x alba 717 used transformation abolished cleavage transgenic lines examined zhou et al 2015 in case mismatches form 2 single nucleotide polymorphisms snps one per allele located near pam these results together highly heterologous nature woody perennials suggest target cleavage crispr cas9 likely low species the ability crispr cas9 discriminate single base differences makes powerful tool investigate functional redundancy highly homologous genes otherwise difficult discern using gene silencing approaches for instance 4cl1 abundantly expressed isoform populus xylem constituting 85% 4cl transcripts 4cl5 distant second based rna seq data swamy et al 2015 however crispr cas9 knockout 4cl1 reduced lignin content 23% zhou et al 2015 4cl5 locus unmodified it likely involved residual lignin biosynthesis 4cl1-knockout mutants populus study targeted pds 4 grnas designed based one gene model potri.014g148700 without considering genome duplicate potri.002g235200 shares high degree 93% coding sequence identity genome sequence p. tomentosa yet available analysis p. trichocarpa p. tremula x alba orthologs revealed different degrees sequence variation 2 duplicates grna target regions these differences plus unknown allelic heterozygosity likely contributed variation reported editing efficiencies different grnas fan et al 2015 examples include designing multigene targeting grnas based conserved sequences homologous genes brooks et al 2014 jacobs et al 2015 multiplexing individual grna cassettes brooks et al 2014 fan et al 2015 zhang et al 2014 a recent study hijacked trna processing machinery efficient processing 8 potentially grnas one single construct xie et al grna positioned downstream trna polycistronic gene repeating trna grna units multiplexing xie et al 2015 mature grnas released following cleavage polycistronic transcript trna processing machinery sequence constraint 5 end grnas xie et al 2015 this greatly simplifies grna design sequences upstream pam ngg used e.g. n20-ngg truncated lengths fu et al 2014 unlike standard design grna transcribed directly pol iii u6 u3 promoter using specific transcription initiation sequence e.g. gn19-ngg an19-ngg respectively wang et al 2008 in cases grna stacking either transformation via controlled crosses primary transformants may necessary order discern individual gene functions as discussed numerous studies exploited sequence polymorphisms developing gene- allele specific grnas achieve precision editing crispr cas9 however studies addressed added complexity sequence polymorphisms crispr cas9 genome editing probably common plant models arabidopsis rice soybean tomato selfing species homozygous genomes we argue sequence polymorphisms concern genome editing flowering plants especially woody perennials outcrossing nature this supported high frequency genic snps reported trees one per 60 bp populus tremula ingvarsson 2005 one per 16 33 bp eucalyptus depending species klheim et al 2009 a recent population genomics study 544 populus trichocarpa individuals identified 17.9 million snps whole genome resequencing evans et al 2014 using similar approach resequencing rna seq data uncovered 10 snps single individual p. tremula x alba clone 717 commonly used populus transformation xue et al 2015 given high levels heterozygosity tree species need consider sequence polymorphisms genome editing experiments emphasized in fact published genome sequences default consensus sequences pseudo)haploid genomes thus several web based grna design programs available plants crispr plant xie et al 2014 and crispr p lei et al 2014 utility outcrossing species limited preloaded genome sequences lack biallelic multiploid coverage furthermore often case populus species genotype chosen whole genome sequencing e.g. p. trichocarpa nisqually-1 different routinely used genetic transformation e.g. p. tremula x alba 717 facilitate crispr cas9 genome editing 717 constructed custom 717 genome substituting 10 sequence variants p. trichocarpa reference genome xue et al 2015 we assessed impact sequence polymorphisms grna specificity 1000 randomly selected genes grnas designed based haploid genome 1 p. trichocarpa 2 717 cross checked snps indels 717 target sequences first analysis found 57% grnas designed based p. trichocarpa genome correspond regions harbor snps indels 717 xue et al the rates slightly lower nevertheless high 42 44% second analysis custom 717 genome used owing allelic variations zhou et al 2015 together data suggest standard grna designs may suffer high probability failure crispr cas9 genome editing due frequent occurrence snps indels outcrossers the 717 sequences associated blast gene model query tools available via aspendb http://aspendb.uga.edu/s717 tool particularly useful screening custom grnas pcr primers known snps indels p. trichocarpa custom 717 genome xue et al 2015 a set pre selected grnas known sequence variants 38,509 populus genes provided zhou et al 2015 the modified variant sensitive pipeline grna design called aspen crispr designer also available aspendb applied species outcrossing species lacking genomic variant database several approaches applied identify snps indels gene(s interest prior grna selection rna seq data transformation genotype available excellent source high confidence snp discovery provided gene interest reasonably expressed e.g. high read coverage manual inspection candidate grnas rna seq alignments using programs popular integrative genomics viewer http://www.broadinstitute.org/igv usually effective confirm specificity absence deep sequencing data pcr primers without degeneracy ) designed amplify target gene coding region based closely related reference genome conserved amino acid sequences orthologs conventional rt pcr cloning hu et al 1998 as pam ngg)the sequence constraint grna design occurs frequently necessary obtain full length gene sequences however use multiple primer pairs recommended increase likelihood capturing alleles direct sequencing pcr products identify sequence variants established practice molecular ecology research several programs developed decode overlapping sanger chromatograms dmitriev rakitov 2008 researchers convenient access high throughput sequencing sequence reads processed ageseq search potential variants target gene sequences xue tsai 2015 ageseq available standalone program galaxy compatible tool https://toolshed.g2.bx.psu.edu support web based data analysis it noted pcr amplification noncoding sequences tricky due lower degree sequence conservation xue et al 2015 thus crispr cas9 applications target promoter noncoding sequences e.g. transcriptional activation chromatin modification sander joung 2014 resequencing transformation clone unbiased variant calling discussed populus 717 xue et al 2015 recommended the populus study extended ever growing list plant species successfully genome edited crispr cas9 bortesi fischer 2015 kumar jain 2015 woody perennials woody perennials suffer experimental systems due lengthiness genetic transformation plant characterization many forest horticultural tree species genotypes notoriously recalcitrant tissue culture regeneration low transformation efficiencies litz padilla 2012 busov et al 2005 limitations associated established technologies incomplete silencing position effects epigenetic modifications transgenes matzke matzke 1998 impede progress transgenic tree research even species facile transformation system populus tremula x alba 717 common practice generating multiple independent events preliminary screening prior depth characterization selected lines resource demanding time consuming fig 2 the ability crispr cas9 generate null mutations primary transformants promise phenotypic consistency among independent biallelic mutants demonstrated populus study make compelling argument may soon become acceptable characterize transgenic lines sequence verified mutations high throughput methods mapping genome editing patterns xue tsai 2015 transgene e.g. dna harboring cas9 grna selectable marker insertion sites kanizay et al 2015 ) are expected facilitate effort depicted figure 2 primary transformants confirmed editing used directly depth characterization multiple independent events available biological replicates zhou et al 2015 even mutation events obtained difficult transform species suboptimal transformation trials ability bypass rna level screening obtain stable mutations still confers advantages gene silencing approaches crispr cas9 thus offers enticing prospect streamlined transgenic characterization expedited large scale functional characterization figure 2.schematic comparisons experimental approaches involving gene silencing vs. crispr cas9 genome editing ( gene silencing antisense sense rnai approaches knowledge spatiotemporal expression pattern target gene used select appropriate promoter construct preparation expression knowledge necessary crispr cas9 editing dna level vectors pol iii promoter e.g. u6 u3 grna expression cas9 control constitutive e.g. 35s promoter widely applicable ( b following regeneration putative transgenic plants conventional screening involves pcr confirmation transgenes followed expression analysis select events desired maximum levels gene suppression it common screen large number events 10 identify minimum 3 subsequent analysis this process greatly simplified crispr cas9 mutants dna level analysis amplicon sequencing identify events biallelic mutations analysis ( c species robust transformation system multiple biallelic crispr cas9 events used directly biological replicates depth characterization case difficult transform species biallelic events may obtained micropropagation necessary obtain biological replicates depth characterization typically done using gene silencing ( gene silencing antisense sense rnai approaches knowledge spatiotemporal expression pattern target gene used select appropriate promoter construct preparation expression knowledge necessary crispr cas9 editing dna level vectors pol iii promoter e.g. u6 u3 grna expression cas9 control constitutive e.g. 35s promoter widely applicable ( b following regeneration putative transgenic plants conventional screening involves pcr confirmation transgenes followed expression analysis select events desired maximum levels gene suppression it common screen large number events 10 identify minimum 3 subsequent analysis this process greatly simplified crispr cas9 mutants dna level analysis amplicon sequencing identify events biallelic mutations analysis ( c species robust transformation system multiple biallelic crispr cas9 events used directly biological replicates depth characterization case difficult transform species biallelic events may obtained micropropagation necessary obtain biological replicates depth characterization typically done using gene silencing biallelic mutations target gene(s conjunction hemizygous nature transgene e.g. dna integration primary transformants t0 means dna edited transgene free progenies readily obtained t1 segregants demonstrated annual species zhang et al trait stacking early flowering induction thus highly desirable example expression flowering locus ft demonstrated prunus plum populus eucalyptus hoenicka et al 2014 ; another concern outcrossing species progenies different parents necessitates additional screening selection we note however introgressing transgenic mutant events elite genotypes established practice crop tree breeding programs hence unique crispr cas9-edited mutants a well known tree example loblolly pine pinus taeda clone 756 harbors naturally occurring null allele cinnamoyl alcohol dehydrogenase involved lignin biosynthesis extensively used parent several breeding programs us gill et al 2003 another example early flowering ft plum serves parent fasttrack breeding program expedite development improved commercial cultivars callahan et al various molecular genomics tools available facilitate progeny selection transgenic breeding programs recently virus based systems explored transient expression genome engineering reagents ali et al however systems still utilize dna express repurposed viral genome components resulting plants transgene free without crossing these methods also depend agroinfiltration deliver vector plant cells unfortunately applicable woody species open minor vein structure leaves gamalei 1989 clearly development innovative methods necessary facile removal dna genome edited plants without crossing regardless null segregants crop cultivars derived genome editing indistinguishable naturally occurring chemically induced mutants may therefore exempt gmo regulation countries adhere product based regulations voytas gao 2014 this expected significantly reduce timeline financial burden associated developing new crop varieties thereby encouraging adoption crispr cas9-based genome editing forest products fruit tree nuts woody ornamental industries the research tsai laboratory discussed article supported department energy office biological environmental research grant de sc0008470 department agriculture national institute food agriculture grant 2015 67013 22812 georgia research alliance hank haynes forest biotechnology endowment

abstractthe crispr / cas9 technology is a welcome breakthrough for genome editing , owing to its precision , efficiency , versatility and ease of adoption . we recently reported the first application of crispr / cas9 for biallelic mutations in stably transformed populus , extending the species range of this powerful technology to woody perennials . an underappreciated obstacle in genome editing of outcrossing species is the frequent occurrence of sequence polymorphisms that can render crispr / cas9 unproductive . we discuss experimental evidence as well as genome - wide computational analysis to demonstrate the sensitivity of crispr / cas9 to allelic heterozygosity , and highlight tools and strategies that can help deal with such sequence polymorphisms . with its specificity , crispr / cas9 offers a less equivocal means than previous approaches for discerning functional redundancy of paralogous genes that are prevalent in plant genomes . continuing improvements of the crispr / cas9 system for multiplex genome engineering should facilitate these efforts . the paradigm shift brought about by crispr / cas9 promises to accelerate not only basic research but also applied crop improvement progress .

like co@fe3o4 recently underwent extensive study elucidate oxidative stability core phase shell fept@fe3o4 core shell nanoparticles used building blocks form nanocomposites enhanced magnetic properties potential novel applications include magnetic data storage catalysis targeted drug delivery terms nanomagnetics specifically hope presence inert oxide shell may function inhibit agglomeration cores upon annealing necessary step creating ordered l10 fept bimetallic structure higher magnetic coercivity the determination core composition important tailoring synthesis order ultimately achieve desired 50:50 fept alloy composition solution core shell particles drop cast onto 3 mm holey carbon copper grid edx data acquired using fei osiris tem equipped high brightness schottky x feg gun super x edx system comprising four silicon drift detectors approximately 30 mm area arranged symmetrically around optic axis achieve collection solid angle 0.9 sr edx data collected form spectrum images focused electron probe scanned raster across region interest scanning tem stem point scan structural information obtained electron scattering incident high angle annular dark field haadf detector simultaneously edx spectrum obtained collecting x rays emitted local volume probed electron beam the resulting edx spectrum image three dimensional data set whose x axes correspond position probe whose z axis corresponds energy detected x ray spectrum images acquired probe current approximately 0.7 na acceleration voltage 200 kv spatial sampling 0.5 1 nm pixel 50100 ms pixel dwell times x ray intensities obtained fitting model edx spectra experimental data using weighted least squares atomic fractions quantified intensities using cliff lorimer quantification the edx model quantification implemented hyperspy available future releases software figure 1a displays haadf stem image obtained acquisition spectrum image enclosing cluster 13 co@fe3o4 nanoparticles although particle morphologies seen vary slightly one particle another majority particles round core approximately 20 nm diameter surrounded thin shell approximately 5 nm thickness edx elemental maps cobalt iron oxygen figure 1b obtained integration element background subtracted k line x ray peak show individual particles comprised cobalt core surrounded shell composed iron oxygen expected the largest particle lower left region map appears iron core compared smaller particles these conventional edx element maps show location various elements composition particle core example determined elemental mapping due presence shell core projection elemental maps b cobalt c iron oxygen display location various elements respect particle morphology scale bar 50 nm greyscale x ray counts the edx spectrum image data co@fe3o4 nanoparticle cluster shown figure 1a subsequently processed using bss methods hyperspy first spectral dimension data set binned four 5 ev channel 20 ev channel order increase number counts per channel next we note binning step necessary order optimize accuracy variance stabilization channel the first three principal components pc#0 pc#1 pc#2 exhibited significantly greater variance remaining components figure 2a suggests three phases present sample that case three pca components linear combination spectra distribution maps phases mixing matrix unknown next compute numerically first derivative pca spectral components order diminish correlation caused edx background use fastica estimate mixing matrix compute independent components ics ic#0 ic#1 ic#2 figure 2b distribution maps figure 2c e pca results component independence much stringent property uncorrelatedness imposed pca if disregard small copper peaks contained independent components likely originating copper support mesh see ic#0 contains cobalt x ray peaks ic#1 iron oxygen peaks ic#2 carbon peak the three ics appear belong three phases present originally scanned area core shell supporting film this hypothesis explored next section point however important note unlike conventional edx mapping shown figure 1 elements selected prior performing ica thus analysis free external bias except choice number components result bss pca ica edx si co@fe3o4 core ( b corresponding independent component spectra contain expected x ray lines elements present independent component maps c e show c ic#0 concentrated nanoparticle cores ic#1 shells e ic#2 everywhere carbon supporting film scale 50 nm greyscale normalized weighting we move analysis second cluster particles comprised bimetallic iron platinum core surrounded iron oxide shell a crystalline core surrounded polycrystalline oxide shell observed representative high resolution stem haadf image shown figure 3 the particle morphologies found mean core diameter approximately 3.3 nm mean shell thickness approximately 1.7 nm figure 4a also visible pure iron oxide particles lower right hand corner figure 4a ica cluster bimetallic platinum iron nanoparticle seeds coated fe3o4 shells ( b scree plot first 50 principal components showing first three components lying noise ( c e element maps c platinum iron e oxygen f h the ic maps f ic#0 g ic#1 h ic#2 corresponding ic spectra selected element maps figure 4c e clear exception two particles lower right hand corner particles comprised platinum rich core surrounded iron oxide shell however clear maps alone whether iron present core conventional elemental mapping one tell whether particles contain pure platinum core surrounded iron oxide shell whether iron alloyed platinum form bimetallic core we address questions performing bss edx spectrum image using procedure detailed once inspecting scree plot figure 4b find sample consists three phases the spatial distribution ic#0 concentrated particle cores ic#1 shell around cores ic#2 approximately uniformly distributed map figure 4f h disregard spurious copper peak ic#0 contains iron platinum x ray peaks ic#1 iron oxygen peaks ic#2 single carbon peak figure 4i analysis it appears ica components represent different phases present edx spectrum image ic#0 ic#1 ic#2 genuinely represent bimetallic fept cores iron oxide shells carbon support respectively order verify accuracy ica results evaluated whether ic#0 represented true composition core analyzing bare fept seed particle clusters obtained chemical synthesis extracted prior shell addition step being made synthesis composition bimetallic seed particles expected match composition bimetallic cores core shell particles analyzed figure 4 a total 12 edx sis acquired order capture analyze multiple fept bimetallic seed clusters the segmentation one edx sis shown figure 5a b accurately extract intensity fe k pt l peaks model composed one gaussian per x ray line and a background based kramers small expressions developed elsewhere used shown green figure 5c the free parameters model area gaussian height background negligible the mean reduced fit particles 1.01 indicating discrepancies model data accordance poisson noise variance intensities fe k pt l peaks fitted model quantified using cliff lorimer method the obtained compositions plotted particle figure 5d along fitting error estimated poisson statistics the raw data decomposed using pca fept seed data first three components retained noise reduction the 103 individual fept bimetallic seeds analyzed found mean composition 82.0 % pt lies well within one standard deviation average bimetallic seed composition the data points figure 5d displayed order ascending particle size as calculated compositions right hand side tend smaller error bar account signal noise ratio higher larger particles the compositions larger seed particles also closer mean composition composition ic#0 confirming homogeneity composition validity bss analysis summary composition 103 bare fept bimetallic nanoparticles extracted synthesis prior shell addition step ( b segmentation edx spectrum image prior quantification particle ( c fitting edx spectrum single seed circled b model spectrum determine fe k pt l peak intensities ( particle seed compositions obtained quantifying fitted intensities 103 different particles error bars 1 standard deviation a comparison raw edx spectra extracted fept bimetallic seed particles pure fe3o4 particles ic#0 ic#1 respectively provided figure 6 cases the ics scaled constant obtain best fit raw spectra despite strong overall agreement case the carbon peak difference cases caused separation carbon different component ic#2 the difference shell cu peaks due compositional difference cu signal spurious origin the iron oxide particle spectrum also contains small silicon sulfur peaks likely originate residue carbon film the difference pt core peak may due attenuation pt x rays shell core shell nanoparticles nearby particles along trajectory detector the strong overall similarity raw ic spectra provide direct evidence showing spectral components extracted ica core shell spectrum image data strongly representative buried core surrounding shell carbon support compositions comparison raw edx spectra extracted fept bimetallic seed particle top iron oxide particle bottom ic#0 ic#1 respectively fept seed fe3o4 x when analyzing beam sensitive materials main limitation accuracy bss analysis method propose intensity edx signal achievable without inducing significant sample damage case despite use high efficiency edx system the number collected x rays low order avoid artifacts arise when using variance stabilizing transformation domain application binned data four spectral dimension 5 ev channel 20 ev channel given resolution edx detector approximately 130 ev mn k overlapping x ray lines case increase number counts per channel hence accuracy analysis comes without significant resolution loss therefore adverse effect analysis a blind source separation method based pca ica applied analysis edx spectrum images core the analysis accurately determined number phases analyzed volume core shell supporting film well spectra distribution maps we confirmed accuracy analysis comparing calculated spectra platinum iron core iron oxide shell obtained structures isolation excellent agreement suggests bss therefore used accurately analyze edx data the use ica edx spectrum image data promises powerful technique extracting buried compositions nanoscale variety materials testing method applicability different systems initiated

the chemical composition of core shell nanoparticle clusters have been determined through principal component analysis ( pca ) and independent component analysis ( ica ) of an energy - dispersive x - ray ( edx ) spectrum image ( si ) acquired in a scanning transmission electron microscope ( stem ) . the method blindly decomposes the si into three components , which are found to accurately represent the isolated and unmixed x - ray signals originating from the supporting carbon film , the shell , and the bimetallic core . the composition of the latter is verified by and is in excellent agreement with the separate quantification of bare bimetallic seed nanoparticles .

ionic calcium ca controls multiple cellular signaling processes eukaryotic cells including proliferation gene expression neurotransmitter release ca binding proteins calmodulin play pivotal role ca signal transmission amplification increases concentration intracellular ca activate specific protein targets among ca calmodulin dependent protein kinase ii camkii critical signal mediator response increase intracellular ca thr-286 camkii the coupling ca calmodulin one camkii subunits allows phosphorylation adjacent subunit thr calmodulin trapping confers ca calmodulin independent kinase activity complex thus prolongs ca signal thus calmodulin trapping represents molecular mechanism memory defined capacity acquire store consolidate retrieve evocate information camkii major synaptic protein activated induction long term potentiation ltp ca influx n methyl aspartate nmda receptors calmodulin trapping allows camkii remain activated long initial ca signal dissipated suggesting camkii memory molecule crucial ltp consistent notion camkii null mice present impaired memory formation camkii essential genesis maintenance ltp postsynaptic neurons following presynaptic stimulation camkii activated postsynaptic neurons creates physiological imprint initial ca signal increases translocation nmda receptors plasma membrane because capacity remain activated long initial pulse ca signaling camkii perpetuates ca effects modulates gene expression epigenetic profile postsynaptic neurons camkii also participates glucose stimulated insulin secretion gsis multiple insulin secretagogues increase camkii activity perfused rat pancreas the dynamics camkii activation correlate amplitude gsis camkii activation temporally associated insulin secretion camkii essential appropriate gsis involved several steps process including synthesis insulin granules modulation cytoplasmic content atp activation synapsin importantly camkii also regulates transcription factors central cell function creb mafa here investigated whether pancreatic cells like neurons acquire store information contained calcium pulses form metabolic memory indeed find cells retain memory prior activation describe molecular mechanism contributes memory min6 insulinoma cells mouse human pancreatic islets distributed three groups control pulse pulse kn93 10 initially groups maintained medium 5.6 mm glucose 24 h. acclimation period control group exposed 3-mm glucose 24 h pulse pulse kn93 10 groups exposed 30 mm glucose four 1-h periods intercalated 7-hour periods 3 mm glucose kn93 camkii inhibitor 10 present 30 mm glucose pulses all groups maintained 3 mm glucose 24-h consolidation period insulin secretion min6 cells mouse pancreatic islets conducted following standard procedures insulin measured ria one hundred fifty islets handpicked light microscope pre incubated 1 h krbb krebs bicarbonate buffer containing 0.3 the medium discarded islets incubated additional hour 500-l krbb containing 2.8 16.8 mm glucose subsequently supernatant collected evaluate insulin secretion ria perifusion assays 150 treated human islets placed perifusion chamber millipore billerica usa computer controlled fast performance hplc system allowed programmable rates flow concentrations appropriate solutions held 37 c water bath islets perfused 80 min krbb absence glucose followed krbb increasing concentrations glucose glucose ramped 0 30 mm 0.75 mm min end experiment islets tested maximal insulin secretion adding 30 mm kcl perifusate samples collected 2 ml min insulin content determined using ria statistical analyses performed using student test two way anova bonferroni posttest required statistical significance set p 0.05 in order investigate metabolic memory insulin producing cells first develop paradigm memory evident as detailed established exposure cultured min6 cells four 1-h pulses high glucose interspersed 7-h intervals low glucose thus mimicking postprandial glucose spikes vivo able elicit robust metabolic memory detailed experimental paradigm outlined figure 1a as shown figure 1b min6 cells exposed glucose pulse regimen showed higher insulin secretion exposed low 2.8 mm high 16.8 mm glucose cells cultured continuously low glucose this increase insulin secretion accompanied significant rise levels phosphorylated camkii consistent notion camkii might molecular mediator metabolic memory figure 1c importantly increases basal stimulated insulin secretion glucose pulse group abolished kn93 figure 1b specific camkii inhibitor next evaluated kinetics cell response acute glucose exposure observed pulse group secreted insulin basal time zero stimulatory concentrations glucose 16.7 mm 5 60 min following stimulation figure 1e this effect persisted even glucose concentrations returned 2.8 mm parallel phosphorylation camkii higher glucose pulse group glucose concentrations remained elevated even glucose concentration reduced 2.8 mm figure 1f thus min6 cells acquired metabolic memory prior exposure glucose pulses retained 24-h consolidation period it important determine metabolic memory confined min6 insulinoma cells also property primary human cells therefore cultured human islets multiple non diabetic deceased organ donors see table 1 donor information exposed pulses 30 mm glucose paradigm described pulse treatment increased insulin secretion basal 2.8 mm stimulatory 16.8 mm glucose concentrations figure 2a case min6 cells the pulse group showed increased camkii phosphorylation basal stimulatory glucose concentrations figure 2b next determined human islet response glucose challenge islet perifusion assay islets glucose pulse group showed increased first second phase insulin secretion compared islets control group figure 2c as effects abolished camkii inhibitor kn93 figure 2a we also tested metabolic memory cells using isolated mouse pancreatic islets similar outcome extended data figure 1 ) also found using live cell calcium imaging mouse islets increases cytoplasmic calcium levels following acute glucose stimulation representing penultimate step insulin secretion significantly higher pulse group compared controls extended data figure 1c investigate molecular mechanisms glucose pulse paradigm induces memory cells evaluated expression essential mediators insulin secretory response the glucose pulse paradigm induced expression glucokinase gck main glucose sensor cells figure 3a voltage gated ca channel cav1.2 figure 3b snap25 essential component exocytotic machinery figure 3c mafa key transcription factor insulin gene mature cell phenotype general figure 3d all effects pulsed glucose paradigm protein levels reduced abolished treatment kn93 high glucose exposure finally asked metabolic memory cells dependent glucose metabolism memory produced membrane depolarization alone end treated human islets pulses 30 mm kcl causes membrane depolarization opening voltage gated ca channels insulin secretion without prior increase intracellular atp levels as shown figure 3e depolarization potassium chloride acquisition period produced similar somewhat lower increases pcamkii psynapsin levels 24 h last kcl pulse thus increases intracellular calcium elicited membrane depolarization sufficient activate camkii produce metabolic memory total camkii protein levels affected treatments used data shown glucose stimulated insulin secretion complex process translates glycolytic flux elevated atp production increased cytoplasmic ca levels finally fusion insulin granules plasma membrane this process accompanied increased phosphorylation camkii extended data figure 2 process shown part establishment metabolic memory cells cerasi colleagues previously reported time dependent potentiation insulin secretion exposure rat islets high glucose 27.7 mm 60 min prior test stimulation glucose increased subsequent insulin secretion however studies focused analyzing acute effects high glucose pre treatment yet investigate molecular mechanism underlying phenomenon we demonstrate human mouse pancreatic cells able acquire consolidate retrieve information induced high glucose exposure determined ability dependent camkii conclusion shown like neurons human mouse cells able acquire store retrieve information process similar neuronal ltp this process presented schematically figure 4 dependent activation camkii case neuronal memory these findings provide evidence similarity neurons cells transcriptome epigenome level accidental important aspect biology embryologically distinct cell types metabolic memory cells likely represents useful evolutionary adaptation variation food availability periods food abundance nature can vary dramatically length metabolic memory repeated carbohydrate loads cells ensures higher insulin secretion thus efficient uptake excess glucose skeletal muscle adipose tissue long term storage contributing adaptation periods starvation given pivotal role altered insulin secretion metabolic disorders future work need establish extent metabolic memory pancreatic cells contributes pathophysiology diseases

ca2+/calmodulin - dependent protein kinase ii ( camkii ) functions both in regulation of insulin secretion and neurotransmitter release through common downstream mediators . therefore , we hypothesized that pancreatic - cells acquire and store the information contained in calcium pulses as a form of metabolic memory , just as neurons store cognitive information . to test this hypothesis , we developed a novel paradigm of pulsed exposure of - cells to intervals of high glucose , followed by a 24-h consolidation period to eliminate any acute metabolic effects . strikingly , - cells exposed to this high - glucose pulse paradigm exhibited significantly stronger insulin secretion . this metabolic memory was entirely dependent on camkii . metabolic memory was reflected on the protein level by increased expression of proteins involved in glucose sensing and ca2 + -dependent vesicle secretion , and by elevated levels of the key - cell transcription factor mafa . in summary , like neurons , human and mouse - cells are able to acquire and retrieve information .

health related absence disease therefore need conceptualize operationalize health increasingly come understand information functional status needed order appreciate full picture regarding health individual population an individual health fundamentally includes capacity carry full range actions activities tasks required fully engage areas human life the health state person described terms capacity carry set tasks actions in addition health state also includes changes body functions and/or structures arising health condition the impact health state person life understood measuring performance tasks actions person real life actual environment the full picture health experience appreciated taking cognizance value people place levels functioning given domains association health condition plainly concept functional status integral health achievement two individuals identical diagnoses may utterly different levels functioning determine actual health status without fsi our picture health individual population flawed incomplete fsi course long collected various ways used clinically especially rehabilitative medicine physical occupational speech language therapy nursing home home care settings fsi essential needs assessment well development monitoring rehabilitative interventions restore maintain functions it also essential area health care aim therapy assist patients maximizing capacities perform activities needed lives although one doubts restoring functioning restoring health ultimate purpose forms health care clinicians focusing exclusively acute care needs see need collect utilize fsi countries sophisticated health administrative data collection utilization infrastructure wide variety information what often missing information would link diagnosis treatment health outcomes fully meaningful patient life namely information presence decrements capacity carry tasks actions areas life well decrements play person actual real life environment deyo patrick 1989 lubetkin et al 2003 there growing recognition gap health administrative records failure collect disseminate fsi across health care settings unless fsi becomes essential part administrative records the potential value data lost merely clinicians health administrators concerned management quality care issues health researchers public health agencies this insight clearly expressed report national committee vital health statistics ncvhs 2001 without functional status information researchers policymakers others already using administrative data best rough idea people individually collectively worst making erroneous assumptions decisions the report outlines detail benefits routinely collecting fsi across entire health care delivery system throughout care settings fsi serve management needs stakeholders health care system clinicians providers payers patients government regulatory bodies true especially respect evaluating outcomes comparing treatment modalities predicting managing costs this links directly debates modes service provision single multiple payer managed care fee service hybrid mixture the policy research applications fsi evident local health management quality control broader arena public health policy decisions priorities must made level individual clinics hospitals local regional health care agencies level government planning budgeting given importance getting complete picture health outcomes fsi essential input evidence based policy decisionmaking researchers areas health social policy levels need valid reliable data functional status order make informed decisions for example matter debate whether world population lives longer ages unhealthy pose greater burden health systems evidence suggesting elderly persons today functioning higher levels without reliable information levels functioning debate would unresolvable would possible detect functional status since disease morbidity may changed much compression morbidity occurs disability decrement functioning postponed longevity extended example effects exercise better eating habits the direct test compression extension morbidity depends effects reduced health risks cumulative lifetime disability fries 1980 2001 vita et al fsi crucial element description health states quantification overall health status individuals aggregated summary measure population health use fsi area particular data collected world health survey field 70 countries feeds ongoing endeavors determine levels distributions health this survey would inconceivable without information health outcomes describe health multiple dimensions terms levels functioning parsimonious set domains it commonly known demographic trends toward older population least developed counties create unprecedented burdens age sensitive social policies social security pensions retirement unemployment long term care aging according recent organization economic cooperation development oecd 2001 report principal factor currently driving pension spending costs since age sensitive social programming constitutes 40 60 percent total public spending impact aging considerable comprehend nature magnitude social impact responsible policies transportation housing employment taxation need reliable data functional status plays lives aging population fsi available wide variety uses however it must routinely consistently collected across entire health care delivery system preferably electronic format nonetheless contemplating systemwide changes required collect fsi classification provides common language framework describe universe functioning disability required order complement classification scheme comprehensive coding system creates consistent comparable data across settings care method routinely capturing disseminating data mode manner consistent social interests preserving privacy linked measurement tools clinical related encounters the foundation new structure collecting fsi therefore standard classification coding system make feasible fsi included administrative data ncvhs report stated international classification diseases icd served us well century characterizing diagnoses time complement parallel system characterizing functional status although committee argued research analysis testing demonstration projects required final recommendations made concluded concepts conceptual framework icf promise code set reporting functional status information administrative records computerized medical records committee view icf existing classification system could used code functional status across age span article want briefly describe extensive international developmental process lead revision original international classification impairments disabilities handicaps icidh world health organization 1980 produced icf we also want describe basic principles structure icf particular show value context collecting fsi administrative records the primary mandate production dissemination reliable timely information health populations 1947 constitution requires member shall provide statistical epidemiological reports manner determined health assembly countries long reported causes death mortality statistics based 1992 international statistical classification diseases related health problems icd-10 though useful calculating life expectancy different countries however recognized data capture overall health status living populations missing information non fatal health outcomes i.e. functioning disability across areas life meet need 1980 issued tool classification consequences disease namely icidh a considerable academic literature built around clinical uses icidh much literature critical underlying model disability responding critiques international call updated version launched revision process 1993 address many viewed urgent international need framework measuring reporting health functional status individual population levels next 10 years international collaborating centers governmental non governmental organizations including groups representing persons disabilities engaged systematic revision icidh exhaustive literature search existing classifications assessment tools the revision team developed 3,000-plus item pool potential classification domain names areas human functioning body person social levels all efforts made ensure icidh-2 initially named would suitable classification domains functioning associated physical mental health conditions adopting strategy computer software development alpha beta drafts prepared 1996 forward the original 1980 icidh approved field trial purposes light team felt icidh-2 necessary credibility legitimacy serve international standard language health functioning revision process include several years field trials tests the first phase field trials concentrated cross cultural linguistic applicability model classificatory structure language icidh-2 the intent phase field trials establish conceptual functional equivalence items contained within classification stn et al.(1999a b 2000 provide rationale methodologies presentation analysis 15-country field trials these results fed international collaboration team relied global network collaborating centers non governmental organizations disability groups individual experts key informants the next revision phase began 1999 series expert drafting teams assembled geneva produce beta 2 draft this draft used second round international field trials focusing questions reliability utility feasibility use once results tests collected analyzed pre final draft produced early fall 2000 result intensive editing process grounded expert input received around world the icidh-2 unlike predecessor outset developed multiple languages primarily identify respond cross cultural linguistic differences might affect usefulness classification the collaborating centers others provided constant input stage language classification structures redrafted refined multiple iterations the draft put internet comment wide range individuals including providers consumers presentation executive board december 2000 classification put agenda fifty fourth world health assembly renamed icf the new title reflected philosophy moving beyond consequence disease approach highlighted functioning component health may 2001 it unanimously endorsed member states urged use icf research surveillance reporting appropriate approval icf became member family international classifications whereas icd-10 provides codes mortality morbidity icf provides codes describe complete range functional states capture complete experience health the icd-10 icf therefore complementary encourages users utilize together wherever applicable this ensure meaningful complete picture health people populations soon official release director general gro harlem bruntland announced icf framework measuring health disability individual population levels already implemented icf basis extensive world health survey program demonstrating use global universal tool to improve health tools needed measure health particular measure changes health brought interventions icf ruler take precise measurements health disability brundtland 2002 public health perspective usefulness icf goes beyond measuring population health effectiveness internationally coordinated interventions funded initiatives global fund fight aids tuberculosis malaria in addition icf framework countries able identify social factors education transportation housing determinants health social factors influenced improvements health making links support relationship health economic development short shape little red book extraordinarily versatile tool swiss army knife health ministries researchers decision makers ( brundtland 2002 undoubtedly primary reason icf plausibly claim universal tool classifying states functioning disability underlying model icf reflects best understanding complex phenomena functioning disability manner greatest extent possible theory neutral therefore compatible whichever theoretical account disability arises individual population levels evidence may confirm it conceptual basis definition measurement policy formulations aspects disability a paradigmatic shift thinking regard disability captured icf stress placed health levels functioning heretofore disability construed none phenomenon distinct category individual either belonged the icf hand presents disability continuum relevant lives people different degrees different times lives disability something happens minority humanity common indeed natural feature human condition the icf people people traditionally referred disabled isolated separate group icf thus mainstreams experience disability recognizes universal human experience shifting focus cause full range lived experiences places health conditions equal footing allowing compared using common metric ruler health disability emphasizing people disabilities labeling people disabled focus level health functional capacity people decrements functioning may result decrements intrinsic capacity problems body functions structures result features person physical human built social environment lead problems performance decrements capacity very likely decrements functioning result processes yet extent intrinsic decrements capacity environmental factors cause matter determined priori moreover icf grounded principle universality namely functioning disability applicable people irrespective health condition particular disability decrement functioning one levels mark specific minority class people feature human condition epidemiologically speaking lifespan universal phenomena in addition icf committed principle parity states functional status determined background etiology particular whether one physical rather mental health condition much time effort international collaboration gone development icf it longer plausible insist icf medical classification people disability reduces issues functional status underlying medical conditions ignores often salient role physical social environment creation restrictions participation experienced persons functional problems the revision process produced classification already stood rigorous tests validity reliability cross cultural applicability it ncvhs concluded existing classification system could used code functional status across age span turn structure icf classification system part show committee correctly assessed value icf coding system functional status suitable use administrative records the model informs icf portrays functioning decrements functioning disability dynamic interaction health conditions diseases disorders injuries contextual factors contextual factors include environmental factors aspects physical human built social attitudinal environment create lived experience functioning disability although classified icf contextual factors also include personal factors sex age coping styles social background education overall behavior patterns may influence disability experienced individual the terms functioning disability icf general umbrella terms respectively positive negatives aspects interaction individual health condition individual contextual factors environmental personal factors icf health condition umbrella term disease acute chronic disorder injury trauma health condition may also include circumstances pregnancy aging stress congenital anomaly genetic predisposition the icf interactive model identifies three levels human functioning functioning level body body part whole person whole person complete environment these levels turn define three aspects functioning body functions structures activities participation disability similarly denotes decrement functioning one levels impairment activity limitation participation restrictions table 2 shows complete list chapters found three classifications included icf chapters are second third instances fourth levels categories arranged hierarchical tree branch stem leaf arrangement this structure makes possible icf used classification tool systematically describing situations human functioning problems functioning this complex information organized icf means hierarchical coding system thereby creating common international language functioning disability icf organizes information means several classifications distributed two parts 1 component functioning disability includes component body body function body structure classifications component activities participation includes domains denoting aspects functioning individual social perspective organized single classification 2 component contextual factors list environmental factors organized individual immediate wider environment the classifications first part identify domains functioning basic physiological functions body structures simple complex actions tasks social performances relationships the environmental factors list provides tool identifying features person physical human built social attitudinal environment interaction domains functioning constitute complete lived experience human functioning disability within contextual factors part besides environmental factors icf recognizes existence personal factors another component provides classification domains practical meaningful set related physiological functions anatomical structures actions tasks areas life domains make different chapters blocks within component world health organization 2001 order domains capture descriptive information functioning disability particular cases they must used conjunction qualifiers record presence severity problem decrement functioning body person social levels classifications body function structure the primary qualifier indicates presence impairment five point scale degree impairment function structure impairment mild moderate severe complete case activity participation list domains two essential qualifiers provided capture full range relevant information disability the performance qualifier used describe individual current actual environment including whatever assistive devices accommodations person may use perform actions tasks whatever barriers hindrances exist person actual environment because current environment always incorporates overall social context performance might understood involvement lived experience disability the capacity qualifier describes individual inherent ability execute task action operationally qualifier identifies highest probable level functioning person given functional domain given moment without specific assistance measurement purposes level capacity presumes standardized assessment environment namely one reveals inherent capacity person specific functional domain without particular enhancements the environmental factors list used describe standard assessment environment order ensure results across different studies compared holding environment constant intuitively performance qualifier captures people actually lives whereas capacity qualifier identifies person inherent capacity without explicit environmental facilitation hindrance who developing standard application guide operationalize constructs capacity performance respect individual items form classification table 3 shows data organized reflect role two qualifiers used domains activity participation classification general matter describing functioning disability phenomena fully accurately performance capacity having access performance capacity data enables icf users determine gap capacity performance if capacity less performance person actual current environment enabled perform better data capacity would predict environment facilitated performance hand if capacity greater performance aspect environment acting barrier level performance feasible suitable environment icf thus makes possible measure effect person environment decrement functioning given health condition the environmental factors classification used identify specific features person actual environment barriers facilitators general person specific regard item person body functions body structures activities participation described it also used previously stated describe specific testing environments capacity measured use classification functional status relevant health administrative records icf provides complete classification body person level domains functioning given designed multiplicity uses users far icf could ever plausibly integrated viable coding system health records although remains ultimate lexicon coder clinical research purposes could turn clearly implementation purposes area simplified checklist items needed such checklist produced used beta 1 2 field testing phase revision process world health organization 2001 this checklist takes less 30 minutes complete currently extensively tested clinical studies different disorders order study feasibility reliability concurrent validity existing assessment instruments part larger project define core sets items may used rehabilitation settings specific conditions across several disorders stucki et al 2002 the core sets items corresponding scales could also converted even shorter assessment instruments the challenge incorporating icf clinical administrative records beyond lexicon framework lies identifying parsimonious set domains items captures decrements functioning across different health conditions smaller subset domains items uniquely describe decrements functioning typify given health condition in addition mapping instruments measure functioning disability already use onto icf categories allow ready crosswalk measurements already made points encounter common framework cieza et al 2002 the use icf larger population based surveys also provide data norms distributions health functioning disability enable setting appropriate thresholds multitude purposes table 4 maps domains icf included different waves world health survey ought included minimum ideal set information systems these domains also included icf checklist designed clinical tool primary data collection strategies regard functional status manner truly comparable infancy especially international use use across population groups further tools need developed standards procedures established data become meaningful usable final issue must mentioned icf conceived dynamic classification serve multiple users requiring different levels detail also continue evolve advancements science the classification flexible structure expanded level detail example fourth level specific uses new codes added gaps left numbering system a set operational rules specify procedure evidence based expansion adaptation revision classification a common language describing fsi key ensuring comparability data myriad sources well providing users tool precise accurate communication the recognition description health health related outcomes must go beyond narrow view health restricted absence disease well definition disability must move beyond narrow impairment based view traditionally adopted define minority population go long way bridging gap health disability data it also fill void existing health outcomes data measuring impact interventions monitoring time health records must include functioning information order ensure complete description health states the icf common language framework users employ way languages grow evolve flourish time adapted modified express new ideas icf multitude applications creatively used continues living classification as new languages important develop tools learn new language toward end who developing standardized application manuals web based learning courses use state art pedagogic methodology assist end users its usefulness describing functional health status information one measures success

a common framework for describing functional status information ( fsi ) in health records is needed in order to make this information comparable and of value . the world health organization 's ( who 's ) international classification of functioning , disability and health ( icf ) , which has been approved by all its member states , provides this common language and framework . the biopsychosocial model of functioning and disability embodied in the icf goes beyond disease and conceptualizes functioning from the individual 's body , person , and lived experience vantage points , thereby allowing for planning interventions targeted at the individual 's body , the individual as a whole or toward the environment . this framework then permits the evaluation of both the effectiveness and cost effectiveness of these different interventions in devising programs at the personal or societal level .

centers disease control prevention cdc united states preventive services task force uspstf recommend universal hiv screening pregnant women entering prenatal care 1 2 this screening enables hiv infected women infants benefit appropriate timely interventions antiretroviral medications when recommended antiretroviral obstetric interventions used woman knows hiv infection early pregnancy less 2% chance delivering hiv infected infant without intervention risk approximately 25% united states 36 testing hiv began 1985 introduction enzyme immunoassay eia order account false positive results using screening tests low prevalence population confirmatory testing implemented using western blot immunofluorescence assay low prevalence population the false positive rate using eia increased compared high prevalence population positive predictive value test always depend prevalence condition population tested testing performed cdc the eia positive predictive value ranges 71 83% populations hiv prevalence 0.5 1% some investigators believe presence alloantibodies account increased false positive rate associated pregnancy transfusions transplantation autoimmune diseases however risk factors specific pregnancy account poorly understood conversely recent large retrospective study found false positive hiv eia rate lower pregnant women compared nonpregnant individuals 0.14% versus 0.21% our objective determine maternal characteristics correlated false positive hiv eia testing delivery this review women delivered parkland memorial hospital dallas tex october 1 2005 september 30 2008 all women routinely received serum hiv testing initial prenatal visit time presentation labor delivery delivery via opt approach abbott commander hiv ab hiv-1/hiv-2 rdna eia abbott laboratories abbott park ill hiv test results performed time delivery analyzed study woman considered hiv negative eia testing negative positive test results confirmed fluorognost immunofluorescent assay ifa hiv-1 sanochemia corp stamford conn usa women considered falsely positive eia results positive ifa negative women delivered time period identified obstetric operations database linked pathology database hiv hepatitis b surface antigen hbsag rapid plasma reagin rpr results maternal characteristics including race parity age singleton versus multiple gestation diagnoses diabetes hypertension obtained using obstetrics operations database laboratory results drawn 28 days prior delivery seven days delivery included the study approved institutional review board university texas southwestern medical center categorical data reported frequencies statistical significance determined using analysis statistical analyses performed using sas version 9.2 sas institute cary nc a total 47,794 women identified delivered study time frame compared hiv negative patients false positive patients likely nulliparous 43% versus 31% p 0.001 younger mean age 23.9 5.7 versus 26.2 5.9 p 0.001 hiv positive patients significantly older false positive patients 27.4 versus 23.9 p 0.001 hiv negative patients 27.4 versus 26.2 p 0.012 of 47,794 women 47,391 99% hiv negative 145 0.3% false positive test 172 0.4% true positives 86 0.2% tested equivocal missing hiv results the specificity hiv eia test 99.7% positive predictive value 54.3% the sensitivity eia test presumed near 100% false negative rate using eia previously demonstrated negligible studies performed manufacturer table 2 shows prevalence diabetes hypertension hepatitis b results syphilis testing study population hiv positive women likely test positive hepatitis b surface antigen 1% versus 0% p 0.002 rpr 2% versus 0% p 0.02 there significant difference prevalence diabetes hypertension three groups there also significant difference rate hbsag rpr positivity hiv negative false positive groups when evaluating interaction nulliparity age significant correlation two variables parous patients likely older therefore nulliparity age independent predictors hiv false positivity however hiv testing groups positive false positive negative stratified parity comparison age across three groups remains significant nulliparous women table 3 p 0.0003 the interaction parity age means difference age nulliparous parous women different depending hiv status for example hiv positive group nulliparous parous women closer age false positive group this first population based study evaluate risk factors hiv false positivity pregnant women presenting delivery large urban institution we found younger nulliparous women likely false positive testing using hiv eia the observed positive predictive value ppv 54.3% lower previously reported cdc ppv 7183% nonpregnant population suggesting pregnancy may associated higher rate false positivity the low positive predictive value hiv eia study may impacted relatively low hiv prevalence 0.4% population this information could useful counseling women test positive hiv delivery emphasizes limitations eia testing used rapid test determine need intrapartum neonatal antiretroviral prophylaxis the false positive rates currently available rapid hiv tests reported much lower found eia testing study evaluated hiv false positive rate 900 pregnant women hispanic using eia rapid point care poct test oraquick they found false positive tests oraquick seven false positives using eia ppv 100% versus 35.7% mother infant rapid intervention delivery miriad ) study jamieson et al found ppv oraquick test 90% ppv eia 74% 12 13 current recommendations cdc american college obstetricians gynecologists include rapid hiv screening women presenting labor delivery undocumented hiv status repeat hiv testing third trimester women high risk live areas high hiv prevalence 7 14 15 a woman testing preliminarily positive hiv labor counseled may hiv infection neonate may exposed immediate antiretroviral prophylaxis recommended without waiting confirmatory test results the results study may aid counseling women test preliminarily positive hiv using eia awaiting confirmatory testing results it remains determined whether risk factors false positive hiv eia testing apply poct tests used real life setting our study found positive predictive value eia testing 54.3% younger nulliparous women likely test falsely positive importantly data may represent real world performance eia testing large obstetric population based setting investigators also noted significant relationship influenza vaccination false positive screening hiv antibodies 1618 a potential reason cross reactivity similarities homology transmembrane domains influenza envelope protein hemagglutinin hiv-1 envelope proteins population significant differences age parity influenza vaccination acceptance rates unpublished data women study single institution predominantly hispanic background therefore results may applicable populations reasons false positive hiv serology may vary depending geographical region find significant association young age nulliparity hiv false positive testing our study capability identify causal relationship explain association may exist in addition study address risk factors false positive testing apply hiv tests further studies needed confirm findings elucidate biological mechanisms increased hiv eia false positivity young nulliparous women compare conventional testing method contemporary rapid screening assays including poct

objective . to examine risk factors for false positive hiv enzyme immunoassay ( eia ) testing at delivery . study design . a review of pregnant women who delivered at parkland hospital between 2005 and 2008 was performed . patients routinely received serum hiv eia testing at delivery , with positive results confirmed through immunofluorescent testing . demographics , hiv , hepatitis b surface antigen ( hbsag ) , and rapid plasma reagin ( rpr ) results were obtained . statistical analyses included pearson 's chi - square and student 's t - test . results . of 47,794 patients , 47,391 ( 99% ) tested negative , 145 ( 0.3% ) falsely positive , 172 ( 0.4% ) positive , and 86 ( 0.2% ) equivocal or missing hiv results . the positive predictive value of eia was 54.3% . patients with false positive results were more likely nulliparous ( 43% versus 31% , p < 0.001 ) and younger ( 23.9 5.7 versus 26.2 5.9 years , p < 0.001 ) . hiv positive patients were older than false positive patients and more likely positive for hbsag and rpr . conclusion . false positive hiv testing at delivery using eia is associated with young maternal age and nulliparity in this population .

childhood obesity serious growing public health problem arisen past three decades the increasing occurrence disorders type 2 diabetes childhood believed consequence obesity epidemic in addition several behavioral dietary risk factors genetic predisposition important factor pathogenesis childhood obesity it estimated 4070% adiposity variance explained direct indirect genetic factors growth arrest specific 6 gas6 cloned 1988 characterized 1993 secreted vitamin k dependent protein present human circulatory system 4 5 initially gas6 shown upregulated growth arrested fibroblasts suggesting plays protective role certain cellular stresses apoptosis gas6 expression widespread many tissues including immune cells endothelial cells vascular smooth muscle cells adipocytes 79 the protein also ligand tam tyro-3/axl mer family tyrosine kinase receptor the gas6/tam system implicated cell survival proliferation cell adhesion migration hemostasis inflammatory cytokine release 4 10 recently gas6/tam pathway found involved mediating adipocyte survival proliferation vitro 11 12 experiments mice fed high fat diet indicated overexpression gas6 might enhance body fat accumulation blocking gas6 signaling using axl antagonist could reduce body fat mass body weight interestingly transgenic animals ectopically express axl tyrosine kinase receptor also develop progressive obesity elevated circulating proinflammatory cytokines severe systemic insulin resistance this protein array study also revealed higher levels axl mrna subcutaneous adipose tissue obese humans lean control counterparts this indicates axl receptor may involved development human obesity in addition studies transgenic mice indicate gas6/axl signaling might recruit macrophages immune cells adipose tissue resulting production secretion proinflammatory mediators this suggests gas6/axl signaling might play role pathogenesis obesity associated systemic inflammation 8 16 17 recent studies indicated systemic inflammation hallmark childhood adult obesity pivotal mechanism linking obesity insulin resistance type 2 diabetes 1821 although gas6 gene polymorphisms reported associated stroke acute coronary syndrome type 2 diabetes 2224 knowledge gas6 axl gene polymorphisms associated childhood obesity yet identified order address issue conducted community based study determine whether common variations gas6 axl genes correlate adiposity systemic inflammation insulin resistance among adolescents the taipei children heart study iii epidemiological survey investigated obesity cardiovascular disease risk factors among adolescents taipei city 2006 sampling method results briefly survey included junior high school students taipei city collect representative distribution demographic lifestyle biochemical characteristics measure risk cardiovascular disease those autoimmune diseases cancers active infection taking medications known interfere insulin glucose metabolism excluded excluding missing data 727 adolescents 358 boys 369 girls ) the institutional review board tri service general hospital approved studies obtained informed consent parents adolescents all participants completed structured questionnaire detailing gender age puberty development lifestyle characteristics including cigarette smoking alcohol consumption physical activity based responses subjects divided young adolescents history smoking without currently smoke physical activity divided 5 levels based amount exercise per week less 1 h 13 h 35 h 57 h 7 h. survey questions concerning puberty onset included development penis testis pubic hair boys development breasts pubic hair girls body weight measured barefoot students wearing light indoor clothing rounded nearest 0.1 kg waist circumference wc measured midway point inferior margin last rib crest ilium horizontal plane recorded nearest 0.1 cm body mass index bmi calculated weight kilograms divided square height meters reduce extraneous variation subjects collected blood samples students 12 h fasting consumed usual diet previous 3 days children recently attended holiday family celebration contacted blood sample several weeks event plasma glucose concentrations determined glucose oxidase method using beckman glucose analyzer ii beckman instruments fullerton ca the intra- interassay coefficients variation cvs glucose 0.6% 1.5% respectively plasma insulin measured using commercial immunoradiometric kit biosource europe nivelles belgium serum levels high sensitivity c reactive protein hscrp measured using tina quant latex high sensitivity assay roche mannheim germany serum il-6 concentrations determined using human high sensitivity enzyme linked immunosorbent assay elisa innotest besancon france serum tnf- measured biotrak high sensitivity human elisa kit amersham biosciences buckinghamshire uk insulin resistance assessed using homeostasis model assessment homa homa insulin resistance homa ir fasting insulin u ml fasting glucose mmol l)/22.5 gas6 protein concentration measured using sandwich elisa polyclonal mouse anti human gas6 antibody r&d systems lille france catcher biotinylated goat antiserum detector r&d systems using previously described methods the technique validated food drug administration guidelines previous study intra- interassay cvs 6.5% 8.5% resp ; mean recovery 10 patients 97% lower limit quantification 0.26 ng ml dna isolated buffy coats using qiaamp dna blood kit following manufacturer instruction qiagen valencia ca usa the qualities isolated genomic dnas quantified using agarose gel electrophoresis quantities determined using spectrophotometer snps rs8191973 rs8191974 gas6 well rs4802113 rs2304232 axl genotyped using taqman assay allele specific probes abi prism 7900ht sequence detection system applied biosystems foster city ca usa according standardized laboratory protocols descriptive results continuous variables expressed means sd prior statistical analysis normal distribution homogeneity variables were evaluated using levene test quality variance variables given base logarithmic transformation necessary the parameters homa ir triglycerides hscrp il-6 tnf- analyzed tested significance using log scale the studied adolescents categorized subgroups based gas6 rs8191973 genotype cc cg gg gas6 rs8191974 genotype gg ga aa axl rs4802113 genotype cc ct tt axl rs2304232 aa ag gg gender specification differences anthropometric biochemistry data across genotypes analyzed using general linear model adjusting age tanner stages smoking status drinking status physical activity chi square tests used determine genotype distributions hardy weinberg equilibrium compare proportions abnormal anthropometric biochemistry variables across genotypes we tested different genetic inheritance models recessive model applied final analyses gas6 axl determine whether gas6 axl snps predictors obesity obesity associated complications logistic regression analysis used calculate odds ratio 95% confidence interval ci genotype combined genotypes two sided p value 0.05 considered statistically significant all statistical analyses performed using pasw statistics 18.0 software spss inc chicago il usa in total 727 adolescents 358 boys 369 girls included study the mean age adolescents study 13.3 years range 1215 similar boys girls in general boys higher bmi 22.3 4.0 versus 21.2 3.3 kg wc 80.0 10.1 versus 75.1 8.1 cm hscrp 0.9 1.3 versus 0.6 0.9 mg l glucose levels 93.8 6.3 versus 91.5 6.5 mg dl girls p 0.001 however girls higher tanner stages 3.2 0.5 versus 3.0 0.4 boys p 0.001 there statistically significant difference ages tnf- il-6 insulin levels homa ir boys girls the allele frequency least frequent allele boys 12.6 22.1 41.9 29.7% 13.4 19.6 32.7 33.5% girls gas6 rs8191973 gas6 rs8191974 axl rs4802113 axl rs2304232 polymorphisms respectively there significant difference allele genotype distribution boys girls 4 polymorphisms no statistically significant association anthropometric characteristics biochemistry data gas6 rs8191973 genotypes observed boys girls table 1 however significantly different hscrp levels gg ga aa genotypes gas6 rs8191974 boys regardless age tanner stages smoking status drinking status physical activity table 2 moreover boys gg genotype gas6 rs8191974 significantly higher bmi wc hscrp levels carrying allele the gas6 rs819174 genotypes significantly associated anthropometric characteristics biochemistry girls the p values comparisons anthropometric biochemistry data across gas6 genotypes presented supplemental tables 1 2 available online http://dx.doi.org/10.1155/2014/674069 in addition association circulating gas6 protein levels gas6 polymorphisms investigated we found gas6 rs8191973 rs8191974 genotypes significantly associated circulating gas6 protein levels sexes there significantly different hscrp levels tt tc cc genotypes axl rs4802113 boys independent age tanner stages smoking status drinking status physical activity table 3 in addition boys gg genotype axl rs2304232 significantly higher il-6 insulin levels increased homa ir carrying allele table 4 however girls axl rs4802113 rs2304232 polymorphisms significantly associated anthropometric characteristics biochemistry tables 3 4 the p values comparisons anthropometric biochemistry data across axl genotypes presented supplemental tables 3 4 boys gg genotype gas6 rs8191973 1.87-fold likely higher hscrp levels c allele carriers even adjusting age tanner stage smoking status drinking status physical activity a significant relationship gg genotype gas6 rs8191973 higher hscrp levels still observed boys table 5 moreover boys gg genotype gas6 rs8191974 exhibited 1.40-fold greater risk developing high bmi 1.58-fold greater risk developing high wc 2.68-fold greater risk higher il-6 levels allele carriers even adjusting possible confounding factors including age tanner stage smoking drinking status physical activity relationship gg genotype gas6 rs8191974 higher bmi wc higher il-6 levels still remained significant boys however axl rs4802113 rs2304232 polymorphisms showed significant association abnormal adiposity inflammatory markers homa ir boys girls see supplemental table 5 logistic regression analyses applied evaluate whether combination gas6 rs8191974 rs8191973 polymorphisms stronger risk factor high adiposity inflammatory markers levels homa ir alone the combined effects 2 gas6 gene polymorphisms risk high bmi wc il-6 hscrp levels shown figure 1 after adjusting relevant confounding factors still observed boys gg genotype gas6 rs8191973 gg genotype gas6 rs8191974 exhibited 47-fold higher risk high bmi wc il-6 hscrp levels individuals c allele gas6 rs8191973 allele gas6 rs8191974 4.92 95% ci 1.0823.6 p 0.018 4.18 95% ci 1.0522.5 p 0.016 4.08 95% ci 1.0628.56 p 0.015 7.22 95% ci 1.4635.72 p 0.010 resp however girls statistically significant association combination gas6 rs8191974 rs8191973 polymorphisms abnormal variables in addition evaluated combined effect gas6 rs8191973 rs8191974 marker axl gene polymorphisms association risk high adiposity inflammatory marker homa ir however combinations gas6 markers axl gene polymorphisms found significantly associated abnormal variables boys girls data shown in study strong association gas6 axl polymorphisms body adiposity systemic inflammation insulin resistance identified among boys the risk possessing high adiposity inflammatory markers levels higher boys carrying gg genotype gas6 rs8191973 rs8191974 noncarriers moreover combination gas6 polymorphisms additive effect development obesity obesity associated inflammation boys these data strongly suggest gas6 axl genes play role pathogenesis childhood obesity associated complications gas6 originally identified gene expressed fibroblasts increases serum starvation contact inhibition gas6 also potential growth factor fibroblasts maquoi colleagues demonstrated fed high fat diet gas6-deficient mice significantly less fat wild type counterparts the authors also reported expression gas6 3 receptors tyro-3 axl mer murine adipose tissues thus suggesting gas6 may act autocrine and/or paracrine manner promote murine adipose tissue development previous experiments transgenic mice demonstrate gas6 might also induce obesity associated inflammation via recruiting immune cells adipose tissue producing secreting proinflammatory cytokines 8 16 17 our recent clinical study found circulating gas6 protein levels associated adiposity inflammatory markers overweight obese adolescents study gas6 implicated candidate susceptibility gene obesity systemic inflammation however association gas6 genotypes circulating gas6 protein levels observed among adolescents we hypothesize gas6 polymorphisms could affect biology gas6 protein rather transcription process rate thus influencing adiposity regulation systemic inflammation validate recent studies demonstrated gas6/tam signaling involved releasing inflammatory cytokines il-6 hscrp diverse human diseases 23 31 32 in addition gas6/tam signaling also known involved several inflammation related systems including maturation immune cells endothelial activation immunoregulation our present study found gg genotype gas6 rs8191973 gg genotype gas6 rs8191974 strongly associated higher circulating il-6 hscrp levels boys therefore gas6 polymorphisms presumably influence gas6/tam signaling could activate inflammatory reactions result releasing circulating il-6 hscrp however comprehensive effects gas6 polymorphisms regulation inflammatory cytokines still remain determined researches interestingly previous study found allele aa genotype gas6 rs8191974 associated decreased risk stroke moreover allele aa genotype also thought related lower risk developing acute coronary syndrome type 2 diabetes suggesting genotype exhibits protective activities developing acute coronary syndrome type 2 diabetes 23 24 we also observed similar results allele aa genotype gas6 rs8191974 these subjects exhibited lower risk developing obesity systemic inflammation gg genotypes together findings suggest gas6 rs8191974 polymorphisms play important role development obesity obesity associated complications e.g. type 2 diabetes cerebrovascular cardiovascular diseases the protective role aa genotype gas6 rs8191974 developing childhood obesity obesity associated complications requires study the axl protein membrane bound receptor belongs tam family receptor tyrosine kinases axl exhibits highest affinity gas6 compared members tam family whereas protein predominantly binds mer tyro-3 gas6/axl signaling shown involved pathogenesis obesity systemic inflammation 1315 however study demonstrates axl polymorphisms associated systemic inflammation rather childhood obesity moreover combination gas6 axl gene polymorphisms significantly associated variables adiposity among adolescents our findings indicated axl gene polymorphisms might play significant role childhood obesity recently scroyen colleagues published similar findings indicating deficiency single axl receptor significantly affect adipogenesis adipose tissue development mice this axl deficiency partially compensated tam family members tyro-3 mer via gas6 interaction further studies needed investigate effect tyro-3 mer receptors development childhood obesity in addition present study also indicates gender disparity exists regarding effects gas6 polymorphisms anthropometric characteristics inflammatory markers we found significant difference genotype frequencies boys girls however effects gas6 polymorphisms individually combined manifest boys the gas6 gene contains estrogen response element promoter upregulated estrogen via activated estrogen receptor mammary epithelial cells therefore hypothesized gender specific effect gas6 polymorphisms childhood obesity might due disparity sex hormone distributions this previously reported associated gas6 expression body composition 40 41 despite results study certain limitations first cross sectional study might able assess gas6 polymorphisms weight dynamics development obesity associated complications throughout life second limitations questionnaire able comprehensively estimate every adolescent daily intake the impact dietary energy intake genetic susceptibility also requires investigation better understand confounding effect in conclusion indicate association gas6 axl polymorphisms adiposity circulating inflammatory markers insulin resistance adolescents especially boys moreover gg genotype gas6 rs8191973 rs8191974 strongly correlates susceptibility develop obesity systemic inflammation boys nonetheless results together studies cellular animal models encourage study gas6/tam system childhood obesity potential complications support hypothesis modulation gas6 activity may indeed provide important intervention point future therapies

the present study was designed to explore the effects of gas6 and axl gene polymorphisms on adiposity , systemic inflammation , and insulin resistance in adolescents . after multistage sampling from the data of the taipei children heart study - iii , we collected 358 boys and 369 girls with an average age of 13.3 years . we genotyped the adolescents ' gas6 rs8191973 , gas6 rs8191974 , axl rs4802113 , and axl rs2304232 polymorphisms . significantly higher body mass index ( bmi ) , waist circumference ( wc ) , and hscrp levels were found in boys with the gg genotype of gas6 rs8191974 than a allele carriers ; higher il-6 and insulin levels and increased homa - ir were found in boys with the gg genotype of axl rs2304232 than the a allele carriers . there was a significant difference in hscrp levels of boys with the tt , tc , and cc genotypes of axl rs4802113 . boys with both the gg genotype of gas6 rs8191973 and the gg genotype of gas6 rs8191974 exhibited higher bmi , wc , il-6 , and hscrp levels than the boys carrying both the c allele of the gas6 rs8191973 and the a allele of the gas6 rs8191974 . in conclusion , gas6 and axl polymorphisms are associated with adiposity , systemic inflammation , and insulin resistance in adolescents , especially in boys .

infertility one crucial critical events sex life engages 1015% couples world one distressful life experiences exposes couples social psychological problems couples faced critical situation prone depression anxiety loss self esteem dissatisfaction sex life others however intensity psychological problems resulting cultural social circumstances varies different societies point frequency anxiety infertile couples reported wide range 48% 96% although advances assisted reproductive techniques opened new doors infertile couples studies shown treatments accompanied stress anxiety depression intensity disorders could defined cause infertility evaluating related factors depression anxiety among iranian infertile couples showed women infertile showed higher levels anxiety depression women male factor infertility however societies define women main source fertility starting assisted reproductive treatments limited successful outcomes could harmful women mental health utilization assisted reproductive techniques requires processes daily injection stimulate ovulation vaginal ultrasound painful processes oocyte aspiration expensive alongside fear failure could become harmful condition although fertile women start assisted reproductive treatments due husband infertility natural biological conditions get pregnant tolerate critical processes due male factor infertility also women cultural social pressures conditions could affect vulnerability fertile women assisted reproductive treatment therefore aim study evaluate effect assisted reproductive treatments fertile women mental health thus prospective study conducted 70 fertile women referred receive assisted reproduction treatments vitro fertilization intracytoplasmic sperm injection due male infertility subjects referred fertility infertility center esfahan september 2013 march 2014 the number samples calculated based 80% test power 95% confidence level inclusion criteria primary infertility corporal mental illnesses drug addict according individual report history mental illnesses experiencing severe distress 1-month prior treatment based holmes rahe scale exclusion criteria included experiencing distressful conditions study discontinuation treatment cancellation egg harvesting the study approved medical ethics committee isfahan university medical sciences mental health evaluation tool valid 28-questioned general health questionnaire measures mental health likert scale 03 hypochondriasis anxiety social impairment depression dimensions method gaining score 5 subscale 23 dimensions together defined mental disorder sampling conducted simple sampling persons referred fertility infertility center esfahan treatment start process protocol due male factor infertility interviewed referring medical records conducting holmes rahe scale their eligibility study assessed considered eligible entering study their demographical features including age educational level couples economic condition duration infertility recorded ovulation stimulated long protocol participants treatment period ovarian reaction conditions number injections employed ovarian stimulation followed 3 h pickup process appropriate circumstances questionnaire general health completed circumstances inappropriate filling questionnaire was delayed 2 h. research data analyzed using spss software version 16 spss inc : chicago il usa statistical paired tests multi variable linear regression tests seven qualified subjects quit study unwillingness continue three persons ovarian hyper stimulation four persons demographic clinical data results showed significant difference mean score different dimension mental health ovulation induction oocyte harvesting table 2 also rate psychological disorder anxiety dimension showed significant different induction 71.4% pickup 66.7% p 0.19 but level depression pickup 31.7% significantly lower induction 39.7% p 0.007 comparison mental health dimensions b results showed significant difference dimension hypochondriasis induction 61.9% harvesting 66.7% p 0.07 also level social impairment showed significant difference induction 84.1% pickup 87.3% p 0.08 the results multi variable linear regression evaluate relation underlying variables mental health condition starting process level depression anxiety harvesting shown table 3 the relation mental health dimensions background variables ovulation stimulation level depression egg harvesting related physical condition depression social impairment independent underlying variables also level depression egg harvesting related economic condition also showed significant relation social impairment hypochondriasis table 3 the present study aimed assess level mental health fertile women undergoing assisted reproductive treatments result male factor infertility beginning ovulation stimulation process effect process mental health results showed women start assisted reproduction treatment appropriate mental health conditions but level depression anxiety disorders beginning ovulation stimulation higher present research reports this would indicate process treatment fertile women also critical one might affect mental health pursuit achieve conceptual model effect ovulation induction women health negative effects women functioning health shown a qualitative study showed iranian infertile couples show emotional reactions fear concern anxiety depression result fear failure treatment fertility treatment however mental disorders may harmful even women appropriate fertility potentials also angry husbands due infertility could another explanation women mental reactions positive correlation level depression anxiety dimensions experiences infertility treatment might accompanied social impairment thus affecting levels depression anxiety efforts conceal infertility efforts get treatment result concerns labeled infertile common among iranian couples this could increase level anxiety among women treatment starts another reason high level depression anxiety among women beginning ovulation stimulation might negative impact gonadotropin releasing hormone gnrh agonists mental health although research evaluate mental health beginning gnrh agonists might explain women psychological disorders ovulation stimulation regarding high frequency mental disorders time ovulation stimulation regards negative impact anxiety depression treatment result assisted reproduction treatment it necessary group women would examined treatment process since exposed risks mental health disorders treated case high levels depression anxiety following assessment main hypothesis research effect ovulation stimulation women mental health study results showed ovulation stimulation affect mental health level depression anxiety measure psychological disorders two dimensions show significant difference ovulation harvesting process contrary depression level decreased harvesting process negative impact distress infertility treatment level depression already reported the cessation treatment distress conclusion ovulation stimulation harvesting processes might reason decrease depression level subjects study furthermore results showed fertile women level depression anxiety depend reaction ovary ovulation stimulation women problem ovarian response ovulation stimulation mental health depends factors addition subjects sustained research reached stage harvesting process potential ovum production proven women this would enhance self esteem subjects decrease concern ovarian nonresponsiveness but direct correlation level anxiety depression stage harvesting process social impairment hypochondriasis indicates stage also awareness social dysfunction independent financial status effect mental health factors ovulation stimulation process might influence individuals levels depression anxiety assessed present research depression anxiety might result variety factors require extensive research another result research financial status independent quantity follicle obtained ovulation stimulation showed reverse correlation anxiety level harvesting process ozken research also financial status factor determining anxiety infertile couples regarding financial pressures resulting high costs assisted reproduction treatments lead success 35% cycle women concerns success results fertilization outcome infertility partner detected harvesting process insemination laboratory far expectation nevertheless although women healthy terms fertility couples undergoing male factor infertility treatment effort babies normal methods facing difficult costly treatment protocols might threaten evaluation feminine role thus reducing self esteem another finding research existence correlation depression level treatment process anxiety level first stage correlation observed depression level treatment process anxiety level second stage this finding indicates women enter process treatment higher anxiety level prone higher level depression therefore necessary measures taken prevent one study limitations mental health assessment conducted starting primary stages treatment therefore stress stage could affect mental health whole process this study showed fertile women undergo assisted reproduction treatments start treatment process appropriate mental health condition condition would continue whole process egg harvesting therefore suggested starting treatment mental health women evaluated using screening tools counseling sessions would applied vulnerable women

introduction : the process of assisted reproductive treatment is a stressful situation in the treatment of infertile couples and it would harm the mental health of women . fertile women who started infertility treatment due to male factor infertility have reported to experience less stress and depression than other women before the assisted reproductive process but considering the cultural and social factors and also the etiology of the assisted reproductive process , it could affect the metal health of these women . therefore , this study was conducted to evaluate the mental health of fertile women who undergo assisted reproductive treatment due to male factor infertility.materials and methods : this study was a prospective study on 70 fertile women who underwent assisted reproductive treatment due to male factor infertility . the exclusion criterion was to stop super ovulation induction . to assess mental health , anxiety and depression dimensions of the general health questionnaire were used . before starting ovulation induction and after oocyte harvesting , the general health questionnaire was filled by women who were under treatment . data were analyzed using multi - variable linear regression , paired t - test , and chi-square.results:the results showed that the mean score of depression and anxiety before ovulation induction and after oocyte harvesting were not significantly different ; but the rate of mental health disorder in the depression dimension was significantly decreased after oocytes harvesting ( 31.7% vs. 39.7% ) . also , there was a significant relation between the level of anxiety and depression before ovulation induction and after oocyte harvesting ( p < 0.05 ) . the anxiety level after oocyte harvesting had a positive and significant correlation with the economic situation ( p < 0.05).conclusion : this study revealed that the process of assisted reproductive treatment does not affect the mental health in fertile women independently , but these women start assisted reproductive process with high levels of depression and anxiety . therefore , prior to the assisted reproductive treatment mental health consultation is needed .

balance impairment important fall risk factor increases range postural sway mediolateral direction older adults associated increased fall risk rates postural sway shown older adults strongly related measures balance multivariate analysis reveals serum vitamin levels independent variable associated postural sway individuals suboptimal levels vitamin epidemiological studies shown vitamin levels show seasonal variation 7 8 lowest levels serum vitamin recorded towards end winter approximately four weeks shortest day year overall vitamin supplementation reduce rate falls rar 1.00 95% ci 0.90 1.11 seven trials 9324 participants risk falling rr 0.96 95% ci 0.89 1.03 13 trials 26 747 participants may people lower vitamin levels treatment older adults risk lower levels serum vitamin age related changes uvb absorption skin capacity synthesize vitamin reduction activation kidneys reduced expression vitamin receptors tissues there many factors affecting fall risk older individuals although may different inside outside falls strength balance remain two important physical fall risk factors a recently published overview literature supports assertion age related changes postural reactions may related vitamin status mediated either central nervous system integration antigravity muscles effectors postural responses despite changes vitamin across seasons muscle strength quadriceps muscles shown remain stable the relationship postural sway potential increased winter fall rate decreased levels vitamin investigated the winter season sees increase injuries falls number accidental deaths falls fracture rates falls older adults also increase end winter season following two eight weeks nadir serum vitamin levels some studies report increased rate falls inside outside falls 13 14 however significant seasonal variation fall rates found three year study second study seasonal variation fall rates reported women men coincident static balance changes potential increased fall rates winter previously reported the data presented forms part larger study two papers clinical trial registration published 12 16 aim study determine differences static balance postural sway vitamin incidence falls type fall serially end season 12-month period older community living adults we hypothesised postural sway falls vitamin would show seasonal variation would inverse relationship vitamin variables at end consecutive seasons static balance vitamin status fall rate measured within longitudinal study design no intervention implemented study researchers study could identify natural variations occur seasons data collected three week period season end spring 2009 end spring 2010 collection data timed coincide expected peaks troughs serum vitamin levels australia latitude 41 degrees south tasmania after assessment participants given appointment next collection block three months time independently living community dwelling adults aged sixty eighty five years recruited local print media community clubs daily intake oral supplementation vitamin greater 800 international units also exclusion criterion participants also excluded history neurological disease withdrawn suffered medical condition participating study would impact ability perform physical tests liver kidney disease impact vitamin metabolism potential participants either conditions excluded a priori sample size calculation based previous study reporting mediolateral sway range sample community dwelling older adults indicated minimum requirement 81 completed participants minimum effect size 2.5 mm sway standard deviation sd 8 mm power 0.8 alpha 0.05 ninety eight participants recruited anticipation 15% drop rate this repeated measures cohort study designed able detect differences postural sway this project received ethical approval human research ethics committee tasmania network h0010561 postural sway range medio lateral sway direction measured using force platform amti accugait pjb 101 massachusetts usa thirty seconds conditions eyes open closed well additional challenge using 6.5 cm foam cushion eyes open eyes closed airex elite balance pad ag switzerland participants asked remain stationary arms sides look straight ahead standing force platform foot position bare feet standardised heels 4 cm apart using marked placement feet ensure repeatability testing occasions venous blood samples collected clotted centrifuged 1610 relative centrifugal force 15 minutes serum concentration 25-hydroxy vitamin measured direct competitive chemiluminescent immunoassay commercial accredited laboratory using liaison method diasorin inc participants received individually coded calendar 12 months study report falls associated details date including information regarding location cause fall information type fall injuries resulted medical attention sought recorded this study utilised definition fall event results person coming rest inadvertently ground lower level annual cyclic trends investigated fitting sine wave formula data postural sway vitamin amplitude seasonal variation percentage change annual mean values estimated using repeated measures nonlinear regression adjusted age gender secondary analysis the three monthly data interpolated linearly estimate intermediate values correspond observed fall incident data mixed methods poisson regression used determine associations falls fall injuries postural balance vitamin d. association postural balance vitamin season estimated using mixed methods linear regression adjusted age gender strength comparison seasonal data falls grouped autumn winter compared spring summer physical activity using champs questionnaire muscle strength using physiological profile assessment tools recorded information published elsewhere forms integral part meta analysis paper data eighty eight participants 70% females included final analysis five people attend appointments five people could complete testing medical events the participants mean sd age 69.2 6.5 years body mass index 27.4 3.9 kg m. participants living homes independently 10% sole occupants common chronic controlled health conditions included cardiovascular disease 39% arthritis 14% twenty six percent participants reported use 4 medications all four balance measures highest sway scores poorest balance first end spring measurement all seasonal measures significantly different first time point p 0.05 subsequent significant difference seen seasonal measures indicating lack seasonal variation outcome p 0.05 no associations postural sway vitamin observed p 0.05 increased postural sway was associated fall injuries irr 1.59 ci 1.14 2.24 p 0.007 fall rates irr 1.36 ci 0.95 1.97 p 0.09 there 15% variation variable year peak end summer lowest values end winter seventy five percent fall diaries posted schedule remaining diaries returned subsequent assessment appointment resulting compliance 100% thirty three percent cohort 29 people fell least 10% whole group falling multiple times 8 people duration study 48 falls recorded 14 occurred inside house 34 occurred outside six falls due fainting dizziness forty due trip related events one categorised pushed horse one able categorised twenty eight falls resulted injury four requiring medical treatment including one fracture further details season variation location type fall provided table 2 there significantly fewer falls spring season p 0.01 differences seasons recorded when falls data combined autumn winter seasons compared combined spring summer seasons falls reported combined autumn winter seasons 30 compared 18 less injuries falls recorded spring season p 0.02 seasonal differences recorded this first cohort study determine seasonal variation postural sway occurs across 12 months population significant seasonal variation serum vitamin levels higher serum levels summer recorded there significant relationship postural sway number injurious falls observed lower values sway range i.e. better stability associated less fall injuries a significant learning effect seen measures mediolateral postural sway time point one larger ranges time points p 0.05 further seasonal variation postural sway four static balance test conditions measured eyes open closed firm surface foam surface postural sway range used identify people balance impairment may useful describing fall risk status particular individual our data indicates postural sway appear subject changes across year within participant it suggested measure important describing sensorimotor deficits disability rather functional abilities hence may subject changes may occur due altered patterns activity sunlight exposure seen seasonally the stability measure cohort across year provides important information researchers planning interventions designed impact postural sway clinicians measuring effectiveness interventions mediolateral sway range shown independent fall risk factor indoor falls study a lower proportion falls occurred indoors 29% compared outdoors 71% although similar studies healthy samples reported greater proportion falls outdoor falls 74% may reason association sway range fall incidence seen a trend association evident larger sample size may found significant relationship two variables study powered determine mediolateral sway changes fall rates an association increased sway range rate injurious falls recorded study reinforcing importance measure risk injury overall significant relationship found postural sway vitamin d. increased postural sway linked low levels vitamin may levels vitamin sufficient parameter even lowest levels participants study influence postural sway if threshold situation true may seasonal variation postural sway may present population much lower levels vitamin outside scope current study annual rates falling adults 65 reported 40% although cohort includes adults ages sixty sixty five mean age 69 years fall rate thirty three percent population appears representative older community dwelling adults terms fall rate fall rates older old adults 75 years shown vary seasonally consistent data general population healthy older community dwelling adults previously reported one previous study grouped peak seasons winter autumn together found differences fall rates manipulation data similar way reveals falls autumn winter half year compared spring summer table 2 these seasonal differences may related intrinsic factors may subject seasonal variation e.g. vitamin physical activity muscle strength well seasonally related environmental factors e.g. weather temperature further research needs investigate interventions address potentially modifiable factors reduce increased falls risk autumn winter period our data indicates higher rate falls summer previously reported perhaps due activity characteristics cohort summer winter falls differ genders men falling due slips winter women falling due trips summer high proportion women study 79% may factor high rate summer falls observed another factor consider relationship fall status vitamin d. although 60 nmol l determined cutoff fall risk function 16/48 falls 33% occurred participants study whose vitamin cutoff level this may explained higher proportion summer time falls observed study summer months longer hours daylight latitude large proportion falls occurred outside 13 14 falls 93% table 2 by contrast winter doors fall rate reduced 64% indicating higher winter time proportion inside falls generally healthy study population it likely participants engaged outdoor activities higher associated risk falls warmer weather example several summer falls occurred bushwalking fall injuries especially fractures found increase winter includes inside hip doors falls wrist studies area seasonal variation fracture rates provide good evidence increased fracture rates falls winter appear populations older participants mean age 75 years 8 13 our study recorded injuries required medical attention hence making difficult compare serious fall injury data although study aimed recruit independently living community dwelling older adults bias sample may present volunteers type research project may robust community members large the lack frail subgroups including cognitive impairment depression using walking aids limits generalisability study this study provides evidence measurements postural sway may affected effect test retest learning needs considered future research this first study investigate effects season postural sway found postural sway remained stable 12 months this study provides important evidence clinicians researchers postural sway remains stable annual cycle may influenced learning effect

introduction . low serum vitamin d levels are associated with increased postural sway . vitamin d varies seasonally . this study investigates whether postural sway varies seasonally and is associated with serum vitamin d and falls . methods . in a longitudinal observational study , eighty - eight independently mobile community - dwelling older adults ( 69.7 7.6 years ) were evaluated on five occasions over one year , measuring postural sway ( force platform ) , vitamin d levels , fall incidence , and causes and adverse outcomes . mixed - methods poisson regression was used to determine associations between measures . results . postural sway did not vary over the year . vitamin d levels varied seasonally ( p < 0.001 ) , peaking in summer . incidence of falls ( p = 0.01 ) and injurious falls ( p = 0.02 ) were lower in spring , with the highest fall rate at the end of autumn . postural sway was not related to vitamin d ( p = 0.87 ) or fall rates , but it was associated with fall injuries ( irr 1.59 ( ci 1.14 to 2.24 , p = 0.007 ) . conclusions . postural sway remained stable across the year while vitamin d varied seasonally . participants with high values for postural sway demonstrated higher rates of injurious falls . this study provides important evidence for clinicians and researchers providing interventions measuring balance outcomes across seasons .

since dawn history nature natural sources plants animals microbes minerals remained veritable source bioactive compounds medicinal values among sources plants explored exploited bioactive medicinal components lead compounds templates rational development drugs specific efficacies fewer side effects 1 one botanicals interest abortifacient claims folk medicine substantiated scientific evidence 2 documentation open scientific literature bioactive abortifacient agent(s senna alata senna alata linn roxb leguminosae also known craw craw plant ringworm plant english asunwon oyinbo yoruba western nigeria nelkhi igbo eastern nigeria filisko hantsi hausa northern nigeria erect tropical annual herb grows 0.15 high the fruit pod seeds small square shape the plant claimed used management several diseased conditions hepatitis dermatitis jaundice gastroenteritis eczema constipation diarrhoea 3 4 previous studies shown s. alata antifungal antibacterial antioxidant activities 3 58 furthermore yakubu et al 2 reported aqueous leaf extract plant contained saponins 1.22% flavonoids 1.06% cardiac glycosides 0.20% phenolics 0.44% alkaloids 0.52% cardenolides dienolides 0.18% aqueous leaf extract s. alata also scientifically validated acclaimed use abortifacient 2 however study open scientific literature reported exact bioactive abortifacient agent(s s. alata leaves therefore present study aimed validate speculation alkaloids aqueous extract s. alata leaves responsible abortifacient activity the focus alkaloid follow previous study speculated alkaloids responsible abortifacient activity crude extract s. alata leaves several studies implicated phytochemical property colchicine quinazoline alkaloids e.g. vasicine vasicinone several botanicals xylopia aethiopica peganum harmala epigeal parts areca catchu nuts gloriosa superba roots abortifacient bioactive agents and/or role contraction relaxation uterine muscles 912 the plant leaves obtained herb sellers oja tuntun new market ilorin nigeria authenticated herbarium unit forestry research institute nigeria frin ibadan nigeria a voucher specimen fhi 10845 deposited herbarium institute assay kits glucose cholesterol products randox laboratories ltd united kingdom progesterone follicle stimulating luteinizing hormones products inteco uk ltd united kingdom thin layer chromatographic lc plates silica gel products merck darmstadt germany para nitrophenyl phosphate reagents products sigma- aldrich inc st male female wistar rats rattus norvegicus weighing 178.913.07 143.99 1.21 g respectively obtained animal holding unit department biochemistry university ilorin ilorin nigeria animals housed individually plastic cages placed well ventilated room temperature 28 31c photoperiod 12 hr natural light 12 hr darkness humidity 50 55% provided unrestricted access rat pellets bendel feeds flour mills ewu nigeria water the animals also handled according guidelines european convention protection vertebrate animals used experimental scientific purposes ets 123 13 the leaves senna alata oven dried 40c 48 hr pulverised using mikachi blender mk-1830 china alkaloids extracted powder according procedure described manske 14 a known amount 500 g powder extracted 1.2 l hexane 72 hr filtered whatman no the hexane extract containing fats oils terpenes waxes discarded resulting residue extracted 1.2 l methanol week subsequently filtered the filtrate evaporated using rotavapor r110 gallenkamp england uk process repeated two times the three filtrates combined concentrated give methanolic green slime 90 g treated 1 hcl basified adding 5 naoh continuous stirring cloudy precipitate appeared a known volume 500 ml chloroform 200 ml 1 nacl added process repeated three times equal volumes 150 ml 1 nacl 5 naoh added organic layer separating funnel mixture evaporated yield brownish black slurry 18 g alkaloids corresponded yield 3.60% used subsequent experiments the procedure described singh sahu 15 adopted preparation thin layer chromatography tlc plates furthermore 10 l test solution extract spotted onto thin layer plate using micropipette plates developed chloroform methanol 10:2 0.01 g ml butylated hydroxyl toluene butylated hydroxyl anisole added prevent oxidation may lead increase number bands time 16 the relative values related solvent front rf spots also computed twenty four pregnant rats allocated complete randomize design four groups b c consisting six animals animals group controls orally received 0.5 ml distilled water aid oropharyngeal cannula groups b c orally received 0.5 ml alkaloids corresponding 250 500 1000 mg kg body weight respectively the administration done daily day 10 day 18 pregnancy period organogenesis wistar rats 18 19th day 24 hr last dose ) the following parameters recorded computed number live fetuses number dead fetuses average weight live foetuses survival ratio number live fetuses/ number live dead fetuses 100 number rats aborted percentage rats aborted= number rats aborted number rats assessed 100 number rats vaginal bleeding number implantation sites number corpora lutea implantation index=(total number implantation sites number corpora lutea 100 pre implantation loss=(number corpora lutea number implantation sites number corpora lutea 100 post implantation loss= number implantation sites number live fetuses number implantation sites 100 number resorption sites number implantation sites control animals number implantations test animals resorption index=(total number resorption sites total number implantation sites 100 the weights animals pairing prior sacrifice well feed water intake also recorded the vivo estrogenic anti estrogenic response rats alkaloids evaluated adopting procedure described kanno et al twenty four ovariectomized female rats 159.677.12 g allocated four groups b c six animals per group group controls orally received 0.5 ml distilled water animals groups b c orally received 0.5 ml alkaloids corresponding 250 500 1000 mg kg body weight respectively the administration commenced eighth day ovariectomy lasted another seven days day 16 weights animals determined prior sacrifice uterine body weight ratio computed the uterine protein glucose cholesterol alkaline phosphatase activity determined using standard procedures 2023 the serum uterine homogenates prepared according procedures described yakubu bukoye 24 the procedures outlined manufacturer protocol adopted quantitative determination progesterone follicle stimulating luteinizing hormones serum animals data expressed meansd six independent replicates statistically analyzed using one way analysis variance duncan multiple range test the plant leaves obtained herb sellers oja tuntun new market ilorin nigeria authenticated herbarium unit forestry research institute nigeria frin ibadan nigeria a voucher specimen fhi 10845 deposited herbarium institute assay kits glucose cholesterol products randox laboratories ltd united kingdom progesterone follicle stimulating luteinizing hormones products inteco uk ltd united kingdom thin layer chromatographic lc plates silica gel products merck darmstadt germany para nitrophenyl phosphate reagents products sigma- aldrich inc st male female wistar rats rattus norvegicus weighing 178.913.07 143.99 1.21 g respectively obtained animal holding unit department biochemistry university ilorin ilorin nigeria the animals housed individually plastic cages placed well ventilated room temperature 28 31c photoperiod 12 hr natural light 12 hr darkness humidity 50 55% provided unrestricted access rat pellets bendel feeds flour mills ewu nigeria water the animals also handled according guidelines european convention protection vertebrate animals used experimental scientific purposes ets 123 13 the leaves senna alata oven dried 40c 48 hr pulverised using mikachi blender mk-1830 china alkaloids extracted powder according procedure described manske 14 known amount 500 g powder extracted 1.2 l hexane 72 hr filtered whatman 1 filter paper hexane extract containing fats oils terpenes waxes ) were discarded resulting residue extracted 1.2 l methanol week subsequently filtered the filtrate evaporated using rotavapor r110 gallenkamp england uk process repeated two times the three filtrates combined concentrated give methanolic green slime 90 g treated 1 hcl basified adding 5 naoh continuous stirring cloudy precipitate appeared known volume 500 ml chloroform 200 ml 1 nacl added process repeated three times equal volumes 150 ml 1 nacl 5 naoh added organic layer separating funnel mixture evaporated yield brownish black slurry 18 g alkaloids corresponded yield 3.60% used subsequent experiments the procedure described singh sahu 15 adopted preparation thin layer chromatography tlc plates furthermore 10 l test solution extract spotted onto thin layer plate using micropipette plates developed chloroform methanol 10:2 0.01 g ml butylated hydroxyl toluene butylated hydroxyl anisole added prevent oxidation may lead increase number bands time 16 the relative values related solvent front rf spots also computed twenty four pregnant rats allocated complete randomize design four groups b c consisting six animals animals group controls orally received 0.5 ml distilled water aid oropharyngeal cannula groups b c orally received 0.5 ml alkaloids corresponding 250 500 1000 mg kg body weight respectively the administration done daily day 10 day 18 pregnancy period organogenesis wistar rats 18 19th day 24 hr last dose ) the following parameters recorded computed number live fetuses number dead fetuses average weight live foetuses survival ratio number live fetuses/ number live dead fetuses 100 number rats aborted percentage rats aborted= number rats aborted number rats assessed 100 number rats vaginal bleeding number implantation sites number corpora lutea implantation index=(total number implantation sites number corpora lutea 100 pre implantation loss=(number corpora lutea number implantation sites number corpora lutea 100 post implantation loss= number implantation sites number live fetuses number implantation sites 100 number resorption sites number implantation sites control animals number implantations test animals resorption index=(total number resorption sites total number implantation sites 100 the weights animals pairing prior sacrifice well feed water intake also recorded the vivo estrogenic anti estrogenic response rats alkaloids evaluated adopting procedure described kanno et al twenty four ovariectomized female rats 159.677.12 g allocated four groups b c six animals per group group controls orally received 0.5 ml distilled water animals groups b c orally received 0.5 ml alkaloids corresponding 250 500 1000 mg kg body weight respectively the administration commenced eighth day ovariectomy lasted another seven days day 16 weights animals determined prior sacrifice uterine body weight ratio computed the uterine protein glucose cholesterol alkaline phosphatase activity determined using standard procedures 2023 the serum uterine homogenates prepared according procedures described yakubu bukoye 24 the procedures outlined manufacturer protocol adopted quantitative determination progesterone follicle stimulating luteinizing hormones serum animals data expressed meansd six independent replicates statistically analyzed using one way analysis variance duncan multiple range test the alkaloids yielded 0.30 g corresponds 1.50% starting material 500 g. five different spots gave rf values 0.28 0.33 0.39 0.47 0.55 the spots gave positive reaction meyer wagner reagents producing creamy precipitate reddish brown spots grey background tlc the alkaloid truncated development fetuses none survived experiment groups average number live fetuses 10.26 distilled water treated control animals table 1 the average weight live fetuses controls 4.92 g none extract treated animals the percentage fetal death 250 500 1000 mg kg body weight alkaloid treated animals 6.03 6.00 6.50 respectively there neither episode abortion vaginal bleeding alkaloid treated animals both number implantation sites corpora lutea decreased significantly p 0.05 implantation index similarly high alkaloid treated animals resorption index well pre- post- implantation losses many fold higher controls table 1 although pregnant rats gained weight end experimental period final maternal weight compared weight prior pairing males initial maternal weight table 1 weight gained alkaloid treated animals 50% less control animals furthermore feed water intake animals treated different doses alkaloid decreased significantly p 0.05 effect alkaloids senna alata leaves abortifacient parameters pregnant rats values expressed meansd six independent determinations test values carrying superscripts different control parameter row significantly different p 0.05 maternal weights animals pregnancy compared corresponding weights pregnancy treatment group p 0.05 different doses alkaloids significantly p 0.05 decreased serum concentrations follicle stimulating hormone luteinizing hormone progesterone pregnant animals table 2 effect alkaloids senna alata leaves female reproductive hormones pregnant wistar rats values expressed meansd six independent determinations test values carrying superscripts different control parameter row significantly different p 0.05 alkaloids also decreased p 0.05 absolute weight uterus computed uterine body weight ratio concentrations uterine glucose cholesterol table 3 in contrast concentration uterine protein activity alkaline phosphatase increased significantly p 0.05 furthermore alkaloids provoke vaginal opening cornification animals table 3 effect alkaloids senna alata leaves indices oestrogenicity pregnant rats values expressed meansd six independent determinations test values carrying superscripts different control parameter row significantly different p 0.05 ) analysis tl chromatogram indicated mixture consisted five alkaloids evidenced creamy precipitates reddish- brown spots produced meyer wagner reagents respectively present study alkaloids s. alata leaves significantly affected fetal maternal parameters animals for instance death fetuses alkaloid treated pregnant rats may suggest inhibition mitotic division fetuses 25 since animals exposed period organogenesis may also show relevance reduction concentrations gonadotropins progesterone present study ( 2 aqueous leaf extract plant 500 1000 mg kg body weight extract produced fetal death furthermore absence abortion vaginal bleeding alkaloid treated animals hitherto observed crude extract previous study suggest zero abortifacient activity alkaloid therefore abortifacient activity aqueous extract plant leaf reported earlier 2 due alkaloidal content alone phytochemicals saponins flavonoids may act synergistically additively produce desired result it interesting note number implantation sites corpora lutea decreased alkaloid treated animals process implantation ought completed implantation takes place normally within 5 6 days post coitus rats exposure animals alkaloid mixture treatment commenced day 10 pregnancy the reason decrease immediately known may unconnected consequence general hormonal effect reduced progesterone and/or absence conceptuses growth 26 it also possible blastocytes activated well positioned implantation probably due impaired muscular activity uterus 27 the implantation index pre implantation loss evaluates number blastocysts implanted uterus resorption index post implantation loss relate number implanted blastocysts developed 18 28 therefore high implantation index pre- post- implantation losses suggest pregnancy interrupted alkaloid probably creating environment conducive fertilized eggs normally abortion cases accompanied vaginal bleeding absent resorption increase therefore increase resorption index alkaloid- treated animals confers antifertility effects anti implantation anti blastocystic antizygotic alkaloid the alkaloid exhibit complete abortifacient effect since pregnant animals exposed alkaloid presented closed vagina like controls the findings present study similar report elbetieha et al ( 29 administration 200 400 800 mg kg body weight ethanolic extract salvia fruticosa cause pregnancy failure increased number resorption pregnant rats the alkaloids reduced sense taste appetite animals evidenced decrease feed water intake such reduction may account decrease computed percentage gain maternal weight may also consequence impaired growth development uterine contents 30 all findings except feed water intake well maternal weight gain contrast previous report yakubu et al it well known implantation fetus sustenance pregnancy exact equilibrium must exist secretion estrogen progesterone regulation controlled luteinizing follicle stimulating hormones 31 thus reduction gonadotropins may equally responsible reduced concentration progesterone present study may account death fetuses also increase resorption sites the reduction progesterone may suggest impaired endometrium function adversely affect normal secretion special proteins required nourish implanted fertilized egg consequently pregnancy failure thus possible alkaloids posses anti gonadotropic anti progestogenic activities inimical continued development fetuses many plant extracts anti fertility properties known exhibit estrogenic activity increasing protein synthesis uterine weight water uptake retention fluid leading ballooning uterus uterine content glucose cholesterol glycogen alkaline phosphatase activity thereby changing uterine milieu creating non receptive conditions uterus 32 therefore contrasting effects alkaloids parameters present study suggest estrogenic activity total selective the alkaloids exhibited anti oestrogenic activity 71.43% oestrogenic 28.57% overall alkaloid s. alata leaves oral doses 250 500 1000 mg kg body weight daily basis days 10 day 18 post coitum exhibited several potential effects maternal fetal outcomes pregnant rats anti implantation anti gonadotropic anti progesteronic selective estrogenic embryonic resorption fetotoxic activities could induce abortion animals therefore alkaloids may alone responsible abortifacient effects crude extract s. alata reported earlier finally work progress isolating phytochemicals saponins flavonoids evaluating synergistic effects pregnant animals

backgroundthe abortifacient claim of senna alata ( s. alata ) was scientifically validated recently with alkaloids speculated to be the bioactive agent . this speculation is yet to be substantiated or refuted by scientific evidence . the present study was aimed to investigate the pregnancy terminating effects of the alkaloids from s. alata leaves.methodstwenty four pregnant rats ( 143.991.21 g ) allocated randomly to four groups : a , b , c and d respectively received , 0.5 ml of distilled water , 250 , 500 and 1000 mg / kg body weight of the s. alata extracted alkaloids orally , once daily from day 10 until day 18 post - coitum . the indices of abortifacient were evaluated at the end of the exposure period . the results were analyzed by both the analysis of variance and duncan 's multiple range test and p < 0.05 was considered as statistically significant.resultsthin-layer chromatographic separation produced five spots with rf values of 0.28 , 0.33 , 0.39 , 0.47 and 0.55 which gave positive reaction with meyer 's and wagner 's reagents , respectively . the number of implantation sites and corpora lutea , as well as the concentrations of fsh , lh , progesterone , weight of uterus , uterine/ body weight ratio , glucose and cholesterol decreased significantly ( p < 0.05 ) whereas the resorption index , pre- and post - implantation losses , uterine protein content and alkaline phosphatase activity increased significantly . none of the alkaloid treated animals presented with provoked vaginal opening or bleeding except fetal deaths . the alkaloid decreased the maternal weight gain , as well as feed and water intake.conclusionoverall , the alkaloids from s. alata leaves exhibited anti - implantation , anti - gonadotropic , anti - progesteronic , embryonic resorptive , feto - maternal toxic activities but not complete abortifacient . the alkaloids alone may not be the sole abortifacient bioactive agent in the leaf extract .

erg protein expression recently suggested reflective erg gene rearrangements prostate cancer pca documenting remarkable concordance two 16 the rearrangements androgen receptor regulated gene tmprss2 21q22.3 members ets family member transcription factor gene commonly erg 21q22.2 among common genetic alterations detected prostate cancer 711 erg gene rearrangements detected roughly half 4060% pca surgical cohorts compared rate 12%15% incidental watchful waiting cohorts 7 1218 previous studies investigating prognostic significance erg gene rearrangements revealed mixed results 1922 however becoming evident erg gene rearrangements signify molecular subtype pca some studies investigating significance erg protein expression localized pca failed show association adverse clinical outcome 23 24 however recent report group demonstrated association erg expression lethal disease patients unsuspected advanced castrate resistant disease treated transurethral resection prostate moreover documented significant association erg expression gleason score tumor volume studies group others also linked erg status responsiveness hormonal therapy longer progression time castration resistant disease compared men erg expression 24 25 current study investigated association erg protein expression clinical pathological parameters cohort men localized prostate cancer the study cohort consisted 198 patients treated retropubic radical prostatectomy localized prostate cancer mean followup 4.8 years range 015.8 clinical progression defined postoperative serum psa elevation 0.2 ng ml prostate samples embedded onto three tissue microarray tma blocks using manual tissue arrayer beecher instruments silver spring md usa one nine cores average 3.3 0.6 mm diameter sampled including benign high grade intraepithelial neoplasia hgpin prostate cancer pca construction 4 sections cut stained haematoxylin eosin initial slides verify histological diagnosis briefly 4 thick sections formalin fixed paraffin embedded tissue blocks stained ventana autostainer prior staining heat induced antigen retrieval carried vegetable steamer sodium citrate antigen retrieval buffer 10 mm ph 6.0 40 minutes cooled room temperature 20 minutes the slides incubated 60 minutes 37c erg rabbit monoclonal antibody epitomics clone epr 3864 1 50 dilution ventana iview dab detection kit ventana tucson az usa ) the diagnoses tma cores confirmed three study pathologists lht cw tab for patient two predominant patterns sampled included tmas analysis erg protein expression assessed semiquantitatively using 3-tiered system 0 negative 1 low 2 high cases either 1 2 intensity considered positive based previous correlation erg gene rearrangement detected fluorescent situ hybridization data shown the erg antibody consistently strongly expressed endothelial cells acted internal control expression intensity level patient characteristics presented frequencies percentages categorical variables means ranges continuous variables chi square tests used test associations erg protein expression gleason score surgical margin pathological stage kaplan meier approach along log rank test used survival analyses test association erg expression serum psa relapse statistical tests mean patients age cohort 64 years range 42.780.5 years average follow time 4.8 years range 0.015.8 months table 1 demonstrates patients demographics study cohort respect erg expression overall significant differences two subgroups erg pos erg neg patients except pathological stage 37% erg positive tumors detected pt3 versus 24% pt2 investigate erg expression different diagnostic categories characterized erg expression based individual cores sampled when accounted foamy type pca morphology rate erg expression 15/84 17.9% compared 302/704 42.9% acinar pca cases foamy type morphology p 0.001 there difference high erg intensity foamy type acinar pca data shown however mean intensity level erg acinar pca significantly higher foamy type pca 1.01 1.27 versus 0.37 0.83 p 0.001 erg intensity levels hgpin comparable foamy type pca slightly lower 0.13 0.56 significantly lower acinar pca p 0.001 figure 1 erg expression noted 106/280 37.8% 175/463 37.8% 37/108 34.2% gleason scores 6 7 810 respectively figure 2 demonstrates examples erg expression tissue samples distribution erg relation gleason score when investigating relations erg expression pathological parameters significant association erg expression higher disease stage cohort erg expression present 50/131 38.1% patients pt2 versus 30/55 54.5% patients pt3 p 0.04 a similar association also noted erg expression extra capsular extension cohort 52/134 38.8% ) erg positive patients demonstrated organ confined disease versus 29/53 54.7% erg positive patients showing extra capsular extension p 0.04 similar trends noted erg expression seminal vesicle invasion statistically significant p 0.10 data shown no significant association noted overall erg positivity positive surgical margins table 1 similarly association observed postsurgical psa levels assessed univariate multivariate analysis figure 3 although informative due limited patients numbers association erg expression higher stage disease pronounced patients higher gs cohort none patients gs 7 erg positive 0/7 stage pt2 compared 47% 7/15 erg negative patients pt2 stage p 0.02 table 2 this study reports potential significance erg protein expression localized prostate cancer erg gene rearrangements erg expression documented roughly 50% localized prostate locally advanced castrate resistant prostate cancer compared 12%15% watchful waiting incidental cohorts 16 17 22 25 29 published reports significance erg expression patients outcome conflicting showing association adverse outcome others document association some suggest indicates better prognosis 16 22 25 2933 however proposed erg signifies molecular class prostate cancer may play role disease progression within tumors this pathway closely linked increased rate pten genomic deletions well increased erg expression erg gene rearrangements 34 35 erg gene rearrangements erg expression associated adverse outcome lethal disease watchful waiting expectant cohorts 16 25 moreover patients erg overexpression demonstrated shorter progression times castrate resistance needing surgical intervention channel turp in localized prostate cancer majority reported data suggest prognostic implication erg rearrangements erg overexpression relation psa relapse recurrence local disease 22 36 37 however two earlier reports suggested adverse association erg rearrangements psa relapse radical prostatectomy 20 31 nam study yashimoto group noted adverse prognostic association linked pten genomic deletions note study reid et al documented erg gene rearrangements addition pten genomic deletions actually favorable outcomes compared pten deletion alone these observations suggest method utilized determining erg status inclusion exclusion genomic aberration cohort chosen may reason different results obtained various studies investigating role erg prostate cancer our results support previous observations showing prognostic relationship erg overexpression clinical outcome localized prostate cancer however contrast earlier studies document significant association erg expression pathological parameters cohort patients whose tumors erg positive higher risk exhibiting extra prostatic extension increased disease stage compared patients whose tumors express erg specifically patients gs 7 erg expression showed pt3 stage disease compared none pt2 however data limited number patients within gs subgroup need confirmation more importantly addition documenting clinical prognostic significance erg expression observe association erg expression pathological parameters gleason score surgical margins diminishes potential prognostic significance erg expression least localized pca another issue worth mentioning regarding erg erg gene rearrangements previously associated specific histopathological features detected frequently morphologic variants prostate cancer others study confirm lower rates erg expression tumors foamy xanthomatous morphology demonstrated lower mean expression intensities compared acinar pca the significance yet known suggests two types tumors may different molecular level conclusion study demonstrates significant association erg expression extra prostatic extension higher pathological stage localized prostate cancer moreover lack association pathological parameters also significantly diminishes potential clinical application erg expression least men localized prostate cancer

background . the prognostic significance of erg expression in prostate cancer ( pca ) has generated mixed results . we sought to investigate the prognostic significance of erg expression in a localized cohort of men with pca . material and methods . we investigated erg protein expression in a cohort of 198 men with localized pca . erg expression was correlated with patients ' clinical outcome and several pathological parameters , including gleason score ( gs ) , pathological stage , surgical margin , and extra - capsular extension . results . erg expression was detected in 86/198 ( 43.4% ) patients exclusively in neoplastic epithelium . overall , erg mean expression intensity was 1.01 1.27 versus 0.37 0.83 in acinar pca compared to foamy type pca ( p < 0.001 ) . in hgpin , erg intensity levels were comparable to those in foamy type pca ( 0.13 0.56 ) but significantly lower than those in acinar pca ( p < 0.001 ) . erg expression was significantly associated with extra - prostatic extension and higher pathological stage and showed a trend toward seminal vesicle invasion . herein , erg expression was documented in 50/131 ( 38.1% ) patients with pt2 versus 30/55 ( 54.5% ) patients with pt3 ( p = 0.04 ) . erg association with higher pathological stage was more pronounced in patients with gs > 7 . grouping patients into those with gs 7 versus > 7 , there was no significant association between erg expression and gs . similarly , no association was present in relation to either surgical margins or postsurgical serum psa levels . conclusion . we report significant association between erg protein levels and extra - prostatic extension and higher pathological stage . erg expression is not associated with adverse clinical outcome and is of limited prognostic value in localized pca .

three main arteries leg anterior tibial artery ata posterior tibial artery peroneal artery form dense vascular network around distal leg ankle foot ramifies perforators basis kinds pedicle flaps lateral medial malleolar perforator flaps there plenty literature describing anatomy clinical application perforators peroneal artery posterior tibial artery around distal lower leg however literature regarding perforator flaps ata anterior supramalleolar artery asma one major branches distal ata scant these papers either mention existence perforators ata asma describe communication medial lateral supramalleolar arteries none detailed anatomical study asma the objective study identify anatomic parameters asma perforators would enable microsurgeons harvest potentially multi paddle flaps composite flaps foot ankle region we try preserve ata intact harvest composite flaps around ankle using asma we also want use ata one pedicle harvest multi paddle flaps decreasing microsurgical risk greatly minimizing sacrifice blood supply ankle foot after study approved university louisville irb 24 lower extremities fresh human cadavers studied the ata cannulated injected 20 ml red latex microfilm flow tech inc mid point lower leg ata identified extensor digitorum longus tibialis anterior muscles then careful dissection along distal 1/3 lower leg ankle proximal foot 8 10 cm lateral malleolus 1 2 cm anterior edge fibula performed observe origin course asma the distance origin asma extensor retinaculum r recorded the diameters asma proper well branches set fixed width hooks used measurement length asma measured the collaterals asma medial lateral supramalleolar arteries number perforators observed chi square test used study analyse variation r fasciocutaneous flaps multiple skin paddles elevated based perforators demonstrate potential application we classified asma four types according pattern origin ata figures 1 4 type n 10 asma originates ata 1 1.5 cm long main trunk gives lateral medial branches figure 1a b consists 2 3 perforators type b n 7 ) asma main trunk lateral medial branches stem directly ata sites origin level figure 2a b type c n 6 similar type b lateral medial branches arising ata different origins figure 3a b type n 1 2 medial 1 lateral branch arising ata figure 4a b ( type anterior supramalleolar artery originates artery stem ( 1 short artery stem 2 lateral branches 3 medial branches 4 descendent perforators 5 ascendant perforators 6 ) proximal end anterior tibial artery ata 7 distal end ata 8) blood supply tibia 9 extensor retinaculum b anterior supramalleolar artery originates 1 1.5 cm short artery stem ramifies lateral medial branches the medial branch gives ascendant perforators descendent perforators type b anterior supramalleolar artery originates lateral medial artery branches point ( 1 medial branches 2 ascendant perforators 3 descendent perforators 4 lateral branches 5 proximal end anterior tibial artery ata 6 distal end ata 7 extensor retinaculum 8) blood supply tibia b anterior supramalleolar artery orients lateral medial artery branches point the medial branch gives ascendant perforators descendent perforators type c anterior supramalleolar artery originates lateral medial artery branches different point ( 1 medial branches 2 ascendant perforators 3 descendent perforators 4 lateral branches 5 proximal end anterior tibial artery ata 6 distal end ata 7 extensor retinaculum b anterior supramalleolar artery orients lateral medial artery branches different point the medial branch gives ascendant perforators descendent perforators type anterior supramalleolar artery originates lateral two medial artery branches different point ( 1 medial branches 2 lateral branches 3 proximal end anterior tibial artery ata 4 distal end ata 5 extensor retinaculum b anterior supramalleolar artery orients one lateral two medial arteries branches different point mean distance origin proximal branch asma superior margin extensor retinaculum r 2.0 0.8 cm the mean diameters medial branch d1 lateral branch d2 main trunk asma d3 type 1.0 0.2 mm 0.8 0.3 mm 1.1 0.2 mm respectively mean feasible length pedicles lateral flap l1 medial flap l2 5.1 1.0 cm 3.7 0.6 cm respectively bi foliate fasciocutaneous flaps harvested based medial lateral branches type asma preservation ata figure 5 data 24 specimens anterior supramalleolar artery biofoliate flap using type anterior supramalleolar artery huber dissected 200 feet first describe asma vessel arising 5 cm ankle joint wee described septocutaneous branch ata runs anterior crural septum tendons tibialis anterior extensor hallucis longus gives 3 perforators further named reverse flow flap based perforators artery anterior tibial type iii later research showed asma always found distal 1/3 lower leg appears 8 10 cm lateral malleolus 1 2 cm anterior edge fibula 2003 koshima dissected 4 ankles described asma 1 2 perforators extensor retinaculum gives anterolateral anteromedial branches however still lack detailed anatomical knowledge origin calibre the diameters lateral medial branches asma 0.8 0.3 mm 1.0 0.2 mm respectively the feasible pedicle lengths two branches 5.1 1.0 cm 3.7 0.6 cm respectively thus island flap harvested based one branches defect coverage around ankle in addition due collateral connection posterior tibial artery peroneal artery reverse flow anterolateral anteromedial flap also designed described literature the flaps asma useful especially patients suffer refractory malleolar ulcers due paralysis diabetes mellitus venous stasis vasculitis patients cosmetic consideration perforator based adipofascial flap also good option use asma the perforators asma suitable bi foliate design situations simultaneous defects volar dorsal aspects hand the flap based asma pliable thin makes excellent option hand wrist coverage if simultaneous metacarpal deficiency time present especially high energy injuries vascularised bone graft also harvested easily supplied 1 2 perforators according research gilbert et al an additional advantage perforator flap ata preserved type asma morbidity donor site minimised based different types asma lumen size vary 0.8 0.3 1.1 0.2 mm still suitable microvascular anastomosis difficult problem hand surgeon encounters conventional methods include inserting hand abdominal pocket several weeks followed skin graft using large flap cover defects together covering wounds several free flaps time often patients still exhibit stiff digits bulky hand combined multiple single flaps would increase surgical risk exponentially instance propose novel idea using multiple foliate flap based different perforators lateral medial branches asma cover multiple digits time these branches derive trunk ata terminal branch this design provides capability harvesting 2 3 skin paddles based one sizable pedicle ata the terminal branches peroneal artery ankle foot well branches posterior tibial artery ankle foot also preserved way vascular network ankle foot still preserved donor site morbidity significantly decreased there several factors kept mind clinical application asma based flaps skin opened lateral medial branches asma generally visible if want stem artery branches follow course branches easily find origin branches however situation would effective repair extensor retinaculum carefully immobilize foot 3 4 weeks further study long term follow needed understand blood supply ankle foot harvesting asma based flap its sizable diameter lengthy pedicle make suitable bi foliate fasciocutaneous flaps composite flaps

purpose : a further understanding of the anterior supramalleolar artery ( asma ) and its potential applications in reconstructive surgery.materials and methods : a total of 24 fresh lower limbs from fresh cadavers were injected with red latex for dissection . the type of origin , course , diameter of the pedicle , and the distance between the origin of the asma from the anterior tibial artery to the extensor retinaculum ( o - r ) were recorded . bi - foliate fasciocutaneous flaps were harvested using the branches of the asma.results:we found four types of origin of the asma , and we have accordingly classified them into four types . 10 of them were type a , 7 were type b , 6 were type c and 1 was type d. the mean o - r ( origin of asma to retinaculum ) distance was 2.0 0.8 cm . the diameter of the medial branch ( d1 ) , the diameter of the lateral branch ( d2 ) , and the diameter of artery stem ( d3 ) ( only in type a ) were 1.0 0.2 mm , 0.8 0.3 mm , 1.1 0.2 mm , respectively . the mean pedicle length of the lateral flap ( l1 ) and medial flap ( l2 ) were 5.1 1.0 cm and 3.7 0.6 cm , respectively.conclusions:the asma exists constantly with four different types of origin . its sizable diameter and lengthy pedicle make it suitable for bi - foliate fasciocutaneous flap transfer .

ankle dorsiflexion passive range motion df prom measurements performed field physical therapy estimate ankle motion functional activities1 prevent lower extremity injuries2 although clinical setting ankle df prom frequently measured non weight bearing non wb conditions1 3 4 many researchers stated wb position appropriate estimating amount ankle df motion functional activities5 6 therefore wb ankle df prom measured interventions focused increasing ankle df prom limited ankle df prom knee extended may result gastrocnemius tightness insufficient posterior talar glide7 thus gastrocnemius stretching talocrural joint mobilization performed intervention strategies increase ankle df prom3 8 9 previous studies reported significant increase ankle df prom interventions3 8 9 however knowledge study demonstrated combined effect interventions wb ankle df prom therefore aim present study examine influence gastrocnemius stretching combined joint mobilization wb ankle df prom in total 11 male subjects bilateral limited non wb ankle df prom knee extended mean age 22.82 3.09 years mean height 175.91 3.39 cm mean weight 69.55 3.78 kg mean non wb ankle df prom 4.17 2.48 participated study inclusion criteria 1 ankle df prom knee extension 10 2 ankle df prom knee flexion 10 3 5 difference ankle df prom knee extension knee flexion conditions bilateral sides non wb positions3 subjects history surgery lower extremity fracture neurological diseases excluded study all participants signed informed consent form approved institutional research review committee inje university prior participation study the study protocol study complies ethical standard declaration helsinki wb ankle df prom knee extended measured following procedures suggested munteanu et al10 subjects stood front wall placed leg tested behind contralateral leg lunge posture subjects asked place hands wall lean forward without heel knee flexion maximum stretch felt gastrocnemius tested leg the force applied tested leg maintained 60 5% subject weight using scales11 an examiner determined maximum tibial inclination using inclinometer measure wb ankle df prom knee extended measurements wb ankle df prom repeated 3 times ankle pre- post intervention conditions the mean value 3 trials used data analysis gastrocnemius stretching combined joint mobilization subjects leaned forward wall lunge posture measurement wb ankle df prom knee extended maximum gastrocnemius stretch felt subjects held end range posture examiner provided talus tested leg sustained anterior posterior gliding force an intervention trial performed 30 10 trials repeated 30-s rest periods ankle difference wb ankle df prom knee extended pre- post intervention conditions analyzed using paired test wb ankle df prom knee extended significantly increased post intervention compared pre intervention conditions 42.60 5.49 versus 38.24 4.69 p 0.001 our findings demonstrate gastrocnemius stretching combined joint mobilization significantly increases wb ankle df prom knee extended stretching exercises increase tolerance resulting increased rom12 additionally increased displacement myotendinous junction mtj gastrocnemius stretching 5 min found previous study13 therefore change tolerance and/or increase mtj displacement might influenced findings the addition talocrural joint mobilization gastrocnemius stretching another possible explanation findings previous research dinh et al.3 showed 4.25 increase wb ankle df prom knee extended gastrocnemius stretching alone 3 weeks although gastrocnemius stretching combined joint mobilization was applied 5 min present study amount increase wb ankle df prom intervention i.e. 4.36 similar found previously considering outcome despite relatively short period intervention present study may inferred addition talocrural joint mobilization might maximize effects general gastrocnemius stretching thus conclude gastrocnemius stretching combined joint mobilization might decrease gastrocnemius tightness increase posterior talar gliding movement effectively increases wb ankle df prom knee extended first although non wb ankle df prom used inclusion criterion changes non wb ankle df prom intervention measured however believe wb ankle df prom clinically important functional activities performed wb condition second study included male subjects results generalized women

[ purpose ] the purpose of this study was to investigate the effect of gastrocnemius stretching combined with talocrural joint mobilization on weight - bearing ankle dorsiflexion passive range of motion . [ subjects ] eleven male subjects with bilateral limited ankle dorsiflexion passive range of motion with knee extended participated in this study . [ methods ] all subjects received talocrural joint mobilization while performing gastrocnemius stretching . ankle dorsiflexion passive range of motion was measured using an inclinometer under weight - bearing conditions before and immediately after intervention . a paired t - test was used to analyze the difference between weight - bearing ankle dorsiflexion passive range of motion pre- and post - intervention . [ results ] a significant increase in weight - bearing ankle dorsiflexion passive range of motion was found post - intervention compared with pre - intervention . [ conclusion ] these findings demonstrate that gastrocnemius stretching combined with joint mobilization is effective for increasing weight - bearing ankle dorsiflexion passive range of motion .

dox one key chemotherapeutic drugs cancer treatment use limited chronic acute toxic side effects dox antibiotic anthracycline isolated pigment streptomyces peucetius early 1960s employed 30 years battle cancer chemically synthesized renal dox induced toxicity may part multiorgan damage mediated mainly free radical formation eventually leading membrane lipid peroxidation induction apoptosis modulation nox mechanisms involved toxic adverse effects associated dox therapy addition dox direct renal damaging effect accumulates preferentially kidney dox toxic effects organs heart liver may lead modulation blood supply kidney alter xenobiotic detoxification processes respectively thus indirectly contributing dox induced nephropathy dia new anti inflammatory analgesic antipyretic drug developed specially treatment osteoarthritis it highly effective relieving symptoms osteoarthritis may able modify course disease interleukin 1 proinflammatory proapoptotic agent induces cytokine production activating nfb mitogen activated protein kinase signaling a major cause dox induced nephrotoxicity production reactive oxygen species induce cytokines including interleukin 1 6 9 10 the aim present study study effect interleukin 1 receptor antagonist diacerein dia dox induced nephropathy dia powder eva pharma company dissolved 1% carboxymethylcellulose dox hydrochloride 10 mg vial pharmacia italia spa italy polyclonal rabbit antirat caspase-3 tnf nfb antibody lab vision usa biotinylated goat anti rabbit secondary antibody transduction laboratories usa urea gsh sod catalase kits biodiagnostic egypt creatinine humen germany purchased adult male wistar rats weighing 250350 g obtained animal research centre giza egypt animals kept standard housing conditions cages left acclimatize one week this work conducted pharmacology department faculty medicine el minia university egypt animal experimental protocol approved faculty board rats randomly assigned 6 groups n 6 follows group received vehicle 1% carboxymethylcellulose 15 days ip saline day 11 group ii treated dld 25 mg kg orally 15 days ip saline day 11 group iii treated dhd 50 mg kg orally ip saline day 11 group iv treated vehicle 15 days dox 15 mg kg day 11 group v treated dld 25 mg kg orally 15 days ip injection dox 15 mg kg day 11 group vi treated dhd 50 mg kg orally 15 days ip injection dox 15 mg kg day 11 the doses dox dia based previous studies 4 11 group received vehicle 1% carboxymethylcellulose 15 days ip saline day 11 group ii treated dld 25 mg kg orally 15 days ip saline day 11 group iii treated dhd 50 mg kg orally ip saline day 11 group iv treated vehicle 15 days dox 15 mg kg day 11 group v treated dld 25 mg kg orally 15 days ip injection dox 15 mg kg day 11 group vi treated dhd 50 mg kg orally 15 days ip injection dox 15 mg kg day 11 the doses dox dia based previous studies 4 11 after 4 days dox injection rat weighed anesthetized ip injection urethane 25% dose 1.6 gm kg sacrificed a longitudinal section left kidney one half fixed 10% formalin embedded paraffin histopathological immunohistochemical examinations the rest kidneys snap frozen liquid nitrogen kept 80c briefly method based fact sulfhydryl group gsh reacts 5 5-dithiobis 2-nitrobenzoic acid ellman reagent produces yellow colored 5-thio-2-nitrobenzoic acid measured colorimetrically 405 nm using beckman du-64 uv vis spectrophotometer usa assessment renal catalase antioxidant enzyme activity determined rate decomposition h2o2 510 nm addition tissue homogenate described colorimetric kit the assessments sod levels based ability enzyme inhibit phenazine methosulfate mediated reduction nitroblue tetrazolium dye results expressed unit g tissue the renal contents lipid peroxides assayed spectrophotometric method based reaction mda thiobarbituric acid the absorbance values samples blank determined 535 nm using beckman du-64 spectrophotometer usa blank absorbance value subtracted sample absorbance value standard curve mda concentration unknown sample extrapolated corresponding absorbance using regression line standard curve expressed nmol gm tissue multiplying tissue dilution factor nitric oxide form nitrite determined spectrophotometric method using griess reagent systems the stable oxidation end products nitrite no2 nitrate no3 used indicators production nox measured reduction nitrate nitrite copperized cadmium granules glycine buffer ph 9.7 quantification no2 based griess reaction chromophore strong absorbance 540 nm formed reaction nitrite mixture n naphthylene diamine sulfanilamide the absorbance sample blank measured 545 nm using beckman du-64 spectrophotometer usa the blank absorbance subtracted sample absorbance standard curve nox content unknown sample was extrapolated corresponding absorbance using regression line standard curve expressed nmol g tissue renal tissue fixed 10% formalin embedded paraffin sectioned microtome 5 thickness stained hematoxylin eosin routine histopathological assessment the renal tissues examined random microscopic areas semiquantitatively 40 high power fields number changes assessed counting 3 nonoverlapped fields slide animal the frequency severity lesions kidneys assessed semiquantitatively follows score assigned normal score normal mild score mild level less 25% examined fields revealed histological alterations score moderate level less 50% examined fields revealed histological alterations score severe level less 75% total fields examined revealed histological alterations the caspase-3 tnf nfb immunolabeled cells counted animal 3 sections examined cells counted 3 adjacent nonoverlapping fields levels immunohistochemical staining performed caspase-3 tnf nfb using polyclonal rabbit antirat antibody according previously published protocol 20 21 respectively table 1 shows results effect dia serum creatinine urea rats receiving single dose dox 15 mg kg ip showed significant increase serum creatinine urea levels compared control group both doses dia resulted significant decrease serum creatinine compared dox treated rats dia 50 mg kg day 25 mg kg day resulted significant decrease serum urea compared dox treated rats renal mda evaluated indicator kidney lipid peroxidation nitrites nitrates indicator renal nox levels table 1 dox 15 mg kg significantly increased renal mda nox levels compared control group administrating doses dia dox treated rats significantly decreased mda nox compared dox treated group treatment dox 15 mg kg caused significant decrease renal gsh sod catalase levels compared untreated control group table 2 concomitant treatment dox dia significantly increased levels renal gsh sod catalase compared dox treated group the histological study rat renal cortical tissue control group figure 1(a dld 25 mg kg day group figure 1(b dhd 50 mg kg day group figure 1(c showed normal architecture renal glomeruli tubules dox treated group figure 1(d showed marked enlargement vascular glomeruli tightly fill renal corpuscles dox dld group figure 1(e showed amelioration damaging effects dox there less tubular distortion narrow bowman spaces fewer cytoplasmic vacuolations renal corpuscle tubular cells also observed dox dhd group figure 1(f obvious decrease morphological changes caused dox exposure the severity morphological changes assessed semiquantitatively dox exposed group showed increase glomerular tubular morphological changes light microscopic levels compared control group these changes suppressed administration doses dia high dose showed marked improvement low dose table 3 administration dox caused significant increase immunoreactivity caspase-3 nfb tnf figures 2 3 4 table 4 respectively highly expressed renal glomeruli tubules cytoplasmically nuclei administration doses dia concomitantly dox decreased expression compared dox group administration doses dia vehicle treated rats alone control groups showed expression effective anticancer therapy anthracyclines dox limited toxicity various organs including kidneys nephrotoxic action dox also considered via drug induced free radical generation the formation free radicals induces production proinflammatory cytokines interleukin 1 initiating biological effects associated inflammation this directed attention investigate role dia interleukin 1 receptor antagonist possible nephroprotective agent dox induced renal damage induction dox nephrotoxicity detected study significant elevation serum urea creatinine levels confirmed toxic histopathological changes compared control group urea serum creatinine sensitive markers nephrotoxicity implicated diagnosis renal injury 24 25 the nephrotoxic effect dox characterized decreasing glomerular filtration rate leading rise serum urea creatinine our results good agreement previous studies 22 26 improvement dox induced nephrotoxicity previously tried compounds partially succeeded preserving normal renal function structure probably antioxidant anti inflammatory effects caffeic acid phenethyl ester zingiber officinale roscoe solanum torvum investigated role another antioxidant anti inflammatory drug dia dox induced nephrotoxicity dia could significantly decrease serum urea creatinine compared dox treated group due anti inflammatory antioxidant effects dia suppress dox mediated oxidative stress inflammation tissue damage our histopathological changes showed dox treated group presented marked damage renal tubules these results agreement zhao et al detected protective effect rhein active metabolite dia acetaminophen induced hepatotoxicity nephrotoxicity rats they found serum urea creatinine significantly decreased rhein acetaminophen coadministration compared acetaminophen group normalization toxic histopathological changes the elevated levels gsh could effectively provide thiol group possible gsh mediated detoxification reactions gpx glutathione peroxidase gst glutathione transferase involved scavenging o2 generated dox our findings consistent previous reports showed gsh concentration significantly decreased upon dox treatment compared control group 4 22 sod extensively distributes cells significant shielding role oxidative injury induced reactive oxygen species study activities sod catalase significantly decreased dox treated rats kidney compared control rats the accumulation highly reactive free radicals leads reduction activity sod catalase turn results damaging effects form loss cell membrane integrity function the decrease sod catalase activities related increase intracellular levels h2o2 catalase reported responsible detoxification h2o2 effective inhibitor sod coadministration dia significantly improved sod gsh catalase levels compared dox treated group these results may due antioxidant effect dia approved previously tamura et al indicated inhibitory effect dia indomethacin induced gastric ulceration could mediated suppression reactive oxygen species production based inhibition neutrophil activation antioxidant activity in addition hu et al investigated protective effects rhein lysinate rhl kidney impairment senescence prone inbred strain 10 samp10 mice treatment samp10 mice rhl significantly increased sod gpx levels kidneys o2 reacts lipid form lipid peroxides followed -oxidation form mda detected study showed significant increase mda level dox treated group compared control group these results agreement el sheikh et al yagmurca et al the high production nox results peroxynitrite formation potent aggressive cellular oxidant involved dox toxicity the current findings showed dox administration significantly increased renal level nox compared control group agreement studies 26 37 these results agreement zhao et al detected protective effect rhein acetaminophen induced nephrotoxicity rats approved significant decrease mda nox coadministration rhein plus acetaminophen group compared acetaminophen group our results agreement martel pelletier pelletier reported produced activity inducible nitric oxide synthase major catabolic factor involved pathophysiology oa our results consistent hu et al investigated protective effects rhein lysinate rhl kidney impairment senescence prone inbred strain 10 samp10 mice induction p53 mediates cell apoptosis activation caspase-3 family proteases apoptotic cell death our study showing significant increase caspase-3 expression dox treated group comparison control group our study consistence torina et al showed treatment dia day 4 weeks myocardial infarction improved ventricular remodeling partial blockage proinflammatory cytokines led lower caspase-3 activity nfb p65 transcription b pathway dox induced superoxide anion production reported responsible tnf-induced nuclear factor nf activation increases nf tnf expression our study showed significant increase tnf nfb expressions dox group compared control group results found al saedi et al coadministration dia significantly decreased tnf nfb expression compared dox treated group agreement gadotti et al showed dia inhibits neuropathic pain decreasing proinflammatory cytokines tnf nf. also hu et al the active metabolite dia rhein possesses anti inflammatory activity may effective suppressing inflammatory cytokines contributing pathogenesis diabetic nephropathy demonstrated rhein protective effect different models nephropathy iga induced nephropathy obstructive nephropathy chronic allograft nephropathy high glucose angiotensin ii induced nephropathy oral administration rhein 150 mg kg ameliorated renal lesions rhein capable protecting renal injury decreasing activities nfb caspase-3 early phase glomerulosclerosis our results consistent meng et al reported rhein possesses various pharmacological activities including anti inflammatory antioxidant antitumor in study model hyperuricemia nephropathy induced adenine ethambutol mice established the results demonstrated rhein significantly improved symptoms nephropathy decreasing production proinflammatory cytokines including interleukin 1 prostaglandin e2 tnf. yu et al aimed explore effect rhein sepsis induced acute kidney injury injecting lipopolysaccharide lps cecal ligation puncture clp vivo lps induced hk-2 cells vitro rhein could significantly decrease concentration serum urea creatinine level tnf nfb il-1 two different mouse models experimental sepsis in conclusion dia protected dox induced nephrotoxicity rats probably due antioxidant anti inflammatory activities however dhd 50 mg kg day showed protective effect dld 25 mg kg day

nephrotoxicity is one of the limiting factors for using doxorubicin ( dox ) . interleukin 1 has major role in dox - induced nephrotoxicity , so we investigated the effect of interleukin 1 receptor antagonist diacerein ( dia ) on dox - induced nephrotoxicity . dia ( 25 and 50 mg / kg / day ) was administered orally to rats for 15 days , in the presence or absence of nephrotoxicity induced by a single intraperitoneal injection of dox ( 15 mg / kg ) at the 11th day . we measured levels of serum urea , creatinine , renal reduced glutathione ( gsh ) , malondialdehyde ( mda ) , total nitrites ( nox ) , catalase , and superoxide dismutase ( sod ) . in addition , caspase-3 , tumor necrosis factor alpha ( tnf ) , nuclear factor kappa b ( nfb ) expressions , and renal histopathology were assessed . our results showed that dox - induced nephrotoxicity was ameliorated or reduced by both doses of dia , but diacerein high dose ( dhd ) showed more improvement than diacerein low dose ( dld ) . this protective effect was manifested by significant improvement in all measured parameters compared to dox treated group by using dhd . dld showed significant improvement of creatinine , mda , nox , gsh , histopathology , and immunohistochemical parameters compared to dox treated group .

suicide leading cause death among adolescents become significant public health issue globally 1 statistics korea report 2014 showed suicide cause 28.4% adolescent deaths 2013 number one cause death among adolescents 2 furthermore suicide second third cause mortality among adolescents western world important concern developing countries 3 numerous causes suicidal behavior adolescence reported including mental disorders peer affiliations level achievement school 4 additionally weight related concerns common cause suicidal behaviors 56 this transition often leads confusion personal identity especially context enduring developments identity cognition well physical growth 7 adolescents typically enter period high level self consciousness body shape size 8) they greater tendency consider look others life stage period life 9 these weight related issues influenced many factors including friends peers social norms media 10 the media particularly strong influence become general source information adolescents easily exposed 11 the media encourages ideal slim thin body shapes girls muscular bodies boys 1213 provides abundant information newest diet methods quick fixes weight control 14 this may induce adolescents particularly keen interest figure distort body image engage unneeded inappropriate weight control behaviors wcb 15 many adolescents engage inappropriate wcb vomiting taking nonprescription diet pills taking laxatives diuretics among korean adolescents engaging wcb 13.4% boys 18.8% girls took inappropriate methods control weight 16 according study using data national surveys similar rates were also observed united states 10% boys 21.3% girls conducting least one inappropriate wcb 17 inappropriate wcb harmful influence adolescents physical psychological development 12 for instance 5-year longitudinal study reported engagement inappropriate wcb predictor obesity eating disorders 18 moreover adverse outcomes inappropriate wcb also include onset depression 19 suicide ideation 20 due high prevalence possible negative side effects associated inappropriate wcb growing serious public health concern therefore prevention inappropriate wcb among adolescents imperative protect negative physical psychosocial consequences date studies inappropriate wcb merely suggest association inappropriate wcb negative psychosocial consequences 212223 present study investigate association inappropriate wcb suicide ideation attempt also difference association body mass index body weight perception body shape misperception moreover investigate top five wcb combinations used korean adolescents examine association five wcb combinations suicide ideation attempt we used cross sectional design thus results interpreted caution due possibility bi directional effect we used data 2014 korea youth risk behavior web based survey kyrbs the kyrbs conducted annually since 2005 korean centers disease control prevention kcdc korea ministry education science technology korea health human services the data collected via ongoing anonymous web based survey self reporting format conducted nationally representative sample middle- high school students it aimed plan assess korean adolescent health promotion policies investigating health related behaviors status 2014 survey 799 middle high schools selected including 72,060 students grades 7 12 stratified national scale however excluded 2,334 individuals due missing data variables used study therefore cohort ultimately comprised 69,726 adolescents 35,224 boys 34,361 girls suicide ideation attempt measured via responses following questions seriously considered suicide past 12 months tried suicide past 12 months possible responses questions yes " we characterized wcb via responses following multi part question experienced following weight control methods past 30 days following activities listed 1 regular exercise 2 fasted least 24 hours 3 ate less 4 took prescription diet pills 5 took nonprescription diet pills 6 took laxatives diuretics 7 vomited 8) ate one food 9 took oriental medicine 10 ate diet food possible responses questions yes " if participants responded yes least one 2 5 6 7 8) classified inappropriate wcb group 16 if participants responded 2 5)-8 classified appropriate wcb group if participants responded activity choices classified nothing group body mass index bmi calculated self reported height weight bmi percentiles age gender calculated according 2007 standard growth charts korean children adolescents korean pediatric society 24 four categories created underweight 15th percentile normal weight 16th 84th percentile overweight 85th 95th percentile obese 95th percentile bmi 25 we grouped overweight obese groups single overweight group thus using three bmi categories body weight perception bwp split five categories underweight underweight normal weight overweight overweight we grouped categories three groups thin normal obese body shape misperception bsm determined agreement bmi bwp categories participants perceiving weight least one category actual bmi categories designated part underestimate group perceiving weight least one category actual bmi designated part overestimate group i.e. participants whose bmi normal weight perceived body weight obese placed overestimate group 25 control variables included age household economic status parents presence residential area school level academic achievement school subjective health status sleep satisfaction physical activity current alcohol consumption current smoker stress level depression we performed statistical analyses survey data using sas version 9.4 sas inc the relevant primary sampling units sample weights stratification considered analysis given kyrbs designed complex sample a pearson test used determine significant differences distribution variable next logistic regression analysis conducted determine association wcb suicide ideation attempt additionally performed set subgroup analyses using bwp bmi bsm determine whether body related variables led differences association wcb suicide ideation attempt results presented adjusted odds ratios ors 95% confidence intervals 95% cis the ethics approval publicly open kyrbs data waived institutional review board irb after purpose survey fully explained students written informed consent provided students assured could refuse withdraw research stage 16 we used data 2014 korea youth risk behavior web based survey kyrbs the kyrbs conducted annually since 2005 korean centers disease control prevention kcdc korea ministry education science technology korea health human services the data collected via ongoing anonymous web based survey self reporting format conducted nationally representative sample middle- high school students it aimed plan assess korean adolescent health promotion policies investigating health related behaviors status 2014 survey 799 middle high schools selected including 72,060 students grades 7 12 stratified national scale however excluded 2,334 individuals due missing data variables used study therefore cohort ultimately comprised 69,726 adolescents 35,224 boys 34,361 girls suicide ideation attempt measured via responses following questions seriously considered suicide past 12 months tried suicide past 12 months possible responses questions yes " we characterized wcb via responses following multi part question experienced following weight control methods past 30 days following activities listed 1 regular exercise 2 fasted least 24 hours 3 ate less 4 took prescription diet pills 5 took nonprescription diet pills 6 took laxatives diuretics 7 vomited 8) ate one food 9 took oriental medicine 10 ate diet food " if participants responded yes least one 2 5 6 7 8) classified inappropriate wcb group 16 if participants responded 2 5)-8 classified appropriate wcb group if participants responded activity choices classified nothing group body mass index bmi calculated self reported height weight bmi percentiles age gender calculated according 2007 standard growth charts korean children adolescents korean pediatric society 24 four categories created underweight 15th percentile normal weight 16th 84th percentile overweight 85th 95th percentile obese 95th percentile bmi 25 we grouped overweight obese groups single overweight group thus using three bmi categories body weight perception bwp split five categories underweight underweight normal weight overweight overweight we grouped categories three groups thin normal obese body shape misperception bsm determined agreement bmi bwp categories participants perceiving weight least one category actual bmi categories designated part underestimate group perceiving weight least one category actual bmi designated part overestimate group i.e. participants whose bmi normal weight perceived body weight obese placed overestimate group 25 control variables included age household economic status parents presence residential area school level academic achievement school subjective health status sleep satisfaction physical activity current alcohol consumption current smoker stress level depression we performed statistical analyses survey data using sas version 9.4 sas inc the relevant primary sampling units sample weights stratification considered analysis given kyrbs designed complex sample a pearson test used determine significant differences distribution variable next logistic regression analysis conducted determine association wcb suicide ideation attempt additionally performed set subgroup analyses using bwp bmi bsm determine whether body related variables led differences association wcb suicide ideation attempt results presented adjusted odds ratios ors 95% confidence intervals 95% cis the ethics approval publicly open kyrbs data waived institutional review board irb purpose survey students assured could refuse withdraw research stage 16 the demographics 35,224 boys 34,361 girls study listed table 1 participants 10.6% n 3,709 boys 15.0% n 5,172 girls reported experienced suicide ideation 2.1% n 722 boys 3.4% n 1,151 girls reported attempting suicide 33.5% n 11,827 boys 45.2% n 15,489 girls reported engaged appropriate wcb 4.2% boys n 1,466 9.6% girls n 3,324 reported engaged inappropriate wcb boys engaged inappropriate wcb likely report suicide ideation engaging wcb group 1.57 p 0.001 girls engaging inappropriate wcb also high suicide ideation rate 1.32 p 0.001 boys engaging inappropriate wcb also likely attempt suicide engaging wcb 2.49 p 0.001 girls engaging appropriate wcb 1.21 p 0.02 inappropriate wcb 1.92 p < 0.001 likely attempt suicide girls engaging wcb association stronger among latter comparison group the association suicidal behavior wcb stratified bmi bwp bsm shown table 3 boys underweight bmi engaged inappropriate wcb experienced highest rate suicide ideation 2.22 p 0.05 compared bmi groups girls underweight bmi engaged inappropriate wcb 4.53 times likely attempt suicide girls engage wcb girls perceived weight normal engaged inappropriate wcb likely experience suicide ideation 1.50 p 0.001 attempt 2.31 p 0.001 girls engage wcb considering bsm boys distorted body shape engaged inappropriate wcb likely experience suicide ideation underestimate 1.44 p 0.01 overestimate 1.91 p 0.01 attempt underestimate 1.96 p 0.01 overestimate 2.94 p 0.01 boys engaged wcb girls underestimated overestimated body shape engaged inappropriate wcb showed significant association suicide attempt underestimate 1.89 p 0.001 overestimate 1.73 p 0.001 compared girls engaged wcb adjusted age sex household economic status parents presence residential area school level academic achievement subjective health status sleep satisfaction physical activity current alcohol consumption current smoker stress status depression calculated due lack number table 4 lists odds ratios top five wcb combinations engaged korean adolescents association suicide behaviors conducting regular exercise eating less together fasting was significantly associated suicidal ideation boys 1.70 p 0.01 girls 1.33 p 0.05 attempt boys 1.84 p < 0.05 girls 2.24 p 0.001 among boys girls girls higher rates attempted suicide adjusted age sex household economic status parents presence residential area school level academic achievement subjective health status sleep satisfaction physical activity current alcohol consumption current smoker stress status depression in present study investigated association inappropriate wcb suicide ideation attempt korean adolescent using nationally represented data inappropriate wcb significantly associated suicidal behaviors boys girls higher rate boys our study findings higher likelihood suicidal behaviors among adolescents engaging wcb especially inappropriate wcb confirm results described previous studies adolescents using inappropriate methods control weight highly likely experience psychological symptoms including anxiety fatigue impaired concentration 26 additionally prospective association wcb depression 27 depression adolescence serious public health concern due increased risk suicide among depressed youth 28 moreover wcb cause eating disorders fasting especially high risk factor development eating disorders 29 another study among adolescents 5 year follow reported unhealthy wcb powerful predictors eating disorders 18 eating disorders adverse consequences adolescents physical mental health 30 cause suicide ideation attempt 31 therefore one possible interpretation finding wcb represent risk factor suicide ideation attempt causing depression eating disorders serious consequences adolescents mental health furthermore study demonstrated stronger associations among boys girls corroborated studies 623 girls sensitive weight easily engage inappropriate wcb 32 whereas boys sensitive weight lower likelihood engaging inappropriate wcb 7 therefore possible boys consider controlling weight inappropriate ways may already suffering severe psychological distress due experiencing immense trauma teasing adverse events we investigated differences association suicide ideation attempt wcb conducting subgroup analyses using bmi bwp bsm context bmi underweight boys engaged inappropriate wcb experienced highest rate suicide ideation attempt bmi groups underweight girls considerably likely attempt suicide additionally suicidal behavior also associated boys girls normal weight engaged inappropriate wcb this suggests adolescents need control weight engage unnecessary wcb nonetheless higher risk experienced adverse consequences 12 regards bsm results study showed misperception body shape also associated suicide ideation attempt the media continues portray slender bodies girls muscular bodies boys ideal body shapes could effect body shape misperception among adolescents 33 this mismatch contributes adolescent depression turn increases risk suicide among youth 34 moreover mismatch could related adolescents unnecessary weight control behaviors obtain ideal body shape eventually effect inappropriate wcb aggravates adverse effects distorted body image seems psychological burden causes adolescents think attempt suicide we also extracted five common combinations weight control methods used korean adolescents investigated association wcb suicidal behaviors conducting regular exercise frequent wcb among boys third common among girls however combination significantly associated suicidal behaviors boys girls the common wcb engaged girls regular exercise eating less also show significant association suicidal behaviors interestingly boys girls engaging regular exercise fasting eating less likely experience suicidal behaviors compared conduct wcb although regular exercise eating less appropriate wcbs fasting classified inappropriate wcb added combination could contribute adolescents suicidal behaviors according previous study fasting weight control showed association depression compared wcbs 35 practice fasting causes blood glucose concentration fall normal status releases hormone cortisol associated anxiety negative feelings 36 therefore seems combination influences suicidal behaviors due strong influence fasting depressive symptoms this study designed cross sectional study therefore could exclude potential bi directional effect in addition time frames wcb within past 30 days suicide ideation attempt within past 12 months differed therefore reverse time order could clearly excluded 6 moreover responses kyrbs represent self reported data therefore may inaccurate additionally could obtain detailed descriptions wcb including frequency amount however despite limitations study generalized using nationally representative data additionally compared previous studies reported associations wcb suicidal behavior investigated differences association context bmi bwp bsm moreover first study investigate common wcb combinations determine association top five combinations suicide ideation attempt considering high incidence suicide severe negative impact adolescents inappropriate wcb health findings represent important motivation health policy makers identify solutions controlling adolescents suicide problem inappropriate wcb among adolescents serious public health concern considering widespread prevalence harmful influence growth physical health psychosocial growth additionally shown wcb associated health compromising behaviors including suicide ideation attempt therefore protect adolescents healthy psychological status context weight concerns policy makers health professionals must endeavor correct distorted body perception experienced adolescents additionally help adolescents develop skills avoiding inappropriate wcb encourage appropriate methods weight control physical activity fruit vegetable consumption avoidance fatty sweet foods future studies designed regardless gender weight status boys normal underweight adolescents currently low priority even though also risk adverse effects due wcb according present study therefore broader viewpoints approaches needed considering adolescents weight related behaviors

suicide is a leading cause of death among adolescents globally , and body weight is also a recognized reason for adolescent suicide . therefore , we investigated the association between weight control behaviors ( wcb ) and suicide ideation and attempt , focusing on inappropriate weight control measures . we used data from the 2014 korea youth risk behavior web - based survey , representing a total of 35,224 boys and 34,361 girls aged 12 to 18 years . adolescents were classified into groups based on wcb : appropriate wcb , inappropriate wcb , and no wcb . we performed logistic regression models to examine associations between wcb and suicide ideation and attempt , controlling for covariates . both boys and girls with inappropriate wcb were more likely to report suicide ideation and attempt . underweight and normal weight boys with inappropriate wcb were more likely to think or attempt suicide , and underweight girls with inappropriate wcb were also more likely to attempt suicide . among five common wcb combinations , the combination of " regular exercise , fasting , eating less " was highly associated with suicide ideation and attempt . we confirmed that inappropriate wcb is associated with suicide ideation and attempt among korean adolescents . given the high incidence rate of suicide among adolescents and the adverse effect of inappropriate wcb , encouraging adolescents to control their weight in healthy ways is imperative .

past 15 years green fluorescent protein gfp changed nearly unknown protein commonly used molecular imaging tool biology chemistry genetics medicine 2006 10 000 papers gfps gfp like proteins i.e. chromoproteins fluorescent proteins particularly useful due stability fact chromophore see figure 1 formed autocatalytic cyclization 65syg67 sequence require cofactor this means unlike bioluminescent reporters gfp fluoresces absence proteins substrates cofactors furthermore appears fusion gfp protein alter function location protein changing residue 66 and/or amino acid residues around chromophore (n1c1c2c3 (c1c2c3c4 dihedral angles gfp chromophore protein r1 gly67 r2 ser65 hbdi often used model compound r1 r2 ch3 one bond flips -obf dihedral rotation occurs around torsional angle -obf around dihedral angle positively correlated hula twist ht dihedral angles concertedly rotate direction shown negatively correlated hula twist ht concertedly rotate opposite directions plot dihedrals perfectly correlated negative ht slope 1 if chromophore cavity complementary planar chromophore best fit line pass origin angles centered around origin a nonzero intercept along axis see example figure 4 dihedrals centered quadrant ii 0 ; 0 quadrant iv 0 0 see example figure 8) indications cavity complementary planar chromophore fluorescent emission chromophore within gfp occurs high efficiency quantum yield fl 0.8 respectable fluorescence lifetime 3 ns).(19 protein denatured fluorescence yield decreases least 3 orders magnitude.(20 model compounds chromophore fluoresce solution quantum yield fl 10 unless rotation arylalkene bond restrained.(21 fluorescence however obtained lowering temperature 77 k freezes solution it suggested twisting phenolate imadazolidinone groups chromophore mechanism ultrafast fluorescence quenching internal conversion process neutral form chromophore phenolic oxygen protonated convert anionic species b going intermediate state the change forms solely protonation change change b conformational change changes occurring thr203 upon excitation state excited state proton transfer espt occurs proton transferred chromophore glu222 time scale order picoseconds following radiative relaxation excited state intermediate the systems returns ground state ground state intermediates i1 i2.(29 excitation anionic b state results direct emission excited state b 482 nm recently nonfluorescent dark state state c observed distinct states b absorbs higher energies.(30 c state perhaps neutral trans form chromophore may populated nonradiative decay may depopulated excitation excited c state transcis isomerization repopulate state a. fluorescent blinking ascribed nonadiabatic crossing conversions neutral anionic states,(31 possible dark z zwitterionic state ground state minimum gfp chromophore close planar necessarily excited state fact cases excited state energy minimum twisted chromophore rings 90 other.(32 according quantum mechanical calculations ground excited states one bond flip obf hula twist ht neutral form obf zwitterionic form come close it proposed absence protein matrix surrounds chromophore prevents twisting process lead fluorescence quenching internal crossing;(32 see figure 3 recent calculations gfp chromophore model compound hbdi suggest anionic form hbdi may also undergo -obf leads favored radiationless decay channel particularly efficient solvent.(34 model compounds gfp chromophore ground state s0 excited first singlet state s1 ht obf freely occur upon reaching perpendicularly twisted conformation fluorescence quenching nac nonadiabatic crossing occurs ( b ground state s0 residues surrounding gfp chromophore exert twisting force chromophore upon excitation conjugation across ethylenic bridge chromophore reduced twist however protein matrix prevents chromophore reaching perpendicularly twisted conformation fluorescence quenching internal crossing prevented recently results number interesting experiments provide evidence chromophore twisting and/or fluorescence quenching internal crossing ic published for example molecular dynamics simulation chromophore cyan fluorescent protein found average dihedral angle 0 however surrounding protein considered simulation average shifted approximately 5 showing protein matrix cfp twists chromophore basis calculations authors concluded driving force twist comes strong short range repulsion four residues ile167 val150 phe165 thr203 surrounding average position chromophore.(46 photoswitching fluorescent proteins switched back forth naturally occurring green state dark state 405 nm irradiation e.g. dronpa mtfp0.7 kfp1 a cistrans isomerization chromophore proposed structural basis photoswitching observed dronpa.(47 supported fact mutating either val157 met159 smaller residues accelerates photoswitching presumably decreasing steric hindrance cistrans isomerization.(48 ) the m159 v157 g mutations also decrease quantum yield dronpa 0.85 quantum yields 0.23 0.77 respectively.(48 recently suggested adoption trans configuration solely responsible nonfluorescent form.(49 basis nmr analyses miyawaki et al propose fluorescence protein regulated degree flexibility chromophore necessarily accompanied cistrans isomerization.(49 interestingly gfp unique photoactive yellow protein pyp protein matrix also prevents chromophore adopting completely planar structure pyp the asymmetric proteinchromophore interaction probably serves initial accelerant light induced photocycle,(50 ultimately leads cistrans isomerization.(51 chromophore wild type gfp planar due extended system see figure 1 however energy barrier deformation low protein matrix wild type gfp exerts strain away planarity when chromophore computationally permitted freely rotate adopt conformation complements protein matrix recently used computational methods show wild type gfp anomaly gfp gfp like proteins protein databank protein matrix complementary planar chromophore.(54 cases freely rotating chromophore undergoes rotations least 20. cases rotations accompanied equal opposite rotation dihedral angle negatively correlated ht none proteins examined cavity causes rotation solely around dihedral angle.(54 calculations done minimizing freely rotating dihedral angles crystal structure 38 gfp analogues mutants found pdb they found energy minimum conformation freely rotating chromophore protein matrix gfp mutant gfp like protein examined however provide information range low energy conformations available freely rotating chromophore get information ran molecular dynamics simulations interesting gfp mutants protein databank.(56 running molecular dynamics simulations freely rotating dihedrals able determine range conformations available chromophores complete rotational freedom the coordinates three crystal structures 1gfl,(57 1myw,(58 2emd(59 obtained protein data bank pdb),(56 hydrogen atoms added protein solvent atoms required opls_2005 force field macromodel v9.0016(60 used starting structures mutants crystal structure determined calculated graphically mutating known structure undertaking conformational search the flexible dihedral angles side chains residues within 8.00 chromophore randomly rotated 0 180 solvent molecules sphere randomly rotated translated 0 1.00 monte carlo mc step.(63 15 000 mc steps taken search structures within 50 kj mol lowest energy minimum kept usage directed method(62 used select structures subsequent mc steps structures found conformational search considered unique least squared superimposition equivalent non hydrogen atoms found one pairs separated 0.25 lowest energy structure obtained monte carlo torsional molecular position variation search the final structures obtained mc search monte carlo torsional molecular position variation large scale low mode fully minimized pdb structures used initiate md simulations freely rotating dihedral angles v1 v2 v3 0.000 the predynamics simulation set 100 ps full md simulation 5000 ps the cambridge structure database csd v5.29 released january 2008 comprises 436 384 small molecule crystal structures the area convex hull graphs calculated smallest convex set containing region molecular mechanics dynamics calculations used examine steric environment chromophore gfp ground state they techniques based classical physics designed model structural electronic properties therefore molecular mechanics dynamics simulations gfp examine excited state chromophore quantum calculations excellent technique determine energy profiles ground excited states chromophore however cpu intensive would cost prohibitive conformational searches excited state series gfp gfp like proteins therefore attempt supplement quantum calculations examined conformational space available chromophore within gfp using freely rotating chromophore approximation based qm calculations conformational space available chromophore excited state shown figure 2 gfp adopts two states neutral state chromophore phenolic oxygen protonated anionic species b ) the change forms solely protonation change change b conformational change changes occurring thr203.(67 order see whether gfp chromophore different dihedral freedom forms b conducted molecular dynamical simulations freely rotating chromophore described not surprisingly table 1 figure 4 show forms b gfp similar dihedral freedom undergo similar negatively correlated slopes best fit lines figure 4 hula twists plot vs dihedral angles see figure 1 nomenclature 2000 gfp pink gfp b green gfp light blue structures obtained freely rotating molecular dynamics simulation however subtle differences forms closer planar ground state conformation b form adopts conformations planarity given rotational freedom around dihedrals intercept 0 anionic b form freedom largest area range neutral form least freedom the form robust hydrogen bonds arg96 gln94 imidazolidinone carbonyl group remain intact throughout simulations intermediate ) form hydrogen bonds supplemented additional hydrogen bond phenolic oxygen chromophore his148 see table 2 the main difference anionic b form intermediate form thr203 rotate order hydrogen bond phenolic oxygen form otherwise hydrogen bonding interactions throughout simulation the y66h mutant gfp exhibits blue fluorescence therefore termed blue fluorescent protein the crystal structure bfp confused blue fluorescent protein aequorin bfp aq(68 solved ph 4.5(27 ph 8.5;(59 overall fold protein identical wild type gfp consists chromophore surrounded 11-stranded -barrel while gfp absorption maxima 395 475 nm emits 508 nm bfp absorbs 382 nm emits 448 nm.(9 unfolding bfp results absorption red shift 15 nm,(27 quantum mechanical calculations suggest 15 nm shift might due protein induced nonplanarity chromophore.(69 blue fluorescent protein bfp much lower fluorescence quantum yield gfp fl 0.20 vs 0.80 it suggested due fact his66 bfp chromophore forms fewer hydrogen bonds surrounding protein tyr66 gfp chromophore smaller imadazole ring his66 bfp may conformational freedom larger phenol tyr66 leads intersystem crossing.(27 elegant series experiments boxer et al have shown fluorescence quantum yield blue fluorescent protein increases fl 0.20 0.35 pressure increased atmospheric pressure 570 mpa.(70 analysis fluorescence lifetimes picosecond nanosecond regimes reveals enhancement fluorescence quantum yield due inhibition fast quenching processes temperature dependent fluorescence measurements reveal two barriers 19 3 kj mol respectively transition nonfluorescing states these steps probably linked dissociation hydrogen bond chromophore his148 intervening water molecule barrier chromophore twisting excited state respectively.(70 order establish consequences y66h mutation flexibility chromophore molecular dynamics simulations ph 8.5 bfp crystal structure pdb code 2emd neutral imidazole rings his66 his148 freely rotating chromophore run thank one referees suggesting ph 8.5 2emd ph 4.5 1bfp structure figure 5 table 1 show chromophore bfp significantly rotational freedom available chromophore gfp bfp cavity less complementary planar chromophore gfp cavity bfp sampled structures planar chromophore 0 intercept best fit line bfp structures origin gfp plot vs dihedral angles 2000 bfp blue gfp green structures obtained freely rotating molecular dynamics simulation analysis 2000 bfp structures revealed hydrogen bond nh his66 imidazole ring glu222 retained entire simulation see figure 7 the smaller imadazole ring bfp chromophore results dihedral freedom chromophore bfp phenol gfp however seems large difference number stability hydrogen bonds formed chromophore two fps recently two new blue fluorescent proteins azurite a5 enhanced brightness photostability created the methodology applied find brighter bfp mutants based concept replacing residues surrounding chromophore bulkier amino acids would constrain chromophore motion thereby increase proteins brightness the crystal structure a5 yet solved order find starting conformation md simulation 2emd crystal structure was graphically mutated a5 thorough conformational search undertaken see given high structural similarity solid state structures gfp mutants protein databank thorough conformational search find lowest energy conformations a5 making relevant mutations 2emd structure figure 6 table 1 show conformational space available chromophore bfp larger a5 bfp conformations tend planarity i.e. a5 median 2.92 median 2.22 intercept best fit line 4.62 vs bfp median 27.59 median 10.18 intercept best fit line 14.27 similar results found md simulations carried five lowest energy conformational families sampled conformational search a5 md simulation initiated a5 structure obtained taking 2emd structure graphically mutating a5 thoroughly minimizing structure without undertaking conformational search plot vs dihedral angles 2000 bfp dark blue a5 pink structures obtained freely rotating molecular dynamics simulation the n his66 imidazole ring hydrogen bonds water305 2emd numbering sampled structures this water connects his66 surface protein via robust hydrogen bonding network his148 also hydrogen bonded glu222 half structures sampled n his66 imidazole ring hydrogen bonds water302 extensive hydrogen bonding network val68 arg224 gln69 in contrast 2emd hydrogen bonding interactions n hydrogen see figure 7 hydrogen bonding interactions --- 2emd top a5 bottom chromophore these results seem indicate enhanced brightness a5 least part due fact chromophore movement restricted relative bfp this restriction due steric factors increased hydrogen bonding networks a5 first rationally designed mutant based crystal structure gfp s65 it decided mutate t203 tyrosine could stack phenolic group chromophore ( 73 resultant mutant yfp red shifted 16 nm relative gfp s65 indeed stacking interaction chromophore tyr203.(74 basis crystal structure yfp remington et al proposed red shift due additional polarizability -stacked tyr203 hydrogen bond pattern around chromophore plane distortion chromophore analogy plane distortions porphyrin systems).(74 comparison t203v mutant revealed t203y substitution leads significant form population 10 nm shift ascribed interaction.(75 new varient yfp venus improved brightness maturation properties well reduced environmental sensitivity developed crystallized.(58 since researchers argued presence tyr203 leads decrease chromophore flexibility van der waals volume tyr 141 vs 93 thr others argue necessarily so,(32 examined conformational space available freely rotating chromophore yfp pdb code 1myw phenol tyr66 protonated unprotonated forms table 1 figure 8 show chromophore phenolic form gfp yfp differing rotational freedom yfp the chromophore approximately 1.2 times dihedral freedom gfp although dihedrals undergo negatively correlated hula twisting proteins yfp average conformation sampled planarity found gfp i.e. majority sampled conformations located quadrant iv plot vs dihedral angles see figure 1 nomenclature 2000 structures obtained freely rotating molecular dynamics simulation gfp dark blue yfp pink phenolic forms the majority yfp conformations sampled nonplanar i.e. quadrant iv 0 0 entire simulation hydrogen bonds tyr66 ser205 arg96 imidazolone carbonyl well tyr203 water354 remain stable tyr203 gln69 less stable we also examined distance centroid tyr66 choromophore tyr203 the distance fairly short change much simulation minimum 3.43 maximum 4.18 average 3.75 sd 0.103 angle planes phenols varies 0.0 22.5 average 6.9 sd 4.11 the short distance phenol rings indicative stacking may responsible red shift observed yfp however variability angle planes phenols shows tyr203 significantly restrict rotational freedom excited chromophore the cambridge structural database csd)(77 v5.29 comprises 436 384 small molecules crystal structures it 5551 structures two phenol rings separate molecules centroids within 5.00 the closest ones 3.16 832 structures within 3.75 i.e. average distance phenol centroids freely rotating yfp a plot distance vs angle phenol planes freely rotating simulation csd structures shows protein matrix yfp restricts distance tyr66 tyr203 larger 4.18 angles two phenols much freedom yfp small molecule structures intermolecular distances less 4.18 see figure 9 it seem increased fluorescence lifetime yfp due decrease dihedral freedom chromophore it likely due electronic effects proposed jung et al.(78 suggested anionic form chromophore described two mesomeric forms benzoidal quinoidal structure the benzoidal form majority negative charge phenol stabilized hydrogen bonding thr203 possible yfp therefore t203y mutation favors quinoidal form may longer fluorescence lifetime.(78 distance vs angle phenol planes yfp structures csd two unconnected phenols separated less 5.00 some suggested crystal structures strongly fluorescent gfp gfp like proteins chromophores cis configuration nonfluorescent proteins trans configuration however trans planar form eqfp611 important exception fluorescent.(82 remington et al have suggested coplanarity might important isomer configuration determining efficiency fluorescence most current theories see suggest restriction rotational freedom fluorescent protein chromophore lead increase fluorescence brightness and/or quantum yield our calculations show case systems examined bfp a5 yfp gfp inverse correlation dihedral freedom chromophore quantum yield see table 1 simulations the protein matrix complementary planar chromophore cases freely rotating chromophore undergoes negatively correlated hula twist also known bottom hula twist mechanism

green fluorescent protein ( gfp ) and gfp - like fluorescent proteins owe their photophysical properties to an autocatalytically formed intrinsic chromophore . according to quantum mechanical calculations , the excited state of chromophore model systems has significant dihedral freedom , which may lead to fluorescence quenching intersystem crossing . molecular dynamics simulations with freely rotating chromophoric dihedrals were performed on green , yellow , and blue fluorescent proteins in order to model the dihedral freedom available to the chromophore in the excited state . most current theories suggest that a restriction in the rotational freedom of the fluorescent protein chromophore will lead to an increase in fluorescence brightness and/or quantum yield . according to our calculations , the dihedral freedom of the systems studied ( bfp > a5 > yfp > gfp ) increases in the inverse order to the quantum yield . in all simulations , the chromophore undergoes a negatively correlated hula twist ( also known as a bottom hula twist mechanism ) .

fnas represent advantageous effective means obtain diagnostic cellular material often sample wide area target lesion acquire tumor cells lower contamination background stromal connective tissue elements allow immediate assessment rapid site evaluation rose site assessment a member cytopathology team present prepares direct smears using contents expelled needle location procedure this advantageous three reasons needle pass examined determine tumor cell adequacy opportunity engage clinical care provider conversation regarding preliminary diagnosis relevant molecular diagnostic tests cytopathology team member help ensure specimen processed manner optimizes judicious triage ancillary tests including molecular studies fnas performed without rose setting contents fna needles typically expelled rinsed cell preservative solution use liquid based cytology lbc preparations examples lbc preparations include thinprep hologic bedford usa surepath becton dickinson franklin lakes nj usa thin layer advanced cytology assay system tacas mbl tokyo japan liqui prep lgm international inc nonetheless rose effective means maximize chances success acquiring adequate tumor cells diagnosis anticipated molecular studies the ultimate goal prevent unnecessary repeat procedures obtain additional tissue molecular studies lead delays treatment patients afflicted lung cancer institution we perform rose cytopathologist performed fnas ebus guided fnas performed clinical colleagues the contents needle pass expelled onto slide utilized prepare direct smears the needle rinsed buffered media utilize rpmi media purpose commonly pair direct smears prepared per needle pass one air dried immediately alcohol fixed the air dried smear stained site diff quik romanowsky stain stained slide examined microscope immediately thereafter the alcohol fixed smear stained later cytopathology laboratory papanicolaou stain alternatively needle contents distributed multiple smears allowing flexibility utilization direct smears cytomorphologic evaluation ancillary studies fig based findings diff quik stained smears determination made perform additional needle passes obtain tumor cells diagnosis and/or anticipated ancillary studies patient still accessible for instance additional direct smears prepared and/or dedicated needle passes rinse solution i.e. needle contents rinsed rpmi solution without preparation smears needle passes obtained cell block preparation this overall approach flexible forgiving engages cytopathology team maximizing chance success obtaining adequate cellular material diagnosis ancillary studies this approach help minimize chances encountering scenario diagnostic cellular material present one smear microdissection cells molecular studies result sacrificing diagnostic slide context medico legal consequences if scenario encountered however risk mitigated digital archiving prior microdissection either via digital slide scanning and/or obtaining photomicrographs after immediate assessment cytomorphologic findings diff quik stained smears preliminary diagnosis rendered cytopathologist communicated clinical care providers after conclusion procedure needle rinse solution containing suspension aspirated cells centrifuged cytopathology laboratory pellet cells once supernatant removed cell pellet congealed matrix agar like substance histogel thermo scientific waltham usa used cells mixed plasma thrombin create clot institution employ histogel purpose commonly cassette fixed formalin processed ultimately create formalin fixed paraffin embedded ffpe cell block this analogous ffpe block small biopsy tissue sectioned evaluation via hematoxylin eosin stain ancillary tests immunocytochemistry molecular diagnostic assays it noted heavy metal fixatives zenker fixative acidzinc formalin acidic fixatives bouin solution decalcification solutions generally avoided render specimens unusable molecular testing the main advantage using cell blocks majority ancillary tests validated ffpe sections ffpe cell blocks treated similarly traditional surgical pathology ffpe blocks furthermore multiple serial sections cell blocks utilized perform battery ancillary studies first adequate cellularity cell blocks guaranteed time procedure performing dedicated needle passes needle rinse solution fna procedure may improve chances obtaining sufficiently cellular cell block still guarantee success in addition hypocellular cell blocks risk depleting cells interest upon deeper sectioning molecular tests second cell block derived needle rinse solution pooled specimen contains contents needle passes thus one needle passes contain tumor cells needle passes contain abundant benign background cellular elements tumor cells diluted benign cells cell block in addition disadvantages dna extracted ffpe cell blocks may produce sequencing artifacts formalin fixation leads crosslinking nucleic acids proteins possibility sequence alterations recently given shortcomings cell blocks increasing appreciation alternative cytopreparatory platforms molecular testing direct smears lbc samples subsequent sections the utilization cytopreparatory platforms discussed context clinically relevant mutations translocations analyzed molecular diagnostic testing nsclcs the epidermal growth factor receptor egfr gene encodes transmembrane growth factor receptor exhibits tyrosine kinase activity upon activation intracellular signaling mediated cytoplasmic effectors ras raf mek erk pi3k akt stat pathways egfr mutations predominantly observed lung adenocarcinomas l858r substitution small frame deletions exon 19 commonly observed mutations account 90% egfr mutations setting these mutations commonly associated east asian ethnicity female gender non smoking history however absolute rules clinical characteristics used exclude lung cancer patients mutation testing lung adenocarcinomas harboring sensitizing mutations egfr shown respond egfr tyrosine kinase inhibitors tkis tki therapy demonstrated result improved progression free survival compared standard chemotherapy patients lung adenocarcinoma harboring egfr mutations 11 16 egfr mutation analysis commonly performed via polymerase chain reaction pcr sequencing based approaches advances development testing modalities afforded multitude methodologies sanger sequencing considered gold standard involves direct dna sequence acquisition provide information regarding presence potential mutations including common known mutations novel mutations nonetheless test requires relatively higher enrichment tumor cell dna content sample the typical analytic sensitivity sanger sequencing 15%20% mutant allele equates 30%40% tumor cells assuming genetic mutation heterozygous event without amplification this problematic small biopsy cytology specimens especially cell blocks tumor cell population diluted background benign cellular elements inflammatory cells bronchial epithelial cells and/or stromal mesenchymal cells especially this setting negative mutation result either due true absence mutation tumor cells insufficient percent tumor cellularity falls analytic sensitivity threshold thereby resulting failure detect mutation even despite presence mutation therefore often times reliance tumor cell enrichment either macrodissection microdissection obtain reliable result sanger sequencing also relatively labor intensive time consuming targeted methods lead longer turnaround times in contrast general sanger sequencing approach targeted mutation detection methods pcr restriction fragment length polymorphism real time pcr pyrosequencing high resolution melting analysis hrma pcr fragment analysis utilized the advantages approaches include improved analytic sensitivity less time consuming nature leading reduced turnaround times institution utilize multiplex pcr fragment analysis assay egfr mutation testing allows simultaneous assessment two commonly observed egfr mutations fig 2 analytic sensitivity method better sanger sequencing minimum 10% tumor cells required past decade myriad studies reported demonstrating variety cytologic samples cytopreparatory platforms effectively utilized egfr mutational analysis these reviewed elsewhere salient examples discussed mentioned previously ffpe cell blocks represent traditional cytopreparatory platform ancillary molecular diagnostic tests performed much reasoning behind lies ffpe cell blocks best approximate ffpe blocks containing tissue specimens majority molecular assays validated using ffpe material nonetheless light inherent disadvantages cell blocks mentioned previously investigation cytopreparatory platforms molecular diagnostic assays performed group many others cytopathology specimen preparation diverse versatile consequence type cytologic analyte platform needs carefully validated given molecular test cytologic direct smears may ultimately prove cytologic platform best suited pcr based analysis due high quality nucleic acids immediate nature specimen assessment tumor cell adequacy cells direct smears exposed formalin rather undergo alcohol based fixation process prior staining thus negative effects formalin fixation nucleic acid quality non contributory direct smears furthermore tumor cells interest directly visualized direct smear isolated nucleic acid extraction molecular analysis essence see get previously demonstrated uncoverslipped previously coverslipped decoverslipped diff quik stained smears robust sources cellular material pcr based mutational analysis egfr mutation testing lung adenocarcinoma braf mutation testing metastatic melanoma fna specimens others observed destaining smears necessary successful dna extraction pcr our preference utilizing diff quik stained smears papanicolaou stained smears rooted following observations 1 cellular material diff quik stained smear easily visualized without coverslip immediately triaged molecular diagnostic testing 2 report killian et al that nucleic acids extracted diff quik stained smears show better preservation integrity dna extracted papanicolaou stained smears respect latter point others pointed papanicolaou stained smears feasible pcr based molecular tests multiple groups successfully demonstrated utilization cytologic direct smears egfr mutation testing lung adenocarcinomas 2,9,25 36 low failure rates high degree concordance egfr molecular testing results corresponding histologic specimens available experience 100 200 tumor cells sufficient successful dna isolation egfr mutation analysis congruent observations others lbc samples also investigated egfr mutation testing shown effective analyte purpose this valuable member cytopathology team available rose several lbc technologies developed including thinprep surepath tacas liqui prep of emerging literature date utilization lbc samples molecular testing nsclc predominantly focused cytolyt cytyc corp marlborough usa cell suspensions thinprep slides collecting fna samples methanol based cytolyt solution results reduction background blood cytolyt solution exhibits hemolytic properties the cell suspension divided aliquot used prepare thinprep slide stained via papanicolaou method similar alcohol fixed papanicolaou stained direct smears tumor cells isolated thinprep slide used dna isolation egfr mutation analysis furthermore cell suspension aliquot used prepare thinprep slide centrifuged cell pellet used analyte mutation testing 38 40 similar needle rinse cell suspension utilized prepare cell blocks cytolyt cell suspension pooled specimen multiple needle passes expelled rinsed cytolyt thus one needle passes high tumor cell content whereas needle passes contain high proportion benign cellular elements tumor cells final pooled cell suspension diluted first targeted methods detecting egfr mutations improved analytic sensitivity relative sanger sequencing utilized second tumor cell enrichment thinprep slide accomplished laser capture microdissection lcm illustrate points malapelle et al directly compared performance egfr mutation analysis sanger sequencing using paired samples case analyzed 1 pelleted cells cytolyt suspension 2 tumor cells obtained thinprep slide via lcm they observed egfr mutations reliably identified latter rather former this difference minimized utilizing sensitive egfr mutation analytic approaches included hrma pcr fragment analysis assays based studies authors speculated coupling use highly sensitive egfr mutation detection assays cytolyt derived cell pellets may sufficient obviating need microscopy nonetheless must emphasized negative molecular testing result carefully reconciled analyte input utilized mutation assay this essential determine whether negative result represents true negative potentially false negative necessitating possible retesting regard the utilization microscopy still remains essential pre analytic quality assurance activity best ensure input analyte sufficient tumor cellularity maximize confidence results mutation assay note follow study bellevicine et al they observed direct smears exhibited significantly higher cellularity thinprep slides average accordingly average yield dna extracted direct smears significantly higher thinprep slides l858r substitution deletions exon 19 represent approximately 90% egfr mutations lung adenocarcinoma one antibody specific exon 21 l858r mutation specific 15-base pair/5-amino acid deletion e746_a750del exon 19 clone 6b6 the immunohistochemical approach detecting mutant egfr proteins using antibodies examined several studies lung cancer tissues well cytologic small biopsy samples 42 48 the sensitivity assays range 47%92% high positive predictive value specificity supports feasibility utilizing approach first line screening approach first immunohistochemistry performed careful validation formulation immunostain scoring criteria the significance best interpret equivocal staining results clarified overinterpreting weak immunoreactivity positive mutation result lead increased false positives decreased specificity second clone 6b6 antibody best detects 15-base pair e746_a750del egfr deletion mutant protein demonstrates variable immunoreactivity egfr mutant proteins resulting non-15-base pair deletions exon 19 the anaplastic lymphoma kinase alk protein receptor tyrosine kinase rearrangements involving alk gene locus observed approximately 5% lung adenocarcinomas these mutations commonly observed younger age patients never smokers however exceptions clinical characteristics used exclude lung cancer patients alk rearrangement testing most alk rearrangements lung adenocarcinoma result interstitial deletions small inversions within short arm chromosome 2 this results fusion portions echinoderm microtubule associated protein like 4 eml4 alk genes other less common alk rearrangements involve fusions alk genes kif5b tfg alk rearranged lung adenocarcinoma recognized legitimate target small molecular inhibitor therapy crizotinib shown efficacious treating patients cancers phase 1 study evaluating 143 patients overall response rate 61% estimated overall survival rates 74.8% 12 months therefore evaluation lung adenocarcinoma fna samples alk rearrangements addition egfr mutations become increasingly incorporated patient management algorithms fish currently preferred approach assaying lung adenocarcinomas alk rearrangements according expert recommendations based review literature united states america there one test approved food drug administration fda purpose this assay utilizes dual alk breakapart probe strategy orange green labeled probes hybridize highly conserved translocation breakpoint region alk gene alk gene loci undergone rearrangement typically display fused orange green signals yellow juxtaposed touching orange green signals when alk rearrangement occurs orange green signals become separated however majority alk rearrangements involve small inversion within chromosome 2p rather rearrangement involving another chromosome extent two signals split finite order score nucleus positive alk rearrangement orange green signals must separated distance 2 signal diameters fig 3 nucleus also scored positive single orange signal without corresponding green signal observed typically 100 tumor cell nuclei scored assay lung adenocarcinoma considered positive alk rearrangement least 15% nuclei scored positive rearrangement the fda approved dual breakapart probe set use paraffin embedded tissue sections mentioned previously paraffin embedded cell blocks processed similarly paraffin embedded tissue blocks thus cell blocks traditionally used performance alk rearrangement fish assays nonetheless observed noticeable failure rate using relying cell blocks assays due insufficient tumor cell material significant proportion cases thus others investigated alternative cytopreparatory platforms alk fish study demonstrated effective use diff quik stained direct smears purpose observed performance assay using direct smears better performance using cell blocks also examined use papanicolaou stained direct smears observed failure rate due insufficient cellularity significantly higher cell blocks direct smears therefore utilization diff quik papanicolaou stained smears feasible analytes alk fish recently thinprep slides also shown feasible platform alk fish the advantage utilizing cytologic preparation platforms direct smears thinprep slides purpose entire tumor cell nuclei analyzed fish evaluation paraffin sections derived cell blocks ffpe blocks prone signal loss tumor cells due section truncation artifacts addition alternative methods fish subject recent investigation immunohistochemistry utilizing antibodies directed alk attractive alternative simpler quicker less expensive the challenge associated approach alk protein expressed much lower levels alk rearranged lung tumors anaplastic large cell lymphoma prototypical alk rearranged tumor fortunately monoclonal anti alk antibodies clones d5f3 d9e4 5a4 shown exhibit high sensitivity specificity immunohistochemistry using d5f3 5a4 monoclonal antibodies cytologic specimens recently described shown exhibit high degree concordance alk fish testing this supports feasibility utilizing immunohistochemical approach first line screening methodology select specimens alk fish testing note the mouse monoclonal anti alk1 antibody cd246 typically used diagnosis anaplastic large cell lymphoma less reliable identifying alk rearrangements lung adenocarcinoma likely attributable limited sensitivity particular antibody detecting lower expression levels alk fusion proteins lung adenocarcinoma relative anaplastic large cell lymphoma finally application reverse transcriptase pcr rt pcr cytologic direct smears alk rearrangement analysis recently reported evaluating cohort paired cytologic histologic specimens rt pcr mitiushkina and nonetheless cautionary note high degree variability eml4-alk fusion events least 13 variants eml4-alk reported furthermore fusion partners alk tfg kif5b observed therefore rt pcr approach may capture clinically relevant alk rearrangements while egfr mutations alk rearrangements represent two best characterized clinically actionable molecular alterations nsclc molecular markers becoming increasingly appreciated investigated ros1 encodes receptor tyrosine kinase rearranged approximately 2% lung adenocarcinomas met encodes another receptor tyrosine kinase hepatocyte growth factor receptor amplified subset nsclc significant proportion cases seen context acquired resistance egfr tkis crizotinib also targets receptor studies way determine whether agent effective met amplified lung cancers therapeutic agents targeting braf dabrafenib currently investigated clinical trials in addition gene rearrangements involving ret tyrosine kinase gene e.g. kif5b ret observed approximately 2% lung adenocarcinomas ret specific tkis sunitinib sorafenib vandetanib may useful treating patients lung cancers finally amplification fgfr1 mutations pik3ca observed lung squamous cell carcinomas agents targeting gene products also investigation the mentioned molecular genetic markers highlight distinct molecular profiles becoming increasingly appreciated different subtypes nsclc especially adenocarcinomas squamous cell carcinomas therefore efforts correctly subtype cases nsclc important including challenging cases poorly differentiated nsclc institution subtyping nsclc deemed challenging based cytomorphologic evaluation alone immunocytochemistry utilized demonstrated accomplished using smears well cell blocks for example napsin thyroid transcription factor-1 often positive lung adenocarcinomas utilized confirming subtype nsclc in contrast p63 p40 useful markers confirming diagnosis squamous cell carcinoma ultimately utilizing fna samples nsclc immunocytochemistry must judiciously leveraged ensure sufficient material still exists molecular ancillary testing given continuously evolving landscape understanding genetic events responsible lung cancer pathogenesis integration anatomic pathology particularly cytopathology molecular diagnostics become even essential emerging molecular technological advances next generation sequencing ngs allow high throughput high sensitivity molecular analyses likely play important role management patients nsclc cytologic specimens based recent reports represent robust source cellular material ngs 62 65

in this era of precision medicine , our understanding and knowledge of the molecular landscape associated with lung cancer pathogenesis continues to evolve . this information is being increasingly exploited to treat advanced stage lung cancer patients with tailored , targeted therapy . during the management of these patients , minimally invasive procedures to obtain samples for tissue diagnoses are desirable . cytologic fine - needle aspirates are often utilized for this purpose and are important not only for rendering diagnoses to subtype patients lung cancers , but also for ascertaining molecular diagnostic information for treatment purposes . thus , cytologic fine - needle aspirates must be utilized and triaged judiciously to achieve both objectives . in this review , strategies in utilizing fine - needle aspirates will be discussed in the context of our current understanding of the clinically actionable molecular aberrations underlying non - small cell lung cancer and the molecular assays applied to these samples in order to obtain treatment - relevant molecular diagnostic information .

tumors classified typical net tnet goblet cell carcinoid gcc atypical gcc histologies ex goblet composite goblet classified signet ring cell carcinoid srcc poorly differentiated adenocarcinoid appendix these tumors distinctive morphology showing tight clusters cells compact nuclei abundant intracytoplasmic mucin resembling goblet signet ring cells often admixed enterochromaffin cells pathologic features gcc include presence large mucin filled cells crescent nuclei arranged small clumps rosettes mixed cells typical carcinoid appearance stain positive chromogranin patients tnet 5-year survival ranging 60% 84% common site metastasis liver on hand atypical gcc aggressive clinical course increased incidence lymph node distant metastases along lower 5-year survival ranging 36% 56% 5 7 current management gcc atypical gcc based limited data small single institutional experiences the rarity appendiceal net gcc srcc limits ability conduct appropriate randomized clinical trials explore optimal management assess role clinicopathologic features survival net gcc srcc patients outcome cases reported national cancer institute surveillance epidemiology end results seer program evaluated furthermore characterize management net gcc srcc treatment strategy based results current analysis published literature institutional experience suggested seer data collected 1973 2011 used identify cases appendiceal tnet gcc srcc the seer registry data collection began early 1970s gradually expanded original nine current 18 registries account quarter united states population eligibility criteria included international classification diseases oncology third edition icd o-3 codes primary site appendix histologic types tnet 8240 8241 8242 8246 8270 gcc 8243 8244 8245 8249 srcc 8490 information regarding age diagnosis sex race year diagnosis grade histology tumor location type surgery vital status duration follow extracted seer database the patients characteristics compared among three histologic types tnet gcc srcc chi square test race sex stage kruskal wallis test age survival functions estimated kaplan meier method log rank test used assess difference overall survival os three histologic types tnet gcc srcc univariate survival analysis covariate carried using cox proportional hazards model the multivariate survival analysis histology conducted adjusting age race sex using backward variable selection method alpha level removal 0.1 the model stratified stage since interaction effect histology stage os 9.3 sas institute inc cary nc used data analyses null hypotheses difference rejected p values less 0.05 equivalently 95% confidence intervals cis risk point estimates excluded 1 seer data collected 1973 2011 used identify cases appendiceal tnet gcc srcc the seer registry data collection began early 1970s gradually expanded original nine current 18 registries account quarter united states population eligibility criteria included international classification diseases oncology third edition icd o-3 codes primary site appendix histologic types tnet 8240 8241 8242 8246 8270 gcc 8243 8244 8245 8249 srcc 8490 information regarding age diagnosis sex race year diagnosis grade histology tumor location type surgery vital status duration follow extracted seer database the patients characteristics compared among three histologic types tnet gcc srcc chi square test race sex stage kruskal wallis test age survival functions estimated kaplan meier method log rank test used assess difference overall survival os three histologic types tnet gcc srcc univariate survival analysis covariate carried using cox proportional hazards model the multivariate survival analysis histology conducted adjusting age race sex using backward variable selection method alpha level removal 0.1 the model stratified stage since interaction effect histology stage os 9.3 sas institute inc cary nc used data analyses null hypotheses difference rejected p values less 0.05 equivalently 95% confidence intervals cis risk point estimates excluded 1 the seer database yielded 1,021 tnet patients 1,582 gcc 534 srcc patients 1973 2011 incidence tnet gcc srcc increased 2011 the incidence tnet reached 6.7 gcc 0.3 srcc two patients per 100,000 persons baseline characteristics compared appendiceal tnet gcc srcc table 1 significant differences age presentation p 0.001 sex distribution p 0.001 surgery p 0.001 type surgery appendectomy right hemicolectomy surgery otherwise specified p 0.001 stage p < tnet patients presented younger median age 41 vs. 54.5 gcc 57 years srcc female patients constituted higher proportion among tnet cases 66.2% vs. 61.4% srcc 48.5% gcc advanced stage disease common srcc patients 60.9% vs. 14.1% tnet 10.4% gcc a higher proportion white patients observed three histologies difference statistically significant p=0.11 surgery performed 839 82.6% tnet patients 1,365 86.4% gcc 419 78.6% srcc patients differences statistically significant p 0.001 appendectomy performed 52 patients tnet 5.9% compared 54 gcc 3.9% 9 srcc 2.1% right hemicolectomy performed 484 tnet 54.9% 1,208 gcc 86.4% 301 srcc patients 70.7% the differences type surgery significantly different among three histologies p 0.001 the mos gcc tnet reached time analysis comparing survival among different histologies tnet survival advantage gcc hazard ratio hr 0.56 95% ci 0.45 0.69 p=0.005 better survival srcc histology hr 0.22 95% ci 0.19 0.26 p 0.001 table 3 stage tnet gcc significant survival advantages srcc figs 1 3 in localized stage mos reached three histologies comparing srcc hr survival 0.26 0.15 0.46 p 0.001 tnet 0.42 0.26 0.69 p 0.001 gcc regional stage disease the mos srcc 35 months 95% ci 30 45 mos gcc tnet reached the tnet regional disease stage patients survival advantage gcc hr 0.37 95% ci 0.24 0.59 p 0.001 gcc better survival compared srcc patients regional disease stage hr 0.29 95% ci 0.21 0.40 p 0.001 distant disease stage mos 32 95% ci 13 reached tnet 23 95% ci 18 28 gcc 15 months 95% ci 13 18 srcc group tnet patients survival advantage gcc hr 0.61 95% ci 0.44 0.83 p=0.002 gcc patients survived better compared srcc patients distant disease hr 0.73 95% ci 0.60 0.90 p=0.003 after adjusting age stage histology statistically significant difference survival srcc patients treated hemicolectomy compared appendectomy p=0.01 there significant difference survival tnet gcc patients based type surgery p=0.21 p=0.94 respectively multivariate analysis stratified stage age statistically significant difference survival favoring tnet hr 0.41 95% ci 0.31 0.55 gcc hr 0.59 95% ci 0.48 0.72 srcc the seer database yielded 1,021 tnet patients 1,582 gcc 534 srcc patients 1973 2011 incidence tnet gcc srcc increased 2011 the incidence tnet reached 6.7 gcc 0.3 srcc two patients per 100,000 persons baseline characteristics compared appendiceal tnet gcc srcc table 1 significant differences age presentation p 0.001 sex distribution p 0.001 surgery p 0.001 type surgery appendectomy right hemicolectomy surgery otherwise specified p 0.001 stage p < tnet patients presented younger median age 41 vs. 54.5 gcc 57 years srcc female patients constituted higher proportion among tnet cases 66.2% vs. 61.4% srcc 48.5% gcc advanced stage disease common srcc patients 60.9% vs. 14.1% tnet 10.4% gcc a higher proportion white patients observed three histologies difference statistically significant p=0.11 surgery performed 839 82.6% tnet patients 1,365 86.4% gcc 419 78.6% srcc patients differences statistically significant p 0.001 appendectomy performed 52 patients tnet 5.9% compared 54 gcc 3.9% 9 srcc 2.1% right hemicolectomy performed 484 tnet 54.9% 1,208 gcc 86.4% 301 srcc patients 70.7% the differences type surgery significantly different among three histologies p 0.001 the mos gcc tnet reached time analysis comparing survival among different histologies tnet survival advantage gcc hazard ratio hr 0.56 95% ci 0.45 0.69 p=0.005 better survival srcc histology hr 0.22 95% ci 0.19 0.26 p 0.001 table 3 stage tnet gcc significant survival advantages srcc figs 1 3 in localized stage mos reached three histologies comparing srcc hr survival 0.26 0.15 0.46 p 0.001 tnet 0.42 0.26 0.69 p 0.001 gcc regional stage disease the mos srcc 35 months 95% ci 30 45 mos gcc tnet reached the tnet regional disease stage patients survival advantage gcc hr 0.37 95% ci 0.24 0.59 p 0.001 gcc better survival compared srcc patients regional disease stage hr 0.29 95% ci 0.21 0.40 p 0.001 distant disease stage mos 32 95% ci 13 reached tnet 23 95% ci 18 28 gcc 15 months 95% ci 13 18 srcc group tnet patients survival advantage gcc hr 0.61 95% ci 0.44 0.83 p=0.002 gcc patients survived better compared srcc patients distant disease hr 0.73 95% ci 0.60 0.90 p=0.003 adjusting age stage histology statistically significant difference survival srcc patients treated hemicolectomy compared appendectomy p=0.01 there significant difference survival tnet gcc patients based type surgery p=0.21 p=0.94 respectively multivariate analysis stratified stage age statistically significant difference survival favoring tnet hr 0.41 95% ci 0.31 0.55 gcc hr 0.59 95% ci 0.48 0.72 srcc the analysis seer registry sample confirms differences presentation outcome diseases tnet tend occur younger age less aggressive clinical course early stage presentation significantly improved os end disease spectrum the aggressive nature srcc reflected high risk distant metastasis diagnosis worse survival outcomes even controlled stage the reported sex distribution tnet ranges female preponderance 63% 73% evenly distributed similarly gcc literature reports range female gender predominance equal distribution most series based small numbers patients single institution studies the current report confirms using large national database gender differences distribution tnet gcc srcc p 0.001 srcc histology confirmed higher prevalence amongst women seer analysis compared gcc histology consistent previous report additionally appendiceal srcc appear clinically similar right sided microsatellite unstable signet ring cell colon adenocarcinoma respect gender distribution age diagnosis outcome this raises question whether appendiceal srcc right colon adenocarcinomas behave like single disease entity distinct colorectal cancer crc adenocarcinoma appendiceal gcc this apparent difference clinical behavior require characterization genomic analysis crc srcc appendiceal srcc typical gcc hence molecularly based classification may facilitate prognostication perhaps target identification future clinical trials the analysis seer data confirms histology stage presentation major determinants outcome the high risk metastatic disease srcc patients confirms aggressive clinical behavior tumor the rate metastasis diagnosis srcc histology ranges 14% 63% survival advantage tnet gcc srcc persisted controlling difference stage distribution similar observations reported 5-year survival patients advanced stage gcc srcc poorly differentiated adenocarcinoid tumor 100% 38% 0% respectively given rarity consensus management appendiceal tnet gcc srcc the treatments employed included surgical resection cytoreduction primary tumor metastatic sites intraperitoneal chemotherapy systemic fluorouracil based chemotherapy debulking surgery hyperthermic intraperitoneal chemotherapy treatment well established appendiceal net gcc srcc tumors although improves appendiceal mucinous adecarcinoma clinically management decisions usually based histologic subtype stage well patient performance status early stage tnet gcc srcc managed surgically although extent surgery open question historically accepted surgical dogma simple appendectomy sufficient resection tnet less 2 cm recent reports demonstrated appendiceal tnet measuring less 2 cm may regional nodal involvement raising question whether extensive surgery simple appendectomy required irrespective size these observations supported seer analysis 32.8% patients net less 2 cm size 20/61 lymph node metastasis the north american neuroendocrine tumor society nanets european neuroendocrine tumor society enets guidelines suggest right hemicolectomy tumors 2 cm presence deep mesoappendiceal invasion positive unclear margins higher proliferative rate grade 2 angi olymphatic invasion mixed histology irrespective tumor size while simple appendectomy may adequate early stage gcc cecal involvement high mitotic count index indication right hemicolectomy surgery srcc always involve right hemicolectomy due high likelihood lymph node metastasis irrespective size primary appendiceal mass this supported analysis seer data indicates superior survival patients srcc undergo right hemicolectomy the role surgical resection ovaries female patients localized srcc gcc remains controversial a summary nanets enets guidelines provided table 4 unlike crc adenocarcinoma role adjuvant therapy established tnet gcc srcc based analysis patients tnet excellent os therefore adjuvant therapy indicated hand given high risk systemic metastasis srcc recommend offering adjuvant therapy patients undergoing resection analysis seer sample the outcome patients early stage gcc appears favorable suggesting patients gcc considered adjuvant therapy high risk features cecal invasion perforation lymph node involvement for gcc patients advanced stage disease options treatments include peritoneal debulking intraperitoneal chemotherapy patient limited peritoneal disease systemic fluorouracilbased chemotherapy srcc patients our recommendations include treating systemic fluorouracil based chemotherapy initially consider peritoneal resection patients good response initial therapy summary proposed treatment algorithm provided fig predictive prognostic biomarkers well defined diseases attempt identify gene variations appendiceal mucinous adenocarcinoma gcc profiled nine gcc samples using second generation gene sequencing one patient gcc 11% kras mutation two tp53 mutation myc smad4 apc mutations absent gcc proved absence kras mutations 16 14 gcc samples light rarity molecular differentiation markers appendiceal tnet gcc and further confirmation larger studies needed evaluate pathologic genomic sequencing three histologies order detect differences survival possible future biomarkers predict response specific target treatments the seer registry findings confirm distinct clinical entities tnet gcc srcc respect presentation outcome

purposeappendiceal tumors are a heterogeneous group of diseases that include typical neuroendocrine tumors ( tnet ) , goblet cell carcinoids ( gcc ) , and atypical gcc . atypical gcc are classified into signet - ring cell cancers ( srcc ) and poorly differentiated appendiceal adenocarcinoids . the prognosis and management of these diseases is unclear because there are no prospective studies . the aim of this study is to assess the characteristics and outcome of appendiceal tnet , gcc , and srcc patients.materials and methodsappendiceal tnet , gcc , and srcc patients diagnosed between 1973 and 2011 were identified in the surveillance epidemiology and end results ( seer ) database . demographics , type of surgery , and clinicopathologic characteristics were collected . survival functions were estimated by the kaplan - meier method , and log - rank test was used to assess the difference in overall survival ( os ) among the three histologies.resultsthe seer database yielded 1,021 tnet patients , 1,582 with gcc , and 534 srcc patients . tnet presented at a younger age ( p < 0.001 ) . patients with srcc presented with advanced stage disease ( p < 0.001 ) . the median os ( mos ) for gcc and tnet patients was not reached ; mos for srcc was 24 months . multivariate analysis stratified for stage revealed significantly longer survival for tnet and gcc than srcc ( p < 0.001).conclusionthis is the largest report to date for appendiceal neuroendocrine tumor patients , suggesting a spectrum of diseases with different characteristics and outcomes . in this report , we present a treatment approach for this complex spectrum of disease , based on the experience of ohio state and emory universities investigators .

we have prepared two new diastereoisomeric 2-aza-5-phosphabicyclo[2.2.1]heptanes from naturally occurring trans-4-hydroxy - l - proline in six chemical operations . these syntheses are concise and highly efficient , with straightforward purification . when we used these chiral phosphines as catalysts for reactions of -substituted allenoates with imines , we obtained enantiomerically enriched pyrrolines in good yields with excellent enantioselectivities . these two diastereoisomeric phosphines functioned as pseudoenantiomers , providing their chiral pyrrolines with opposite absolute configurations .

igg4-rd newly recognized fibroinflammatory condition unknown etiology characterized tumefactive lesions dense lymphoplasmacytic infiltration rich igg4-positive plasma cells storiform fibrosis elevated serum igg4 level 13 the kidney one organs commonly affected igg4-rd tubulointerstitial nephritis tin infiltration numerous igg4-positive plasma cells predominant type kidney lesion 47 high levels igg igg4 striking characteristic features renal involvement multiple lesions low attenuation demonstrated contrast enhanced computed tomography often evident 47 although tin main feature kidney lesion igg4-rd glomerular lesions also described membranous nephropathy mn recognized common form 48 previously reported cases mn associated igg4-rd mn diagnosed together onset igg4-rd 912 here report case idiopathic mn preceding disease onset igg4-rd he previously well significant medical history serum total protein level 46 g l 4.6 g dl serum albumin 17 g l 1.7 g dl urinary protein excretion 4.3 g day without occult blood 24-h creatinine clearance normal 1.51 ml 90.5 ml min table 1 the anti nuclear antibody negative serum immunoglobulins g within normal limits 11.98 g l 1198 mg dl 11.37 complement levels also within normal limits c3 1.12 g l 112 mg dl c4 0.314 g l 31.4 mg dl ch50 30 u ml contrast enhanced computed tomography ct demonstrated small non specific nodules right lung hemangioma liver table 1.clinical course laboratory findings present casemay 2008january 2009july 2009july 2010december 2010march 2011august 2011eventdiagnosed mnworsening nsdiscontinuation psladmission hospitaltreatmentdiureticspsl furosemidefurosemide olmesartanfurosemide olmesartanfurosemide olmesartanfurosemide olmesartanfurosemide olmesartantp g l)46566071778592alb g l)17152931303124igg g l)12nanananana39urinalysis protein)3 3 3 3 3 3 3+up g day)4.33.03.1nanana2.124 h ccr ml s)1.511.121.37nanana1mn membranous nephropathy ns nephritic syndrome psl prednisolone tp total protein alb albumin urinary protein excretion ccr creatinine clearance na data available clinical course laboratory findings present case mn membranous nephropathy ns nephritic syndrome psl prednisolone tp total protein alb albumin urinary protein excretion ccr creatinine clearance na data available percutaneous kidney biopsy performed histology revealed diffuse membranous changes glomerular basement membrane without tubulointerstitial lesions figure 1a b an immunofluorescence study showed diffuse fine granular staining igg c3 fibrinogen kappa- lambda chain glomerular capillary loops there deposits areas including mesangeal matrix subendothelial aspects tubular basement membrane an additional immunofluorescence study igg subclasses showed predominant positive staining igg4 igg1 weak positive staining igg2 igg3 glomeruli figure 1c an electron microscopy examination revealed diffuse homogenous small electron dense deposits subepithelial aspects glomerular basement membrane corresponded ehrenreich churg stage 2 subendothelial deposits present endothelial cells contain tubuloreticular structure the mesangial matrix tubular basement membrane contain electron dense deposits 1.histopathologic findings kidney biopsy previous hospital time onset idiopathic mn ( light microscopy shows significant mesangial cell matrix proliferation glomeruli interstitial lesions ( b diffuse small deposits evident subepithelial aspects glomerular basement membrane ( c immunofluorescence study igg subclasses shows predominant positive staining igg1 igg4 weak positive staining igg2 igg3 glomeruli histopathologic findings kidney biopsy previous hospital time onset idiopathic mn ( light microscopy shows significant mesangial cell matrix proliferation glomeruli interstitial lesions periodic acid schiff stain 200 ( b diffuse small deposits evident subepithelial aspects glomerular basement membrane ( c immunofluorescence study igg subclasses shows predominant positive staining igg1 igg4 weak positive staining igg2 igg3 glomeruli systemic work revealed disease malignancy patient prednisolone administered 40 mg daily patient suffered repeated cerebral infarction attacks starting therapy prednisolone tapered discontinued 6 months start therapy without significant effect the patient proteinuria persisted around 3 g day followed receiving diuretics angiotensin receptor blocker olmesartan two years discontinuation glucocorticoid therapy patient developed epigastric discomfort hospitalized laboratory examinations revealed elevated serum levels ast alt alp total bilirubin -gtp 64 iu l 106 iu l 1948 iu l 111 mol l 6.5 mg dl 1544 iu l respectively accompanied slight increase serum creatinine 100 mol l 1.13 mg dl normal serum amylase level 111 iu l abdominal ct revealed swelling pancreatic head dilatation main pancreatic duct stenosis common bile duct tumor markers including cea ca19 9 within normal ranges hypergammaglobulinemia observed serum igg level elevated 39.21 g dl 3921 mg dl marked elevation igg4 19.2 hypergammaglobulinemia persisted serum iga igm complement studies showed within normal limits serum anti nuclear antibody negative whereas rheumatoid factor positive 120.6 iu ml urinary protein excretion 2.1 g day without occult blood 24-h creatinine clearance mildly deteriorated 1 ml 60.0 ml min table 1 excretion urinary 2-microglobulin 2-mg n acetyl--d glucosaminidase markedly elevated 11 636 g day 25.0 iu day respectively contrast enhanced ct showed bronchial thickening bilateral lungs pancreatic swelling stenosis main pancreatic duct bile duct bilateral swollen kidneys multiple lesions exhibiting low attenuation periaortic periarterial mass lesions diffuse swelling prostate gland systemic lymphadenopathy compatible radiologic abnormalities characteristic igg4-rd figure 2 2.contrast-enhanced ct hospital time onset igg4-rd marked swelling pancreatic head bilateral swollen kidneys multiple lesions exhibiting low attenuation observed contrast enhanced ct hospital time onset igg4-rd marked swelling pancreatic head bilateral swollen kidneys multiple lesions exhibiting low attenuation observed percutaneous kidney biopsy performed since could obtain patient agreement instead percutaneous needle biopsies pancreas prostate gland specimens obtained biopsy prostate gland pancreas revealed dense lymphoplasmacytic infiltration storiform fibrosis infiltration numerous igg4-positive plasma cells igg4/ igg positive plasma cell ratio 50% without malignancy figure 3 3.histopathologic features specimen obtained prostate gland percutaneous needle biopsy hospital time onset igg4-rd there evidence cancer cells typical swirling pattern fibrosclerosing inflammation infiltration numerous lymphocytes called storiform fibrosis. b immunohistochemical staining igg needle biopsy specimen prostate gland 150 immunohistochemical staining igg4 needle biopsy specimen prostate gland 150 the igg4-positive plasma cell igg positive plasma cell ratio 50% tissue prostate gland histopathologic features specimen obtained prostate gland percutaneous needle biopsy hospital time onset igg4-rd there evidence cancer cells typical swirling pattern fibrosclerosing inflammation infiltration numerous lymphocytes called storiform fibrosis. b immunohistochemical staining igg needle biopsy specimen prostate gland 150 immunohistochemical staining igg4 needle biopsy specimen prostate gland 150 the igg4-positive plasma cell igg positive plasma cell ratio 50% tissue prostate gland western blot analysis patient serum detection serum autoantibodies type phospholipase a2 receptor anti pla2r performed described previously negative oral administration prednisolone initiated 40 mg daily patient clinical symptoms including jaundice anorexia improved rapidly the laboratory data multiple organ lesions also improved proteinuria persisted around 3 g day it reported mn present 7% kidney biopsy specimens igg4-rd most cases mn associated igg4-rd accompanied igg4-related tin 46 9 10 although recent reports also documented mn without tin features igg4-rd 8 11 12 mn associated igg4-rd positive deposition igg4 glomerular basement membrane observed either predominantly together igg subclasses 812 originally immunofluorescent examination igg subclasses known useful tool distinguish primary mn secondary mn predominant deposition igg4 often accompanied subclasses igg1 one well known features idiopathic mn moreover idiopathic mn mn associated igg4-rd share essential immunologic feature known th2 cytokine mediated immune reaction 14 15 suggesting two disorders share common pathophysiologic processes increased production th2 cytokines subsequent increase igg4 hand these two disorders differ many features including clinical symptoms laboratory parameters radiographic findings an anti pla2r antibody described major target antigen involved idiopathic mn seen 7080% patients idiopathic mn 13 1618 reported negative cases igg4-rd also cases mn associated igg4-rd 8 10 12 suggesting involvement antibody development igg4-rd present case evidence association igg4-rd based clinical symptoms serological data imaging findings patient developed nephrotic syndrome therefore reasonable diagnosed present case idiopathic mn time onset nephrotic syndrome the anti pla2r antibody described negative cases evaluated mn associated igg4-rkd also negative patient although result obtained serum 3 years diagnosis idiopathic mn corticosteroid therapy however 2025% patients idiopathic mn reported negative antibody 1618 the absence anti pla2r antibody thus partly helpful distinguish idiopathic mn interestingly patient total serum protein level increased gradually without significant improvement proteinuria elevation serum albumin level table 1 eventually clinical symptoms laboratory abnormalities igg4-rd became evident 3 years onset idiopathic mn accordingly possible conditions underlying persistent predominance th2-type immune responses 3 years follow might led development igg4-rd currently idiopathic mn defined mn without disorder could cause secondary mn predominant deposition igg4 glomerular basement membrane however mn associated igg4-rd also revealed igg4-predominant interestingly igg subclass anti pla2r antibody seen idiopathic mn predominantly igg4 although pathogenesis igg4-rd poorly understood may share common mechanisms idiopathic mn thus comparative study two diseases might helpful clarifying pathogenesis consideration igg4-rd mn including systemic evaluation measurement serum igg4 level would necessary addition evaluation anti pla2r antibody igg subclasses immune complex deposited glomerular basement membrane

we report a case of igg4-related disease ( igg4-rd ) diagnosed after 3 years of follow - up for idiopathic membranous nephropathy ( mn ) . mn has been considered as glomerular lesion of igg4-related kidney diseases in recent years and was diagnosed simultaneously with or after a diagnosis of igg4-rd in previously reported cases . in the present case , igg4-rd developed 3 years after the diagnosis of idiopathic mn , indicating a possible relationship between idiopathic mn and igg4-rd through common underlying mechanisms of development .

treatment duration lasts months often fraught potentially dangerous side effects side effects influenza like illness myalgias depression cytopenias intolerable resulting premature treatment cessation lasting effects ocular complications among complications interferon therapy include retinal hemorrhages cotton wool spots loss color vision cataracts glaucoma occasionally retinal artery vein obstruction although incidence ophthalmological disorders interferon therapy low result loss vision.411 in prospective case series study one hundred patients chronic hepatitis c interferon inf therapy consecutively recruited patients attending outpatient ophthalmic clinic university hospital faculty medicine al azhar university assuit the study protocol approved ethics committee al azhar university hospital written informed consent obtained patients included study addition medical laboratory examination patients subjected full ophthalmological assessment evaluate retinopathy associated interferon therapy inclusion criteria 1 seropositivity anti hcv antibodies determined using elisa 2 first use interferon therapy exclusion criteria 1 previous interferon therapy 2 patients hepatitis b 3 patients decompensated liver 4 patients renal failure 5 patients cardiovascular disorders coronary insufficiency congestive heart failure ischemic stroke 6 patients dense cataract visual field abnormality glaucoma ocular abnormalities evaluation treatment history visual loss hazy vision ocular disease ocular surgeries ophthalmological examination 1 best corrected visual acuity bcva measured using landolt broken rings 2 pupillary reaction direct consensual afferent pupillary defect 3 full slit lamp examination 4 intraocular pressure iop measured goldmann applanation tonometer 5 fundus biomicroscopy carried maximum pupillary dilation combination tropicamide 1% eye drops phenylephrine 2.5% eye drops using slit lamp biomicroscopy noncontact 90 volk lens and/or goldmann contact lens 6 examination retinal periphery using indirect ophthalmoscope medical examinations abdominal ultrasonography investigations 1 ocular colored fundus photography fundus fluorescein angiography ffa 2 laboratory including enzyme linked immunosorbent assay ellsa test hepatitis surface ag ab polymerase chain reaction pcr hepatitis c virus rna full blood count prothrombin time direct indirect bilirubin fasting blood sugar serum creatinine liver enzymes serum glutamic oxaloacetic transaminase serum glutamic pyruvic transaminase alanine aminotransferase patients treated pegylated interferon -2a dose 180 mcg injected subcutaneously weekly 48 weeks all patients underwent clinical laboratory assessments ophthalmic examination 15 days 1 month 2 months 3 months 6 months 8 months 9 months start ifn treatment patients treated pegylated interferon -2a dose 180 mcg injected subcutaneously weekly 48 weeks all patients underwent clinical laboratory assessments ophthalmic examination 15 days 1 month 2 months 3 months 6 months 8 months 9 months start ifn treatment initially 120 patients fulfilled criteria ifn therapy 20 excluded due non compliance follow visits due presence diabetic hypertensive retinopathy also two patients died study time due disease related hepatitis patients included therefore total 100 patients 68 male 32 female chronic hcv selected after start interferon therapy 16 100 patients 16% developed retinopathy bilateral 12 75% patients unilateral 4 25% patients retinopathy initially diagnosed appearance cotton wool spot 14 patients four 14 patients retinal hemorrhage two 16 patients developed retinopathy diagnosed retinal hemorrhage without cotton wool spots one patient diabetic hypertensive cystoid macular edema patient complained visual disturbance due interferon all patients bcva 6/6 ifn treatment except three patients one cystoid macular edema bcva 6/12 returned 6/6 cessation treatment two patients ametropic amblyopia in addition confirmed patients hypertension retinopathy using standard classification exclude possibility development diabetic hypertension retinopathy ifn treatment deleted data obtained patients diabetes hypertension retinopathy 2 months cessation ifn treatment retinopathy first diagnosed 214 weeks start treatment disappeared 11 16 patients despite continuation therapy a cotton wool spots retinal hemorrhages observed remaining five patients end treatment resolved within 1 month treatment stopped no ocular complications ie cataracts glaucoma retinal artery vein obstruction observed the mean hemoglobin values white blood cell red blood cell platelet counts decreased significantly p 0.0001 ifn treatment the clinical profiles laboratory data patients shown tables 1 2 respectively interferon associated retinopathy first recognized 1990 ikebe associates reported 39-year old patient developed retinal hemorrhages cotton wool spots following intravenous administration interferon.12 underlying mechanisms interferon induced retinopathy completely understood guyer et al13 proposed immune complex deposition causing occlusion retinal capillaries leading cotton wool spot formation hand ischemic insult similar seen hypertensive diabetic patients could another potential mechanism changes develop.14 studies15,16 have shown relatively higher incidence retinopathy symptomatic asymptomatic ranging 19% 64% treatment interferon panetta gilani17 cuthbertson et al14 show relatively lower incidences retinopathy 3.8% 6.25% respectively similar studies,4,5,9 study also shows retinal changes usually develop within first 3 months interferon treatment fact may favor immune etiology rather cumulative effect interferon leading development retinopathy retinopathy developed week 14 patients 13/16 81.25% start therapy disappeared majority patients 11/16 68.75% 48 week period patients receiving treatment this suggests treatment continued despite development retinopathy many patients however two patients developed cotton wool spots early therapy 2 weeks thereafter suffered retinal hemorrhage prolonged manner therefore patients develop cotton wool spots early therapy carefully monitored however reported previous studies,4,13,14 patients retinopathy study asymptomatic this study confirms previous reports retinopathy temporary asymptomatic complication interferon therapy therefore rule suspending use interferon patients develop retinopathy ocular side effects it commonly agreed among authors careful monitoring performed presence ocular sign even without symptoms.18

purposeto evaluate retinopathy associated with interferon therapy in patients with chronic hepatitis c.methodsone hundred patients with chronic hepatitis c undergoing interferon therapy were examined for the presence of cotton wool spots , retinal hemorrhages , cystoid macular edema , capillary non - perfusion , and arteriolar occlusion . complete ophthalmological examination including indirect ophthalmoscopic fundus examination was carried out for all patients and colored fundus photography and fluorescein angiography were carried out for the patients with positive fundus findings . the follow - up period was 9 months.resultssixteen percent of patients developed retinopathy in the form of cotton wool spots , retinal hemorrhages , cystoid macular edema , and capillary non-perfusion.conclusioninterferon therapy can lead to retinopathy which is mostly reversible and dose related . periodic fundoscopic examinations help in early detection and prevent progression to permanent visual loss .

nathan oncology fellow knew well white blood cells fought infections this experiment repeated front us time says chemotherapy lowered patients white blood cells increased risk infections mackaness shown macrophage activation depend direct contact cells 1 suggesting possibility secreted factor when nathan tested supernatant activated cells saw indeed induce macrophage activation 2 nathan got rough idea molecular weight 3 best anyone could says protein separation methods primitive cloned proteins monoclonal antibodies would become available decade later henry murray one nathan collaborators sums feeling frustration nibbling edges problem nathan therefore changed tack take closer look activated macrophages short lived neutrophils known produce hydrogen peroxide nathan found true longer lived activated macrophages 4 unlike previous signs macrophage activation increased spreading phagocytosis glucose metabolism called respiratory burst ifn cover time magazine recombinant murine ifn found induce macrophages kill tumor cells 5 nathan faculty member zanvil cohn macrophage factory rockefeller university new york ny thought ifn might also activate macrophages kill intracellular parasites consistent idea ifn made antigen stimulated cells associated defense infection now respiratory burst gave nathan assay berish rubin street new york blood center supplied ifn monoclonal antibody phone call genentech yielded recombinant ifn. seminal paper published journal experimental medicine 1983 nathan thus able show depleting ifn unpurified cell supernatants decreased respiratory burst activity killing intracellular protozoa human macrophages adding back recombinant ifn mix restored macrophage activation 6 i assay hunch history purifying proteins serendipity meeting people nearby antibody nathan next showed ifn worked people injecting recombinant ifn directly cutaneous lesions lepromatous leprosy patients induced macrophage infiltration hydrogen peroxide production killing causative pathogen mycobacterium leprae 7 1990s the macrophages children ifn receptor deficiencies shown defective killing mycobacteria 8) tracing pathway cells macrophages bacteria started nathan 1967 says still finished making molecular links

t cells tell macrophages when to start making the toxic soup of lysosomal enzymes , reactive oxygen species , and nitric oxide that destroys intracellular pathogens . in 1983 , carl nathan proved that this start signal comes in the form of the secreted cytokine ifn.

initiated team decade ago continued medical research center kasturba health society mumbai the comparative effects three plant products perimenopausal symptoms quality life qol clinical biochemistry reported group earlier our observation frequent mood changes sleep disturbances women premenopausal group prompted us undertake study cyclic symptoms maitreyi hcp in communication describe preliminary findings analysis premenstrual symptoms 200 consecutive women underwent comprehensive check maitreyi hcp diagnosis premenstrual tension syndrome pmts based following criteria per american association obstetricians gynecologists 30% increase intensity symptoms premenstrual syndrome measured using standardized instrument cycle days 510 compared 6-day interval onset menses documentation changes least two consecutive cycles at least one following affective somatic symptoms 5 days menses previous cycles affective symptoms depression angry outbursts irritability anxiety confusion social withdrawal somatic symptoms breast tenderness abdominal bloating headache swelling extremities symptoms relieved days 4 13 menstrual cycle determine prevalence premenstrual cyclic symptoms women attended maitreyi hcp to determine prevalence premenstrual cyclic symptoms women attended maitreyi hcp maitreyi hcp women 35 includes comprehensive health questionnaire gynecological physician check biochemical investigations complete blood count glucose tolerance test lipid profile liver functions serum creatinine serum thyroid stimulating hormone pap smear pelvic sonography urine stool examination occult blood also included a multidisciplinary trans system team offers community oriented programme women voluntary services consultants bone mineral density mammography this analysis preliminary report restricted premenstrual cyclic symptomatolgy 200 consecutive women attended program 2 years a special case record form used detailed medical surgical history included twelve women continued menstruate beyond 50 55 years included analysis symptoms least two consecutive cycles included analysis the american society obstetricians gynecologists american psychiatric society brought consensus criteria inclusion condition pmts premenstrual dysphoric disorder pmdd latter usually requiring treatment neuropsychiatric symptoms accordingly pmts said present woman reports three following symptoms two cycles more[46 36 symptoms listed sf-36 mental component present analysis symptoms classified per medical outcomes study short form-36 assessment premenstrual symptoms presence three occurring two cycles labelled pmts anxiety irritability depression tension mood swings loss self control difficulty concentration insomnia confusion headache crying attacks fatigue aches breast tenderness cramps bloatedness food craving visual disturbances tiredness fatigue puffiness face weight gain altered libido aggression nausea vomiting acne skin rashes constipation diarrhea joint stiffness backache abdominal cramps pain anger attacks aggravation epilepsy aggravation asthma of 107 women 26 24.3% report premenstrual symptoms 81 75.7% reported least one symptom table 1 number symptoms experienced women different age groups two cycles maximum frequency seen women 35 50 years age forty women 37.4% reported premenstrual symptoms three cyclic symptoms two cycles could classified pmts fifteen 14% five symptoms cyclically least two cycles almost 10% reported five symptoms inclusive anger attacks could labelled pmdd mastalgia common symptom 50.5% followed mood changes 46.7% depression 7.5% anger attacks 6.5% pmdd present 10% cases referred clinical psychologist psychiatrist many women premenstrual cyclic symptoms psychological physical nature sometimes limit functional capacity the symptoms due neurohormonal imbalance ageing may start early 35 years age pmts entity causes considerable morbidity 3% women may disrupt woman life severe symptoms recur when severe symptoms like anger attacks depression suicidal thoughts special attention including psychiatric consultation may required i.e. pmdd the prevalence pmts general 210% disabling symptoms minor symptoms may present 85% women.[468 present series 75.7% reported least one symptom cyclically present series halbreich reported 20% women symptoms severe enough warrant treatment dean et al reported prevalence 1930% women 18 45 years age screened in recent survey 3,913 women 15 54 years age tschudin et al observed 10% reported pmts 3.1% reported pmdd when indian scenario considered chaturvedi et al 1990s reported prevalence 20% general population severe symptoms 8% the authors later study reported suicidal ideas and/or death wish premenstrual period 10% subjects among college students industrial working women compared housewives banerjee et al group 62 women reported pmdd 6.4% there close association mood disorders sleep rhythm disturbances sleep pattern premenopausal age.[31314 many women physicians regard pmts physiological phenomenon think treatment necessary however affect qol therefore essential identify women benefit lifestyle management require pharmacological intervention want reach full functional potential find symptoms hampering progress interfering normal daily routine certainly offered safe pharmacological interventions provided come routine follow ups because many etiological factors described probably causative multiple causes may present individual woman wide variety treatment options combinations depending specific symptoms severity the postulated causes range hormonal imbalances like progesterone deficiency prolactin excess thyroid hypofunction fluctuation circulating level estrogen electrolyte disturbances like rennin angiotensin alterations antidiuretic hormone excess decreased colloidosmotic pressure neurotransmitter disturbances serotonin gamma amino butyric acid -endorphin activity alternations serotonin metabolism alternations prostaglandin imbalance cytokine imbalances like excess interleukin il)-6 il-1 tumor necrosis factor tnf)- nutritional deficiencies like vitamin b vitamin deficiency lack exercise psychosocial disturbances.[8101315 treatment therefore depend particular symptom complex individual woman concordance authors lifestyle measures like regular exercise balanced nutritious diet regular hours sleep benefit may adequate some.[1921 others pharmacological interventions may helpful required the therapy multipronged individualized simple measures like institution physical exercises relaxation techniques like yoga vitamin mineral supplements adequate women,[1924 require hormonal therapy combined oral contraceptives regulation fluid electrolytes matter fact combined oral contraceptives used frequently severe cases drosperidone containing newer combinations relatively free side effects selective estrogen modulators including nonsteroidal agents like centchroman also could useful particularly women contraindications hormones few women need psychiatric consultation benefit antidepressants particularly sertraline fluoxetine respond prolactin inhibitors like bromocriptine cabergoline complementary alternative therapies like soy hypericum perforatum gingko biloba definite role play.[242931 evening primrose oil significant efficacy we observed relief mild moderate premenstrual symptoms soy gycyrrhiza glabra withania somnifera also observed complete relief pmts two women treated extract rich saraca asoka prescribed menorrhagia also controlled there need research area commonly used drugs may side effects may prevent regular long term use table 2 common side effects existing pharmacologic therapies pmts recently two well designed studies shown pmts leads loss work hours economic losses allow women reach full potential.[3436 effective safe therapy indicated also important bear mind chronic diseases like migraine depression irritable bowel syndrome could exaggerated premenstrual phase multidisciplinary team evaluate manage cases many women physicians regard pmts physiological phenomenon think treatment necessary however affect qol therefore essential identify women benefit lifestyle management require pharmacological intervention want reach full functional potential find symptoms hampering progress interfering normal daily routine certainly offered safe pharmacological interventions provided come routine follow ups many etiological factors described probably causative multiple causes may present individual woman wide variety treatment options combinations depending specific symptoms severity the postulated causes range hormonal imbalances like progesterone deficiency prolactin excess thyroid hypofunction fluctuation circulating level estrogen electrolyte disturbances like rennin angiotensin alterations antidiuretic hormone excess decreased colloidosmotic pressure neurotransmitter disturbances serotonin gamma amino butyric acid -endorphin activity alternations serotonin metabolism alternations prostaglandin imbalance cytokine imbalances like excess interleukin il)-6 il-1 tumor necrosis factor tnf)- nutritional deficiencies like vitamin b vitamin deficiency lack exercise psychosocial disturbances.[8101315 treatment therefore depend particular symptom complex individual woman concordance authors lifestyle measures like regular exercise balanced nutritious diet regular hours sleep benefit may adequate some.[1921 others pharmacological interventions may helpful required the therapy multipronged individualized simple measures like institution physical exercises relaxation techniques like yoga vitamin mineral supplements adequate women,[1924 require hormonal therapy combined oral contraceptives regulation fluid electrolytes matter fact combined oral contraceptives used frequently severe cases drosperidone containing newer combinations relatively free side effects selective estrogen modulators including nonsteroidal agents like centchroman also could useful particularly women contraindications hormones few women need psychiatric consultation benefit antidepressants particularly sertraline fluoxetine respond prolactin inhibitors like bromocriptine cabergoline complementary alternative therapies like soy hypericum perforatum gingko biloba definite role play.[242931 evening primrose oil significant efficacy we observed relief mild moderate premenstrual symptoms soy gycyrrhiza glabra withania somnifera also observed complete relief pmts two women treated extract rich saraca asoka prescribed menorrhagia also controlled there need research area commonly used drugs may side effects may prevent regular long term use table 2 recently two well designed studies shown pmts leads loss work hours economic losses allow women reach full potential.[3436 effective safe therapy indicated it also important bear mind chronic diseases like migraine depression irritable bowel syndrome could exaggerated premenstrual phase multidisciplinary team evaluate manage cases it important ensure first option nonpharmacological many women may respond pharmacotherapy added recalcitrant cases must individualized per woman great care taken avoid side effects drug interactions multiple therapies may used medicinal plants may safe alternative women pmts could predictor menopausal syndrome useful warn women pmts families flare need long term follow have reported pmts predictive menopausal syndrome long term follow study shown association hormonal imbalance depressive symptoms women

objective : to determine the prevalence of premenstrual cyclic symptoms in perimenopausal age.subjects and methods : women attending bhavan 's sparc maitreyi 's health care programme ( hcp ) for women around 40 years of age were included in the study . last 200 women who attended from april 2002 to october 2004 are included for analysis . out of these 107 qualified for final analysis as others were post hysterectomy or post menopausal . thirty five symptoms listed under premenstrual tension syndrome were analysed.results:forty one women ( 38.3% ) had 3 or more symptoms whilst 15 ( 14.0% ) had 5 or more cyclic symptoms . five women ( 4.7% ) reported that the symptoms were severe . eleven women had seeked treatment for premenstrual tension syndrome ( pmts ) . the commonest symptom was mastalgia or heaviness of breasts . next was whilst also was reported by several women . women reported anger attacks and reported depression.conclusion:pmts was common between 36 and 55 years . about half of them have experienced 3 more symptoms and 1 in 20 may require treatment .

according korean national statistical office main cause death korea cancer 2012 the total number deaths due cancer 2012 267,221 increased 9,825 3.8% compared 2011.1 time high since 1983 currently treatment cancer patients medical field consists mainly surgery radiation therapy chemotherapy seventy eighty percent cancer patients chemotherapy experienced side effects anemia decreased number white blood cells and/or platelets oral mucositis vomiting diarrhea hair loss disabled generative functions chemotherapy also affects rapidly proliferating normal cells.2 side effects temporary patients recover fully side effects may take months years completely disappear decrease side effects non specific cytotoxicity new drugs targeted agents developed selectively destroy specific cancer cells however problems tolerance manifestation partly critical toxicity decrease sensitivity restriction subjects new drugs take small portion cancer treatment realm.3 chemoprevention defined use nontoxic relatively safe chemical substances vitamins plant extracts pharmaceuticals prevent cancer it effective decreasing cancer risk helpful early stages cancer.4 hence regular consumption anticancer foods display little toxicity body boost efficacy anti tumor drugs stop development tolerance would beneficial preventing cancer thus consumption plant derived natural foods prevent cancer side effects toxicity crucial.5 recently growing interest probiotics due discovery multidrug resistant organisms tolerant antibiotics probiotics derived greek word meaning life holds opposite meaning antibiotics means life. probiotics consist microorganisms substances modify intestinal microflora used dietary supplement positive effects health fortification host immune function suppression diarrhea inhibition carcinogenesis.6 kimchi korean traditional food fermented probiotic lactic acid bacteria.7 kimchi lactic acid bacteria known suppress activity carcinogen activating enzymes azoreductase nitroreductase 7--dehydrogenase -glucosidase -glucuronidase inactivate neutralize cancer causing agents pathogenic microbes.8 addition intake lactic acid bacteria part kimchi improves bowel movement strengthens immunity ameliorates hepatocirrhosis decreases serum cholesterol levels.9,10 among lactic acid bacteria identified fermentation kimchi weissella lactobacillus leuconostoc pediococcus species known play important role kimchi fermentation.1113 commentary deals anticarcinogenic effects kimchi lactic acid bacteria weissella cibaria lactobacillus plantarum separated kimchi known predominant kimchi kimchi fermented cabbage indispensable korean cuisine considered risk factor stomach cancer however unless one consumes kimchi contains excess salt kimchi general healthy food recognized antioxidant antiobese cancer preventive health beneficial effects.7 cancer preventive anticarcinogenic activity kimchi associated type ingredients products formed fermentation.14 kimchi main ingredient chinese cabbage considered effective preventing stomach cancer according epidemiologic studies known inhibit colorectal carcinogenesis due abundance dietary fiber.15 garlic particular acknowledged anticancer effect due high contents organosulfur compounds 11 35 mg g thirty three types organosulfur compounds identified garlic.16 organosulfur compounds garlic shown facilitate detoxification carcinogens glutathione transferase modulate activity metabolizing enzymes cytochrome p450s inhibit formation dna adducts several target tissues.1719 antiproliferative activity organosulfur compounds demonstrated tumor cell lines including colon prostate breast mediated induction apoptosis via caspase-3 signaling pathway cell cycle arrest.20,21 one possible mechanism cancer preventive effects garlic stomach cancer development involves antimicrobial activities helicobacter pylori major risk factor stomach cancer.22 hot red chili pepper powder one main ingredient kimchi contains capsaicin trans-8-methyl n vanillyl-6-nonenamide although role capsaicin carcinogenic processes controversial accumulated evidence capsaicin capable induce apoptosis cancer cells generating excess reactive oxygen species.23 thoennissen et al.24 demonstrated capsaicin caused cell cycle arrest apoptosis breast cancer cells modulating egfr her-2 pathway inhibited development pre neoplastic breast lesions 80% without toxicity in addition ingredient kimchi kimchi extract used investigate cancer preventive anticarcinogenic activity kimchi extract kimchi fermented 3 weeks inhibited proliferation human cancer cell lines gastric adenocarcinoma acute promyelocytic leukemia leukemia cells treated kimchi extract showed increased apoptosis decreased mitochondrial transmembrane potential.25 juice 3-week fermented kimchi suppressed growth k-562 human leukemia cells mg-63 human osteosarcoma cells toxicity kimchi juice found normal cells.26 sarcoma180 cells transplanted mice treated methanol extract 3-week fermented kimchi animals provided kimchi extract showed smaller tumor weight decreased malondialdehyde formation compared control group.27 although general acceptance define probiotic microorganisms lactobacillus species bifidobacterium sp saccharomyces boulardii microbes thought used probiotic strains.28 probiotic microorganisms used food supplement order achieve health benefit effects there many studies reported functionality lactic acid bacteria fermentation process kimchi importance health beneficial effects kimchi including prevention cancer.29 according pyrosequencing analysis commercial kimchi samples identify kimchi lactic acid bacteria genus weissella predominant 44.4% w. koreensis 27.2% w. cibaria 8.7%.7 weissella newly separated lactic acid bacteria lactobacillus family identified recent dna technique it gram positive catalase negative bacteria included geneally recognized safe.30 main lactic acid bacteria involved kimchi fermentation long known lactobacillus genus leuconostoc genus recently weissella genus lactic acid bacteria newly separately identified.30 weissella early dominant kimchi fermentation produces lactic acid acetic acid alcohol dextran co2 account unique fresh taste texture kimchi.31,32 weissella species found kimchi w. cibaria w. koreensis w. hanii.12 sources weissella species shown table 1.33 w. cibaria newly named bjorkroth others separated korean kimchi various sources including fermented foods greek salami spanish sausages animal human excrements w. cibaria gram positive non pore formulating non motile hetero lactic acid fermented catalase negative bacillus produce dextran sucrose.34,35 studies reported microorganisms including lactic acid bacteria secreted exopolysaccharides eps anticancer anti inflammatory immune modulating blood cholesterol declining functions.36 demonstrated w. cibaria leuconostoc mesenteroides w. confusa able produce eps among lactic acid bacteria w. cibaria exhibited higher production eps indicates acid resistance table 2).37 w. cibaria reported anticancer activity immune modulating activity anti inflammatory activity antioxidant activity based patent related w. cibaria anticancer activity registered cha et al.,38 anticancer activity w. cibaria w. cibaria bacteria incubated 24 hours deman rogosa sharpe agar badge diluted phosphate buffered saline 10% concentration bacteria samples provided normal cell strains colorectal cancer cell strains 72 hours cell growth suppressed treatment w. cibaria colorectal cancer cells normal cells ahn et al.33 presented immune control effect w. cibaria stronger well known probiotic bacterium l. rhammosus gg lgg w. cibaria produced higher levels nitric oxide nuclear factor nf)- b cytokines e.g. interleukin-1 tumor necrosis factor- lgg suggesting w. cibaria effective immune control compared lgg furthermore w. cibaria known antiviral function avian influenza virus.39 ornithine type amino acid produced arginine precursor reported accelerate growth hormone excretion antiobesity effect kimchi fermentation process level arginine ornithine precursor decreased ornithine level increased rapidly suggested kimchi source ornithine moreover correlation amount w. cibaria amount ornithine kimchi observed.40 use w. cibaria starter food fermentation promoted formation ornithine arginine turn provide health beneficial effects antiobesity due high levels ornithine fermented food.41,42 lactobacillus genus microorganism form spores anaerobic facultative anaerobic gram positive bacterium this bacterium widely dispersed nature also found human oral cavity digestive organs this bacterium beneficial microorganism widely used starter various fermented dairy products.43 main kimchi lactic acid bacteria lactobacillus l. plantarum the rapid increase l. plantarum late stage kimchi fermentation produces large amounts organic acid known main substance acidifies kimchi acid tolerance l. plantarum allows us use bacterium natural antibacterial antifungal products l. plantarum cancer preventive potential tested ames mutation assay sos chromotest cabbage brined 3% salt concentration kimchi fermented 5c 3 weeks kimchi extract exerted antimutagenic effect aflatoxin b1.44 l. plantarum isolated kimchi also exhibited strong antimutagenic effect n methyl n-nitro n nitrosoguanidine 4-nitroquinoline-1-oxide.45 furthermore l. plantarum isolated kimchi stronger antimutagenic effects compared lactic acid bacteria originated fermented milk.46 macrophagocytes provided l. plantarum separated kimchi strengthened phagocytosis displayed anticancer effects aseites carcinoma solid tumor due polysaccharide chains muramic acid l. plantarum cell well among lactic acid bacteria cell wall substances polysaccharide types rather than glycopeptide play pivotal role cancer suppression.47 evaluate possible use l. plantarum probiotic lee et al.48 measured survival rate artificial gastric fluid intestinal fluid adhesion compatability human intestinal caco-2 cells antibacterial activity result l. plantarum strains showed 90% survival rate artificial gastric fluid intestinal fluid 400 times survival rate control strain l. casei when pathogenic bacteria lactic acid bacteria incubated together l. plantarum suppressed adhesion intestinal crypt cells pathogenic bacteria also suppressed pathogenic bacteria growth escherichia coli stapylococcus aureus salmonella typhimurium 93.4% 75.9% 69.3% respectively weissella newly separated lactic acid bacteria lactobacillus family identified recent dna technique it gram positive catalase negative bacteria included geneally recognized safe.30 main lactic acid bacteria involved kimchi fermentation long known lactobacillus genus leuconostoc genus recently weissella genus lactic acid bacteria newly separately identified.30 weissella early dominant kimchi fermentation produces lactic acid acetic acid alcohol dextran co2 account unique fresh taste texture kimchi.31,32 weissella species found kimchi w. cibaria w. koreensis w. hanii.12 sources weissella species shown table 1.33 w. cibaria newly named bjorkroth others separated korean kimchi various sources including fermented foods greek salami spanish sausages animal human excrements w. cibaria gram positive non pore formulating non motile hetero lactic acid fermented catalase negative bacillus produce dextran sucrose.34,35 studies reported microorganisms including lactic acid bacteria secreted exopolysaccharides eps anticancer anti inflammatory immune modulating blood cholesterol declining functions.36 demonstrated w. cibaria leuconostoc mesenteroides w. confusa able produce eps among lactic acid bacteria w. cibaria exhibited higher production eps indicates acid resistance table 2).37 w. cibaria reported anticancer activity immune modulating activity anti inflammatory activity antioxidant activity based patent related w. cibaria anticancer activity registered cha et al.,38 anticancer activity w. cibaria tested colorectal cancer cells w. cibaria bacteria incubated 24 hours deman rogosa sharpe agar badge diluted phosphate buffered saline 10% concentration bacteria samples provided normal cell strains colorectal cancer cell strains 72 hours cell growth suppressed treatment w. cibaria colorectal cancer cells normal cells ahn et al.33 presented immune control effect w. cibaria stronger well known probiotic bacterium l. rhammosus gg lgg w. cibaria produced higher levels nitric oxide nuclear factor nf)- b cytokines e.g. interleukin-1 tumor necrosis factor- lgg suggesting w. cibaria effective immune control compared lgg furthermore w. cibaria known antiviral function avian influenza virus.39 ornithine type amino acid produced arginine precursor reported accelerate growth hormone excretion antiobesity effect kimchi fermentation process level arginine ornithine precursor decreased ornithine level increased rapidly suggested kimchi source ornithine moreover correlation amount w. cibaria amount ornithine kimchi observed.40 use w. cibaria starter food fermentation promoted formation ornithine arginine turn provide health beneficial effects antiobesity due high levels ornithine fermented food.41,42 lactobacillus genus microorganism form spores anaerobic facultative anaerobic gram positive bacterium this bacterium widely dispersed nature also found human oral cavity digestive organs this bacterium beneficial microorganism widely used starter various fermented dairy products.43 main kimchi lactic acid bacteria lactobacillus l. plantarum the rapid increase l. plantarum late stage kimchi fermentation produces large amounts organic acid known main substance acidifies kimchi acid tolerance l. plantarum allows us use bacterium natural antibacterial antifungal products l. plantarum cancer preventive potential tested ames mutation assay sos chromotest when cabbage brined 3% salt concentration kimchi fermented 5c 3 weeks kimchi extract exerted antimutagenic effect aflatoxin b1.44 l. plantarum isolated kimchi also exhibited strong antimutagenic effect n methyl n-nitro n nitrosoguanidine 4-nitroquinoline-1-oxide.45 furthermore l. plantarum isolated kimchi stronger antimutagenic effects compared lactic acid bacteria originated fermented milk.46 macrophagocytes provided l. plantarum separated kimchi strengthened phagocytosis displayed anticancer effects aseites carcinoma solid tumor due polysaccharide chains muramic acid l. plantarum cell well among lactic acid bacteria cell wall substances polysaccharide types rather glycopeptide play pivotal role cancer suppression.47 evaluate possible use l. plantarum probiotic lee et al.48 measured survival rate artificial gastric fluid intestinal fluid adhesion compatability human intestinal caco-2 cells antibacterial activity result l. plantarum strains showed 90% survival rate artificial gastric fluid intestinal fluid 400 times survival rate control strain l. casei when pathogenic bacteria lactic acid bacteria incubated together l. plantarum suppressed adhesion intestinal crypt cells pathogenic bacteria also suppressed pathogenic bacteria growth escherichia coli stapylococcus aureus salmonella typhimurium 93.4% 75.9% 69.3% respectively this paper describes cancer preventive anti carcinogenic potential kimchi lactic acid bacteria focusing w. cibaria l. plantarum the antibiotic tolerant probiotic presented kimchi suppresses expression carcinogen activating enzymes possesses many health benefits suppression growth development pathogenic bacteria intestinal regulation immune boosts especially w. cibaria l. plantarum found kimchi many effects like anti inflammatory immune modulating blood cholesterol reducing activity may account cancer preventive anticancer potential these probiotic lactic acid bacteria kimchi used antimicrobials foods also implemented developing functional foods reduce risk colon cancer

the number of death due to cancer has been increasing in korea . chemotherapy is known to cause side effects because it damages not only cancerous cells but healthy cells . recently , attention has focused on food - derived chemopreventive and anti - tumor agents or formulations with fewer side effects . kimchi , most popular and widely consumed in korea , contains high levels of lactic acid bacteria and has been shown to possess chemopreventive effects . this review focuses on weissella cibaria and lactobacillus plantarum , the representatives of kimchi lactic acid bacteria , in terms of their abilities to prevent cancer . further studies are needed to understand the mechanisms by which lactic acid bacteria in kimchi prevent carcinogenic processes and improve immune functions .

glomangioma benign vascular tumor derived glomus body specialized neuromyoarterial structure involved thermal regulation it subtype generalized category glomus tumors confused head neck paragangliomas glomus tympanicum glomus jugulare it also distinguished glomangiopericytoma sinonasal type hemangiopericytoma displays different ultrastructural histochemical characteristics.1 glomangiomas commonly found subungually exceedingly rare head neck.2 account 0.6% nonepithelial tumors nasal cavity nasopharynx paranasal sinuses.3 glomangiomas induce paraneoplastic osteomalacia even uncommon one case reported date.4 several documented cases oncogenic osteomalacia oo caused glomangiopericytomas,5 present second reported case glomangioma induced osteomalacia first case documented english a 42-year old man history unexplained hip rib scapula metatarsal fractures left foot pain exercise weakness presented clinic evaluation paranasal sinus tumor the endocrinology service initially diagnosed tumor induced osteomalacia caused fibroblast growth factor 23 fgf23 prompted octreotide scan revealing questionable area enhancement pituitary subsequent magnetic resonance imaging mri showed ethmoid mass extending cribriform intracranially measuring 3.9 1.9 2.4 cm largest dimensions fig the patient reported occasional sinus congestion decreased sense smell preceding 2 3 years occasional blurry vision morning his laboratory workup revealed significantly decreased 1,25-vitamin level less 8 ng ml decreased phosphate level 1.6 mg dl low normal calcium level 8.7 mg dl significantly elevated alkaline phosphatase level 65.3 g l preoperative mri t1 contrast showing ethmoid mass extending cribriform intracranially the patient underwent combined endoscopic endonasal approach anterior skull base tumor resection cribriform defect intraoperative cerebrospinal fluid csf leak pathology revealed vascular neoplasm uniform cluster ovoid cells arranged around vessels moderate focal nuclear enlargement fig tumor cells stained positive cd31 smooth muscle actin sma negative cd34 s100 pan cytokeratin immunohistochemistry fig the patient reported near complete resolution bone pain improvement smell normalization phosphate alkaline phosphatase vitamin laboratory values repeat mri showed gross total resection mass detectable recurrence fig 4 postoperative mri t1 contrast showing gross total resection mass nasoseptal flap reconstruction skull base osteomalacia disease bone characterized defective mineralization osteoid decreased levels available phosphate calcium increased bone resorption it often presents diffuse joint bone pain easy fracturing difficulty walking weakness nonspecific symptoms oo rare disabling curable form osteomalacia affects sexes equally usually presents around 40 years age.6 well described glomangiomas detailed several times relation glomangiopericytomas soft tissue bone tumors 300 reported cases7 since debut 1947.8 predominantly occurs context mesenchymal tumors thought due neoplastic overexpression fgf23 this protein inactivates sodium phosphate pump proximal tubule prohibiting phosphate reabsorption inducing renal phosphate wasting reduces 1-hydroxylation 25-hydroxy vitamin d.9 accordingly common oo laboratory abnormalities include hypophosphatemia normal decreased calcium decreased 1,25-dihydroxy vitamin d3 resistance vitamin supplementation elevated alkaline phosphatase patient exhibited tumors causing oo tend small occult slow growing making diagnosis remarkably difficult when causes osteomalacia ruled oo suspected clinicians consider measuring serum fgf23 level elevated fgf23 setting prompt full body imaging including hands feet expose lesion the current imaging standard investigation oo whole body mri short tau inversion recovery stir).10 another commonly used modality octreotide scintigraphy octreoscan utilizes radiotracer binds somatostatin receptors overexpressed causative tumor.11 neoplasm localized surgical resection wide margins definitive treatment it curative essentially cases typically leads rapid normalization laboratory values reversal clinical symptoms the nonspecific presentation osteomalacia obscure nature tumors cause oo rarity glomangiomas head neck make patient diagnosis challenging we believe second reported case paranasal sinus glomangioma induced osteomalacia first reported english many head neck surgeons may aware existence consider differential diagnoses sinus tumors report serves increase awareness uncommon pathology may considered treated future cases

oncogenic osteomalacia ( oo ) is an uncommon but treatable cause of osteomalacia related to tumor production of fgf23 , usually caused by benign mesenchymal neoplasms . paranasal sinus glomangiomas are a rare cause of oo , with only one previously reported case . here we describe a second case ( first reported in english ) of paranasal sinus glomangioma - induced osteomalacia in a 42-year - old man . he presented with weakness and multiple spontaneous fractures , and was found to have an ethmoid sinus glomangioma with intracranial extension . the tumor was removed via endoscopic endonasal approach to the anterior skull base , which resulted in complete resolution of symptoms and no further evidence of disease 1 year postoperatively .

gestational trophoblastic disease describes number gynecologic tumors originate trophoblastic layer including hydatidiform mole complete partial invasive mole choriocarcinoma placental site trophoblastic tumor epitheloid trophoblastic tumor invasive mole may arise pregnancy event although cases diagnosed molar pregnancy overall cure rate low risk patients nearly 100% high risk patient 90% rare cases molar tissue traverses thickness myometrium leads perforation acute abdomen invasive mole infrequently metastasis the best treatment option chemotherapy according stage score single multiple agent patients fertility matter hysterectomy done a 41 years old g3p2ab1 woman referred firouzgar hospital 2 months curettage molar pregnancy vaginal bleeding acute abdomen workup hcg 224000 miu ml evidence metastasis detected chemotherapy due stage 3 score 9 surgery due acute abdomen done this case reported ovarian metastasis uterine rupture acute abdomen involvement omentum metastatic invasive mole management patient successful follow free disease without sequel kind five years invasive mole penetration molar tissue complete partial mole myometrium uterine vasculature 1 16 19 pathologists mention existence villi trophoblastic tissue 8 12 locally invasive gestational trophoblastic neoplasia develops 15% patients metastatic form 4% patients evacuation complete mole infrequently partial mole 2 hcg level 100000 miu ml excessive uterine enlargement theca lutein cyst size 6 cm considered high risks developing post molar tumors high risk mole 3 the common symptom invasive mole persistent vaginal bleeding evacuation molar pregnancy sub involution uterus persistent theca lutein cyst another symptom the rise hcg titer laboratory test diagnosis invasive mole follow molar pregnancy although definite diagnosis invasive mole based pathology 8) hcg radiologic diagnosis 9 invasive mole diagnosed well rare cases metastasis occurred common sites lungs 80% 4 vagina 30% pelvis 20% liver 10% brain 10% bowel kidney spleen 5% metastatic sites metastasis occur direct extension another pelvic neoplasm hematogenous lymphatic spread transcelomic dissemination possibility metastasis ovary extremely rare even much lower nongestational primary ovary choriocarcinoma incidence 1 3.710 5 invasive mole curable chemotherapy hysterectomy decreases need multiple courses chemotherapy patients heavy bleeding sepsis control complication stabilization chemotherapy needed 6 11 case invasive mole evacuation molar pregnancy presented acute abdomen surgery metastasis ovary omentum parametrium detected a 41- year- old housewife woman gravid 3 para 2 live child 2 nvd last 10 years old child referred firouzgar hospital 24 august 2010 history dilation curettage 2 months cough examination febrile 38c tachycardia leukocytosis 16000 uterus tender enlarged vaginal bleeding persisted second curettage done another hospital time chest x ray normal in hospital report sample pathology given first second curettage complete mole after molar evacuation patient monitored weekly determination hcg level she received antibiotics due fever work malignant trophoblastic disease persistent gtn done high hcg level 224000 miu ml much enlarged uterus involvement whole uterine parenchyma detected sonography largest tumor size uterus 6 cm thyroid function test demonstrated hyperthyroidism metastatic work ct scan chest abdomen brain carried ct scan abdomen pelvis showed involvement left adnexa pelvic lymphadenopathy the patient chest ct scan showed multiple bilateral round pulmonary metastatic lesions 2 cm diameter illustrated figure 1 pulmonary metastasis invasive mole disease diagnosed patient chemotherapy ema started table 1 because acute abdomen severe abdominal pain unstable vital signs diagnosis perforative peritonitis patient taken emergency laparotomy due hyperthyroid state induction anesthesia blocker agent administered patient subtotal hysterectomy left salpingo oophorectomy resection omentum done gross uterus uterine wall perforated tumoral invasion left side posterior wall figure 2 enlarged uterus ovarian metastasis perforation uterus myometrium invasion patient iii:9 according figo staging scoring 7 bilateral uterine parameters external surface endocervical canal omentum invaded tumors villous formation myometrium villosity necrosis invasive mole patient treated 4 courses chemotherapy ema co after negative hcg 5 received additional 3 courses chemotherapy reduce relapse hcg titer later tested monthly for1 year first year testing hcg terminated hcg testing bimonthly basis 2 years done the patient followed 5 years patient free tumor hcg negative invasive mole rupture uterus metastasis ovary omentum manifestation acute abdomen rare 5 according epidemiological retrospective survey invasive mole secondary hydatidiform mole occurred six months evacuation 5 3 partial complete hydatidiform mole distinct disease processes characteristic cytogenetic histologic clinical features 8) ( 13 reported case invasive mole presenting acute hemoperitoneum similar present case molar tissue penetrate myometrium 9 lead uterine perforation 13 cause vaginal bleeding due erosion uterine vessels 14 15 similar atala et al.s case report 1991(14 case uterine perforation acute intra peritoneal hemorrhage seen due ease entry molar tissue large venous lake present myometrium pelvis pregnancy trophoblastic disease metastasis invasive mole commonly lungs lungs vagina cervix broad ligament 16 19 case metastasis lung ovary omentum although theca lutein cysts high risk mole due high serum hcg level seen normally regress spontaneously within 24 months 17 non gestational choriocarcinoma ovary differential diagnosis 5 due occurrence metastasis ovary case molar pregnancy differential diagnosis matter report invasive mole fallopian tube ( 21 first misdiagnosis case another hospital repeat curettage done although first diagnosis could persistent gtn another case report 15 bruner similarity case seen combination chemotherapy continued cases far toxicity permits patient achieves 3 consecutive normal hcg levels 9 18 normal hcg levels are attained 3 additional courses chemotherapy administered reduce risk relapse low risk patients one two courses are adequate 19 case 3 courses chemotherapy normalization hcg done hysterectomy may required invasive mole order control vaginal bleeding unstable patient sepsis 6 20 hysterectomy reasonable option patients wish preserve fertility prevent metastasis 20 furthermore patients extensive uterine tumor hysterectomy may substantially reduce trophoblastic tumor burden 20 thereby limit need multiple courses chemotherapy case due unstable uterine rupture hysterectomy done need chemotherapy courses removed several courses chemotherapy ema co courses cured however final diagnosis patient invasive mole metastasis ovary omentum lung stage 3 uterine rupture the patient responded treatment well follow patient still fine 5 years definite care metastasis invasive mole surgery chemotherapy an invasive mole uterus ovarian omental metastasis diagnosed patient successfully treated hysterectomy chemotherapy fine 5 years follow

background : invasive mole is responsible for most cases of localized gestational trophoblastic neoplasia . gestational trophoblastic disease describes a number of gynecologic tumors that originate in trophoblastic layer including hydatidiform mole ( complete or partial ) , invasive mole , choriocarcinoma , placental site trophoblastic tumor and epitheloid trophoblastic tumor . invasive mole may arise from any pregnancy event although in most cases is diagnosed after molar pregnancy . overall cure rate in low risk patients is nearly 100% and in high - risk patient 90% . in rare cases , molar tissue traverses thickness of myometrium and leads to perforation and acute abdomen and invasive mole infrequently metastasis . the best treatment option is chemotherapy ( according to stage and score with single or multiple agent ) and in patients that fertility is not the matter , hysterectomy can be done.case presentation : a 41 years old g3p2ab1 woman referred to firouzgar hospital 2 months after curettage of molar pregnancy with vaginal bleeding and acute abdomen . in workup , hcg 224000 miu / ml and evidence of metastasis was detected . chemotherapy due to stage 3 and score 9 and surgery due to acute abdomen was done . this case was reported for its rarity.discussion:this case reported about ovarian metastasis and uterine rupture with acute abdomen and involvement of omentum in metastatic invasive mole . lack of surveillance led to extensive morbidity . management of this patient was successful . in follow up , she was free of disease without sequel of any kind for five years now .

expanded research design methods section supplementary figures found online data supplement available http://diabetes.diabetesjournals.org/cgi/content/full/db09-1293/dc1 details glucose insulin tolerance testing plasma insulin level determination lipid metabolite measurement metabolomics exercise capacity studies whole body vivo metabolic assessment immunoblot analysis provided online data supplement all animals received care according canadian council animal care university alberta health sciences animal welfare committee twelve week old c57bl/6 mice placed standard chow low fat diet 4% kcal lard high fat diet 60% kcal lard research diets d12492 12-week period end week 12 animals injected intraperitoneally every day spt1 inhibitors myriocin 0.5 mg kg suspended 1x pbs l cycloserine 25 mg kg suspended 1x pbs vehicle control 4-week period end 4-week treatment protocol animals killed via intraperitoneal injection sodium pentobarbital 12 mg fed state middle dark cycle tissues excised immediately frozen liquid n2 another study 6-week old db db mice heterozygous controls db/+ jackson laboratories ) as expected mice fed high fat diet 12 weeks became obese indicated significant increase weight gain supplementary fig d diet induced insulin resistant lean mice placed comprehensive lab animal monitoring system clams whole body metabolic assessment demonstrated high fat diet induced shift fuel preference toward fatty acids oxidative energy source indicated large drop respiratory exchange ratio rer supplementary fig further support increase fatty acid oxidation obese mice seen increase gastrocnemius -hydroxyacyl coa dehydrogenase activity table 1 contrary previous findings 16,17 also report obesity induced chronic high fat feeding impairs whole body oxygen consumption rates supplementary fig 2c -hydroxyacyl coa dehydrogenase activity gastrocnemius muscle lean obese mice treated vehicle control myriocin values reported mol g wet weight min n 5 mice differences determined using two way anova followed bonferroni post hoc analysis significantly different low fat counterpart after 12 weeks low- high fat diet mice treated either myriocin 0.5 mg kg every day vehicle control after 2 weeks treatment demonstrated inhibition spt1 myriocin reverses diet induced insulin resistance determined glucose tolerance insulin tolerance testing fig if protective effects took place skeletal muscle level group animals killed 30 min insulin injection insulin tolerance test muscles excised harvested immunoblot analysis insulin signaling pathway we demonstrate insulin stimulation akt glycogen synthase kinase 3 gsk3 phosphorylation significantly improved gastrocnemius muscle obese mice treated myriocin fig phosphorylation 5amp activated protein kinase ampk another key signaling molecule regulating glucose metabolism differ gastrocnemius muscle control myriocin treated obese mice data shown induced insulin resistance improves insulin signaling glucose tolerance test low fat fed obese insulin resistant mice treated either vehicle control myriocin c insulin tolerance test low fat diet obese insulin resistant mice treated either vehicle control myriocin e insulin stimulated akt phosphorylation serine 473 f gsk3 phosphorylation serine 9 gastrocnemius muscle obese insulin resistant mice treated either vehicle control myriocin values represent mean se n 812 n 4 e f differences determined using either two tailed student test two way anova followed bonferroni post hoc analysis p 0.05 significantly different groups myriocin treatment without effect food intake body weight plasma insulin levels reduce postprandial fasted plasma glucose levels obese insulin resistant mice table 2 although fasting plasma insulin levels differ diet induced obesity dio mice treated vehicle control myriocin sophisticated studies monitoring changes plasma insulin response meal tolerance test obese jcr la cp rat illustrate significant improvement plasma insulin control treatment spt1 inhibitor l cycloserine supplementary fig 3 interestingly indirect calorimetry revealed improved insulin sensitivity dio mice treated myriocin associated decrease fatty acid oxidation increase carbohydrate oxidation similar rer values observed dio control myriocin treated animals fig 2 effect myriocin body tissue weight plasma glucose insulin levels lean obese mice values reported n 511 mice differences determined using two way anova followed bonferroni post hoc analysis significantly different low fat counterpart significantly different high fat control twenty four hour dark cycle b light cycle respiratory exchange ratio c low fat fed obese insulin resistant mice treated either vehicle control myriocin differences determined using two way anova followed bonferroni post hoc analysis * p 0.05 significantly different low fat diet counterpart parallel series experiments 12 weeks high fat feeding mice treated either spt1 inhibitor l cycloserine 25 mg kg every day vehicle control although dramatic results observed myriocin 2 weeks treatment report improvements glucose insulin tolerance mice treated l cycloserine supplementary fig obese insulin resistant mice run exercise treadmill determine exercise capacity expected obese mice showed dramatic reduction treadmill time distance compared lean counterparts fig interestingly treatment obese mice 2 weeks myriocin reversed reduction exercise capacity fig 3a b this improvement exercise capacity observed obese mice treated myriocin explained enhanced whole body oxygen consumption rates compared control counterparts fig c addition observed greater citrate synthase activity gastrocnemius muscle obese mice treated myriocin fig protein expression peroxisome proliferator activated receptor- coactivator-1 pgc1 transcriptional coactivator plays key role regulating number genes involved energy metabolism 18 showed trend toward reduction control treated dio mice p 0.077 apparent myriocin treated dio mice fig furthermore also demonstrate pretreatment myriocin increases citrate synthase activity c2c12 myotubes exposed 1.0 mmol l palmitate 16 h fig these observations illustrate improvements mitochondrial function possibly explaining exercise capacity whole body oxygen consumption rates enhanced group time distance b exercise capacity challenge running treadmill differences determined using two way anova followed bonferroni post hoc analysis p 0.05 significantly different low fat diet counterpart myriocin treatment reverses impairment whole body oxygen consumption rates caused dio c twenty four hour dark cycle b light cycle c whole body oxygen consumption assessment low fat diet obese insulin resistant mice treated either vehicle control myriocin d gastrocnemius muscle citrate synthase activity vehicle control myriocin treated dio mice e pgc1 expression low fat diet obese insulin resistant mice treated either vehicle control myriocin f citrate synthase activity vehicle control myriocin pretreated c2c12 skeletal muscle myotubes exposed 1.0 mmol l palmitate 16 h. values represent mean se n 512 differences determined using either two tailed student test two way anova followed bonferroni post hoc analysis * p 0.05 significantly different high fat diet control mice auc area curve metabolic profiling mice provided insight regards mitochondrial function obese insulin resistant mice control treated dio mice significant increase long chain acyl carnitine esters versus lean counterparts table 3 indicative mitochondrial overload incomplete oxidation fatty acids 19 however accumulation long chain acyl carnitine esters myriocin treated dio mice even greater table 3 this suggests incomplete fatty acid oxidation rates even pronounced myriocin treated dio mice animals also significant reduction short chain acyl carnitine ester content table 3 consistent long chain acyl coa dehydrogenase inhibition reduced oxidation long chain fatty acids metabolic profiling gastrocnemius muscle lean obese mice treated either vehicle control myriocin values reported pmol mg protein n 6 mice differences determined using two way anova followed bonferroni post hoc analysis significantly different lf counterpart after 3 weeks treatment myriocin vivo heat production ambulatory activity assessed clams apparatus paralleling observations regard whole body oxygen consumption rates obesity caused decline whole body heat production reversed myriocin treatment supplementary fig moreover obesity induced insulin resistance associated reductions physical activity altered myriocin treatment supplementary fig investigation lipid metabolite profile gastrocnemius muscle demonstrated chronic high fat feeding increased long chain acyl coa ceramide dag content trend increase tag content observed fig d treatment myriocin obese mice increased gastrocnemius tag content comparison low fat counterparts change dio associated rise long chain acyl coa dag content expected resulted dramatic reduction ceramide content fig d results suggest key role ceramide mediating skeletal muscle insulin resistance indicate lipid metabolites possibly may important insulin resistance development further support statement seen positive correlation ceramide content area curve glucose tolerance test whereas correlation observed lipid metabolites fig interestingly previous study showed mice deficient malonyl coa decarboxylase mcd/ protected obesity induced glucose intolerance insulin resistance associated reduction incomplete fatty acid oxidation rates 19 study we show mcd/ mice accumulate ceramide gastrocnemius muscle 12 weeks high fat feeding fig 6 although accumulate lipid metabolites long chain acyl coa 19 inhibition spt1 reduces skeletal muscle ceramide levels effect lipid metabolites d gastrocnemius triacylglycerol tag long chain acyl coa b ceramide c diacylglycerol levels low fat fed obese insulin resistant mice treated either vehicle control myriocin differences determined using two way anova followed bonferroni post hoc analysis * p 0.05 significantly different low fat diet counterpart p 0.05 significantly different high fat diet control mice h correlation respective areas curve glucose tolerance test ceramide e tag f long chain acyl coa g diacylglycerol h content n 1418 samples malonyl coa decarboxylase deficient mice mcd/ accumulate skeletal muscle ceramide 12 weeks high fat feeding a area curve glucose tolerance test 12 weeks high fat feeding wild type mcd/ mice b corresponding gastrocnemius ceramide levels mcd/ mice 12 weeks high fat feeding differences determined using two way anova followed bonferroni post hoc analysis p 0.05 significantly different high fat diet wild type mice auc area curve determine ceramides may also involved genetic forms insulin resistance type 2 diabetes treated leptin receptor deficient db db mice myriocin see could prevent progression insulin resistance animals we split db db mice 6 weeks age two groups ensured differences glucose tolerance initiating treatment myriocin fig both db db control myriocin treated groups experienced similar body weight increases 2 weeks treatment data shown however although db db control group became glucose intolerant db db group treated myriocin fig fasting blood glucose levels also significantly lower db db mice treated myriocin although response insulin delayed myriocin treated db db mice demonstrated lower blood glucose levels nearly time points insulin tolerance test fig 7d f placing animals clams apparatus yielded profile similar dio mice the db db controls lower rer dark cycle db/+ lean mice lower whole body oxygen consumption rates ambulatory activity change overall heat production interestingly myriocin treatment db db mice restore altered parameters db db controls except restoration whole body oxygen consumption rates light cycle fig examination lipid metabolite profile revealed tag long chain acyl coa levels elevated gastrocnemius muscle db db controls versus db/+ lean mice whereas unexpectedly dag ceramide levels similar two groups fig h myriocin treatment db db mice effect tag long chain acyl coa dag levels gastrocnemius muscle versus db db control mice lead dramatic reduction ceramide levels fig insulin stimulated akt gsk3 phosphorylation also depressed db db control versus db/+ lean mice showed improvement db db mice treated myriocin fig prevention insulin resistance db db mice via myriocin treatment pretreatment glucose tolerance test gtt db db mice 6 weeks age c respective areas curve post treatment gtt db db mice d insulin tolerance test itt db db mice treated vehicle control myriocin f fed fasted plasma glucose levels db db mice treated vehicle control myriocin differences determined using either two tailed student test one way two way anova followed bonferroni post hoc analysis * p 0.05 significantly different db db control mice vivo metabolic parameters intramyocellular lipid metabolite profile insulin signaling db db mice treated myriocin rer whole body oxygen consumption b heat production c ambulatory activity db/+ heterozygous mice db db mice treated vehicle control myriocin gastrocnemius triacylglycerol e long chain acyl coa f diacylglycerol g ceramide levels h db/+ heterozygous mice db db mice treated vehicle control myriocin i insulin stimulated akt phosphorylation serine 473 j gsk3 phosphorylation serine 9 gastrocnemius muscle db/+ heterozygous mice db db mice treated vehicle control myriocin differences determined using either one way two way anova followed bonferroni post hoc analysis p 0.05 significantly different db db control mice as expected mice fed high fat diet 12 weeks became obese indicated significant increase weight gain supplementary fig d diet induced insulin resistant lean mice placed comprehensive lab animal monitoring system clams whole body metabolic assessment demonstrated high fat diet induced shift fuel preference toward fatty acids oxidative energy source indicated large drop respiratory exchange ratio rer supplementary fig further support increase fatty acid oxidation obese mice seen increase gastrocnemius -hydroxyacyl coa dehydrogenase activity table 1 contrary previous findings 16,17 also report obesity induced chronic high fat feeding impairs whole body oxygen consumption rates supplementary fig 2c -hydroxyacyl coa dehydrogenase activity gastrocnemius muscle lean obese mice treated vehicle control myriocin values reported mol g wet weight min n 5 mice differences determined using two way anova followed bonferroni post hoc analysis significantly different low fat counterpart after 12 weeks low- high fat diet mice treated either myriocin 0.5 mg kg every day vehicle control after 2 weeks treatment demonstrated inhibition spt1 myriocin reverses diet induced insulin resistance determined glucose tolerance insulin tolerance testing fig if protective effects took place skeletal muscle level group animals killed 30 min insulin injection insulin tolerance test muscles excised harvested immunoblot analysis insulin signaling pathway we demonstrate insulin stimulation akt glycogen synthase kinase 3 gsk3 phosphorylation significantly improved gastrocnemius muscle obese mice treated myriocin fig phosphorylation 5amp activated protein kinase ampk another key signaling molecule regulating glucose metabolism differ gastrocnemius muscle control myriocin treated obese mice data shown inhibition serine palmitoyl transferase 1 spt1 reverses high fat diet induced insulin resistance improves insulin signaling glucose tolerance test low fat fed obese insulin resistant mice treated either vehicle control myriocin c insulin tolerance test low fat diet obese insulin resistant mice treated either vehicle control myriocin e insulin stimulated akt phosphorylation serine 473 f gsk3 phosphorylation serine 9 gastrocnemius muscle obese insulin resistant mice treated either vehicle control myriocin values represent mean se n 812 n 4 e f differences determined using either two tailed student test two way anova followed bonferroni post hoc analysis p 0.05 significantly different groups myriocin treatment without effect food intake body weight plasma insulin levels reduce postprandial fasted plasma glucose levels obese insulin resistant mice table 2 although fasting plasma insulin levels differ diet induced obesity dio mice treated vehicle control myriocin sophisticated studies monitoring changes plasma insulin response meal tolerance test obese jcr la cp rat illustrate significant improvement plasma insulin control treatment spt1 inhibitor l cycloserine supplementary fig 3 interestingly indirect calorimetry revealed improved insulin sensitivity dio mice treated myriocin associated decrease fatty acid oxidation increase carbohydrate oxidation similar rer values observed dio control myriocin treated animals fig 2 effect myriocin body tissue weight plasma glucose insulin levels lean obese mice values reported n 511 mice differences determined using two way anova followed bonferroni post hoc analysis significantly different low fat counterpart significantly different high fat control twenty four hour dark cycle b light cycle respiratory exchange ratio c low fat fed obese insulin resistant mice treated either vehicle control myriocin differences determined using two way anova followed bonferroni post hoc analysis * p 0.05 significantly different low fat diet counterpart parallel series experiments 12 weeks high fat feeding mice treated either spt1 inhibitor l cycloserine 25 mg kg every day vehicle control although dramatic results observed myriocin 2 weeks treatment report improvements glucose insulin tolerance mice treated l cycloserine supplementary fig obese insulin resistant mice run exercise treadmill determine exercise capacity expected obese mice showed dramatic reduction treadmill time distance compared lean counterparts fig interestingly treatment obese mice 2 weeks myriocin reversed reduction exercise capacity fig 3a b this improvement exercise capacity observed obese mice treated myriocin explained enhanced whole body oxygen consumption rates compared control counterparts fig c addition observed greater citrate synthase activity gastrocnemius muscle obese mice treated myriocin fig protein expression peroxisome proliferator activated receptor- coactivator-1 pgc1 transcriptional coactivator plays key role regulating number genes involved energy metabolism 18 showed trend toward reduction control treated dio mice p 0.077 apparent myriocin treated dio mice fig furthermore also demonstrate pretreatment myriocin increases citrate synthase activity c2c12 myotubes exposed 1.0 mmol l palmitate 16 h fig these observations illustrate improvements mitochondrial function possibly explaining exercise capacity whole body oxygen consumption rates enhanced group time distance b exercise capacity challenge running treadmill differences determined using two way anova followed bonferroni post hoc analysis p 0.05 significantly different low fat diet counterpart myriocin treatment reverses impairment whole body oxygen consumption rates caused dio c twenty four hour dark cycle b light cycle c whole body oxygen consumption assessment low fat diet obese insulin resistant mice treated either vehicle control myriocin d gastrocnemius muscle citrate synthase activity vehicle control myriocin treated dio mice e pgc1 expression low fat diet obese insulin resistant mice treated either vehicle control myriocin f citrate synthase activity vehicle control myriocin pretreated c2c12 skeletal muscle myotubes exposed 1.0 mmol l palmitate 16 h. values represent mean se n 512 differences determined using either two tailed student test two way anova followed bonferroni post hoc analysis * p 0.05 significantly different low fat diet counterpart p 0.05 significantly different high fat diet control mice auc area curve metabolic profiling mice provided insight regards mitochondrial function obese insulin resistant mice control treated dio mice significant increase long chain acyl carnitine esters versus lean counterparts table 3 indicative mitochondrial overload incomplete oxidation fatty acids 19 however accumulation long chain acyl carnitine esters myriocin treated dio mice even greater table 3 this suggests incomplete fatty acid oxidation rates even pronounced myriocin treated dio mice animals also significant reduction short chain acyl carnitine ester content table 3 consistent long chain acyl coa dehydrogenase inhibition reduced oxidation long chain fatty acids metabolic profiling gastrocnemius muscle lean obese mice treated either vehicle control myriocin values reported pmol mg protein n 6 mice differences determined using two way anova followed bonferroni post hoc analysis significantly different lf counterpart after 3 weeks treatment myriocin vivo heat production ambulatory activity assessed clams apparatus paralleling observations regard whole body oxygen consumption rates obesity caused decline whole body heat production reversed myriocin treatment supplementary fig moreover obesity induced insulin resistance associated reductions physical activity altered myriocin treatment supplementary fig investigation lipid metabolite profile gastrocnemius muscle demonstrated chronic high fat feeding increased long chain acyl coa ceramide dag content trend increase tag content observed fig d treatment myriocin obese mice increased gastrocnemius tag content comparison low fat counterparts change dio associated rise long chain acyl coa dag content expected resulted dramatic reduction ceramide content fig d results suggest key role ceramide mediating skeletal muscle insulin resistance indicate lipid metabolites possibly may important insulin resistance development further support statement seen positive correlation ceramide content area curve glucose tolerance test whereas correlation observed lipid metabolites fig h interestingly previous study showed mice deficient malonyl coa decarboxylase mcd/ protected obesity induced glucose intolerance insulin resistance associated reduction incomplete fatty acid oxidation rates 19 study we show mcd/ mice accumulate ceramide gastrocnemius muscle 12 weeks high fat feeding fig 6 although accumulate lipid metabolites long chain acyl coa 19 inhibition spt1 reduces skeletal muscle ceramide levels effect lipid metabolites d gastrocnemius triacylglycerol tag long chain acyl coa b ceramide c diacylglycerol levels low fat fed obese insulin resistant mice treated either vehicle control myriocin differences determined using two way anova followed bonferroni post hoc analysis * p 0.05 significantly different low fat diet counterpart p 0.05 significantly different high fat diet control mice h correlation respective areas curve glucose tolerance test ceramide e tag f long chain acyl coa g diacylglycerol h content n 1418 samples malonyl coa decarboxylase deficient mice mcd/ accumulate skeletal muscle ceramide 12 weeks high fat feeding a area curve glucose tolerance test 12 weeks high fat feeding wild type mcd/ mice b corresponding gastrocnemius ceramide levels mcd/ mice 12 weeks high fat feeding differences determined using two way anova followed bonferroni post hoc analysis * p 0.05 significantly different low fat diet counterpart p 0.05 significantly different high fat diet wild type mice to determine ceramides may also involved genetic forms insulin resistance type 2 diabetes treated leptin receptor deficient db db mice myriocin see could prevent progression insulin resistance animals we split db db mice 6 weeks age two groups ensured differences glucose tolerance initiating treatment myriocin fig both db db control myriocin treated groups experienced similar body weight increases 2 weeks treatment data shown however although db db control group became glucose intolerant db db group treated myriocin fig fasting blood glucose levels also significantly lower db db mice treated myriocin although response insulin delayed myriocin treated db db mice demonstrated lower blood glucose levels nearly time points insulin tolerance test fig f placing animals clams apparatus yielded profile similar dio mice the db db controls lower rer dark cycle db/+ lean mice lower whole body oxygen consumption rates ambulatory activity change overall heat production interestingly myriocin treatment db db mice restore altered parameters db db controls except restoration whole body oxygen consumption rates light cycle fig examination lipid metabolite profile revealed tag long chain acyl coa levels elevated gastrocnemius muscle db db controls versus db/+ lean mice whereas unexpectedly dag ceramide levels similar two groups fig h myriocin treatment db db mice effect tag long chain acyl coa dag levels gastrocnemius muscle versus db db control mice lead dramatic reduction ceramide levels fig insulin stimulated akt gsk3 phosphorylation also depressed db db control versus db/+ lean mice showed improvement db db mice treated myriocin fig prevention insulin resistance db db mice via myriocin treatment pretreatment glucose tolerance test gtt db db mice 6 weeks age c respective areas curve post treatment gtt db db mice d insulin tolerance test itt db db mice treated vehicle control myriocin f fed fasted plasma glucose levels db db mice treated vehicle control myriocin differences determined using either two tailed student test one way two way anova followed bonferroni post hoc analysis * p 0.05 significantly different db db control mice vivo metabolic parameters intramyocellular lipid metabolite profile insulin signaling db db mice treated myriocin rer whole body oxygen consumption b heat production c ambulatory activity db/+ heterozygous mice db db mice treated vehicle control myriocin gastrocnemius triacylglycerol e long chain acyl coa f diacylglycerol g ceramide levels h db/+ heterozygous mice db db mice treated vehicle control myriocin i insulin stimulated akt phosphorylation serine 473 j gsk3 phosphorylation serine 9 gastrocnemius muscle db/+ heterozygous mice db db mice treated vehicle control myriocin differences determined using either one way two way anova followed bonferroni post hoc analysis p 0.05 significantly different db db control mice our results show inhibition spt1 reduces de novo ceramide synthesis muscle novel effects whole body energy metabolism associated profound reversal glucose intolerance insulin resistance induced chronic high fat feeding furthermore show improvements dissociated lipid metabolites believed play role development insulin resistance interestingly obesity induced insulin resistance mice associated detriment aerobic exercise capacity whole body oxygen consumption rates partially reversed via spt1 inhibition previous studies postulated skeletal muscle insulin resistance caused intramyocellular cytosolic accumulation lipid metabolites tag long chain acyl coa dag ceramide etc ) in particular long chain acyl coa dag received considerable attention ability activate classic novel protein kinase c signaling cascade phosphorylate insulin receptor substrate proteins serine residues preventing activation via insulin receptor 4,5,8,2123 it important note however 95% acyl coa esters located inside mitochondria 24,25 suggesting long chain acyl coa accumulation play role toward insulin resistance development possible mitochondrial opposed cytosolic long chain acyl coa primary contributor although tag shown numerous studies elevated muscle association development insulin resistance recent studies shown tag may actually serve buffer protecting muscle accumulation reactive lipid metabolite species 10,11 regards ceramide data mixed role insulin resistance development studies ceramide accumulation evident muscle 5,26 studies accumulation occur relative increase ceramide pool large 12,27 ( 12 shed light issue demonstrated ceramide accumulation muscle dependent type diet fed animals in particular saturated fatty acids drive de novo ceramide synthesis muscle via spt1 whereas unsaturated fatty acids cause insulin resistance via mechanisms 12 such findings may potentially explain ceramide accumulation observed studies insulin resistance model employed lipid infusion consists primarily unsaturated fatty acids 22 furthermore holland et al 12 showed study preventing de novo synthesis ceramide via spt1 inhibition myriocin prevented development glucose intolerance obese zucker rats prevented palmitate induced inhibition insulin stimulated 2-deoxyglucose uptake isolated soleus muscle ( 28 also reported positive findings myriocin treatment leptin deficient dio mice providing support ceramide plays key role development insulin resistance interestingly authors also observed weight loss effect due myriocin treatment observe studies however authors study used much longer treatment 8 vs. 4 weeks noted observe weight loss effect later treatment period furthermore 3 weeks myriocin treatment dio mice improved hyperglycemia whole body oxygen consumption rates mice despite change body weight compared control treated dio mice consistent results dio mice treated myriocin 2 weeks yang et al also observed dramatic reduction hepatic steatosis consistent observations regards hepatic tag content our study adds support studies examining role ceramide mediating insulin resistance 12,28 illustrating potential targeting spt1 treatment insulin resistance moreover examining lipid metabolites tag dag long chain acyl coa acyl carnitine content skeletal muscle able discern important differences regard relative importance metabolite toward development skeletal mucle insulin resistance importantly reductions skeletal muscle ceramide accumulation may represent potential explanation exercise paradox observed humans dube et al 15 showed obese insulin resistant men placed aerobic exercise training regime elevated intramyocellular lipid tag stores however marked reductions muscle ceramide levels observed may explain enhanced insulin sensitivity men moreover bruce et al 14 showed improved insulin sensitivity observed exercise training humans associated drop muscle ceramide levels particular saturated species ( 29 showed exercise training rats leads dramatic drop saturated species ceramide muscle associated enhanced 2-deoxyglucose uptake in addition mice overexpressing diacylglycerol acyl transferase muscle protected high fat diet induced insulin resistance palmitate inhibition 2-deoxyglucose uptake isolated muscle associated elevation muscle tag drop ceramide levels 10 our results support studies show obese insulin resistant mice treated myriocin significant increases intramyocellular tag long chain acyl coa dag dramatic drop ceramide content moreover observed positive correlation ceramide content glucose intolerance lipid metabolites we believe finding setting obesity ceramide may vital development skeletal muscle insulin resistance lipid metabolites support statement also evident culture models ceramide accumulation whereby inhibition spt1 able prevent palmitate induced insulin resistance human rat l6 myotubes despite elevated tag dag levels 11,13 furthermore recent study humans demonstrated insulin resistant muscle associated elevated ceramide content change dag content 30 nonetheless also important note measurement dag assessed total cellular levels dag possible differences plasma membrane dag significantly reduced via myriocin treatment dag membrane believed specific dag pool responsible mediating skeletal muscle insulin resistance 3 important future studies investigate detail one surprising findings study chronic high fat feeding resulted dramatic decline whole body oxygen consumption rates the majority studies examined effect high fat feeding whole body oxygen consumption rates via use clams apparatus reported elevations oxygen consumption rates 16,17 although differences studies could due duration composition diet propose two possible explanations observation first reported obesity induced insulin resistance causes mitochondrial dysfunction results impairment fatty acid oxidative capacity 58 although may possible model insulin resistance inducing mitochondrial dysfunction highly unlikely due impairments muscle fatty acid oxidative capacity rer values obese mice reported study close 0.7 indicating animals trouble utilizing fat energy source nonetheless factors mitochondrial content protein expression electron transport chain etc complexes activity complexes may account potential mitochondrial dysfunction subsequent impairment oxygen consumption rates observed obese mice 31,32 however observe differences protein expression cytochrome c etc group data shown second relevant findings study obesity induced insulin resistance associated elevated rates incomplete fatty acid oxidation arise rates fatty acid oxidation disconnected tca cycle activity 19,33,34 this disconnect arises due sedentary nature obese individuals animals thus demand tca cycle upregulate activity deal increased fatty acid supply utilized energy source 19,33,34 if tca cycle unable accommodate increasing acetyl coa coming fatty acid oxidation reducing equivalents nadh fadh2 would donate electrons complexes etc accounting reduction oxygen consumption rates our observation increased accumulation long chain acyl carnitine esters muscle dio mice thus consistent elevated rates incomplete fatty acid oxidation in contrast even greater accumulation long chain acyl carnitine esters myriocin treated dio mice first glance would suggest even greater rates incomplete fatty acid oxidation animals however myriocin treated dio mice actually significant reduction content number short chain acyl carnitine esters combination rise long chain acyl carnitine esters suggestive long chain acyl coa dehydrogenase subsequent long chain fatty acid oxidation inhibition 35 another piece indirect support fatty acid oxidation inhibition myriocin treatment dio mice observation tag accumulated muscle animals versus lean counterparts control treated dio mice versus lean counterparts a reduction fatty acid oxidation derived nadh would decrease nadh nadph oxidase activity subsequent superoxide production myriocin treated dio mice would contribute toward improved mitochondrial function this improvement mitochondrial function coupled together improvements glucose metabolism glucose derived acetyl coa production tca cycle may contribute greater oxygen consumption rates animals obesity induced decrements pgc1 protein expression might also explain impairments mitochondrial function 34,36,37 although significant observed trend toward reduction gastrocnemius pgc1 protein expression control treated dio mice p 0.077 evident myriocin treated dio mice interestingly citrulline levels increased myriocin treated dio mice versus control counterparts supplementary fig a previous study humans showed supplementation citrulline enhances aerobic oxidative metabolism 38 supporting findings increased whole body oxygen consumption rates greater exercise time myriocin treated dio mice how myriocin subsequent spt1 inhibition would influence skeletal muscle citrulline levels currently unknown undoubtedly intriguing avenue future investigation in addition previously shown mcd/ mice genetic model fatty acid oxidation deficiency protected obesity induced insulin resistance interestingly show study exact animals accumulate ceramide muscle 12 weeks high fat feeding leading intriguing possibility intramyocellular ceramide accumulation linked mitochondrial dysfunction enhanced skeletal muscle fatty acid oxidation rates observed insulin resistance a limitation interpretation whole body oxygen consumption rates unlike human studies unable normalize oxygen consumption rates lean body mass it entirely possible whole body oxygen consumption rates simply lower dio mice significant increase overall adiposity due fat mass lower metabolic rate lean body mass however fact adiposity body weight similar myriocin- control treated dio mice suggests would contributing factor higher oxygen consumption rates observed myriocin treated dio mice although believe changes accounting greater oxygen consumption rates myriocin treated dio mice primarily reflect muscle ignore possible contributions changes peripheral tissues brown adipose tissue uncoupling protein activity the beneficial effects mediated inhibition spt1 prevention de novo ceramide synthesis could also arise liver effects animals regardless observe increases hepatic ceramide content diet induced obesity myriocin treatment effect insulin stimulated akt gsk3 phosphorylation obese mice versus respective controls supplementary fig recent studies also shown high fat feeding increase ceramide content liver 39 increases hepatic ceramide content via genetic overexpression either dgat1 dgat2 result type insulin resistance inflammation 40 moreover reported difference pyruvate challenge fasted obese control- myriocin treated mice supplementary fig 8) suggesting gluconeogenic capacity different two groups liver likely play key role improved insulin sensitivity observed myriocin treated mice regardless entirely rule possibility liver plays role benefit observed myriocin treatment dio associated rise hepatic tag content reversed via myriocin treatment thus important future studies delineate role hepatic spt1 greater depth finally chronic low grade inflammation shown number studies play role causing obesity induced insulin resistance 4143 inflammatory stress kinases p38 mapk jnk proposed downstream mediators inflammatory effect inhibitors kinases able prevent high fat diet induced insulin resistance 9,4446 unexpectedly the phosphorylation status p38 mapk jnk altered dio altered myriocin treatment supplementary fig 9 suggesting inflammation may play vital role model insulin resistance it may also possible inflammation model mediated kinase ikk 47,48 regard findings db db mice we report similar findings observed obesity induced insulin resistant mice treatment myriocin also yielded similar beneficial profile interestingly gastrocnemius ceramide levels although reduced myriocin treated db db mice differ db/+ lean db db control mice this suggests least model perhaps ceramide metabolites glucosylceramide important mediating skeletal muscle insulin resistance ceramide 49 furthermore ceramide pool dynamic process synthesis degradation 9 although de novo synthesis ceramide may increased animals simultaneous increase ceramide degradation would mask noticeable change summary show ceramide accumulation skeletal muscle plays key role obesity induced insulin resistance whereas lipid metabolites tag long chain acyl coa dag may vital importantly inhibition de novo ceramide synthesis novel effects whole body energy metabolism sufficient reverse obesity induced whole body glucose intolerance insulin resistance furthermore whole body oxygen consumption rates exercise capacity obese mice improved via inhibition de novo ceramide synthesis last finding muscle ceramide levels elevated db db mice inhibition de novo ceramide synthesis still prevents development insulin resistance suggests possibility ceramide metabolites may also play role progression disease

objectiveit has been proposed that skeletal muscle insulin resistance arises from the accumulation of intramyocellular lipid metabolites that impede insulin signaling , including diacylglycerol and ceramide . we determined the role of de novo ceramide synthesis in mediating muscle insulin resistance.research design and methodsmice were subjected to 12 weeks of diet - induced obesity ( dio ) , and then treated for 4 weeks with myriocin , an inhibitor of serine palmitoyl transferase-1 ( spt1 ) , the rate - limiting enzyme of de novo ceramide synthesis.resultsafter 12 weeks of dio , c57bl/6 mice demonstrated a doubling in gastrocnemius ceramide content , which was completely reversed ( 141.5 15.8 vs. 94.6 10.2 nmol / g dry wt ) via treatment with myriocin , whereas hepatic ceramide content was unaffected by dio . interestingly , myriocin treatment did not alter the dio - associated increase in gastrocnemius diacyglycerol content , and the only correlation observed between lipid metabolite accumulation and glucose intolerance occurred with ceramide ( r = 0.61 ) . dio mice treated with myriocin showed a complete reversal of glucose intolerance and insulin resistance which was associated with enhanced insulin - stimulated akt and glycogen synthase kinase 3 phosphorylation . furthermore , myriocin treatment also decreased intramyocellular ceramide content and prevented insulin resistance development in db / db mice . finally , myriocin - treated dio mice displayed enhanced oxygen consumption rates ( 3,041 124 vs. 2,407 124 ml / kg / h ) versus their control counterparts.conclusionsour results demonstrate that the intramyocellular accumulation of ceramide correlates strongly with the development of insulin resistance , and suggests that inhibition of spt1 is a potentially promising target for the treatment of insulin resistance .

antibodies amp kinase ampk phosporylated ampk pampk acetyl coa carboxylase acc phosporylated acc akt phosporylated akt tubulin cell signaling anti oxphos mitosciences anti cd36-[hrp purchased novus biologicals human recombinant insulin novolin novo nordisk canada this study performed approval university alberta animal policy welfare committee experiments carried male wild type c57bl6 cd36 knockout ko mice 19 maintained temperature controlled room reversed 12-h light/12-h dark cycle mice left relatively undisturbed either 1214 5258 weeks age free access water standard rodent diet category 5001 labdiet 3234 weeks age a subset mice randomly divided low fat diet group category d12450b research diets high fat diet group category d12492 research diets period 12 weeks indirect calorimetry performed using comprehensive lab animal monitoring system oxymax clams columbus instruments colombus oh following initial 24-h acclimatization period mice monitored every 13 min 24 h complete 12-h dark active)/12-h light inactive cycle respiratory exchange ratio rer vco2/vo2 ) was used estimate percent contribution fat carbohydrate whole body energy metabolism mice vivo total activity calculated adding z counts rearing jumping total counts associated ambulatory movement stereotypical behavior grooming scratching upon phospholipid digestion phospholipase c 2 h 30c lipid extraction levels triglycerides determined gastrocnemius muscle lysates gas liquid chromatography previously described 20 identification quantification major long chain acyl coa molecular species c16:0 c18:0 c18:1 c18-ceramides performed high performance liquid chromatography previously described 21 overnight fasted mice anesthetized sodium pentobarbital gastrocnemius muscle rapidly removed freeze clamped liquid nitrogen stored 80c acylcarnitine measurements made using flow injection tandem mass spectrometry previously described 14 organic acids quantified previously described 22 comparisons groups performed using unpaired student two tailed test anova bonferroni post hoc test pairwise comparisons appropriate probability value 0.05 considered significant descriptions materials methods refer supplementary material available online appendix available http://diabetes.diabetesjournals.org/cgi/content/full/db09-1142/dc1 antibodies amp kinase ampk phosporylated ampk pampk acetyl coa carboxylase acc phosporylated acc akt phosporylated akt tubulin cell signaling anti oxphos mitosciences anti cd36-[hrp purchased novus biologicals human recombinant insulin novolin novo nordisk canada this study performed approval university alberta animal policy welfare committee experiments carried male wild type c57bl6 cd36 knockout ko mice 19 maintained temperature controlled room reversed 12-h light/12-h dark cycle mice left relatively undisturbed either 1214 5258 weeks age free access water standard rodent diet category 5001 labdiet 3234 weeks age a subset mice randomly divided low fat diet group category d12450b research diets high fat diet group category indirect calorimetry performed using comprehensive lab animal monitoring system oxymax clams columbus instruments colombus oh following initial 24-h acclimatization period mice monitored every 13 min 24 h complete 12-h dark active)/12-h light inactive cycle the respiratory exchange ratio rer vco2/vo2 used estimate percent contribution fat carbohydrate whole body energy metabolism mice vivo total activity calculated adding z counts rearing jumping total counts associated ambulatory movement stereotypical behavior grooming scratching upon phospholipid digestion phospholipase c 2 h 30c lipid extraction levels triglycerides determined gastrocnemius muscle lysates gas liquid chromatography previously described 20 identification quantification major long chain acyl coa molecular species c16:0 c18:0 c18:1 c18-ceramides performed high performance liquid chromatography previously described 21 overnight fasted mice anesthetized sodium pentobarbital gastrocnemius muscle rapidly removed freeze clamped liquid nitrogen stored 80c acylcarnitine measurements made using flow injection tandem mass spectrometry previously described 14 organic acids quantified previously described 22 comparisons groups performed using unpaired student two tailed test anova bonferroni post hoc test pairwise comparisons appropriate probability value 0.05 considered significant descriptions materials methods refer supplementary material available online appendix available http://diabetes.diabetesjournals.org/cgi/content/full/db09-1142/dc1 to determine whether age related decline resting metabolic rate energy expenditure might contribute development insulin resistance c57bl6 mice 1214 young 5258 middle aged weeks age analyzed using indirect calorimetry mice aged body weight increased fig 1a substrate use altered slightly reductions rer indicating middle aged mice used fatty acid throughout day compared young mice fig in addition significant reductions oxygen consumption vo2 fig 1c carbon dioxide production vco2 fig 1d observed dark active light inactive phases middle aged mice compared young mice 1e decreased middle aged mice compared young mice whereas activity measurements significantly different age groups fig our data indicate middle aged mice lower metabolic rate young mice might increase susceptibility weight gain obesity metabolic disease body weight young 1214 weeks age middle aged 5258 weeks age mice fed standard laboratory diet indirect calorimetry performed measure respiratory exchange ratio rer b vo2 c vco2 heat production adjusted bodyweight e total activity f measured dark active light inactive phases p 0.05 indicates comparisons performed young middle aged mice either dark light phases mann whitney u test two way anova performed rer b indicated main effect age p 0.01 given skeletal muscle metabolism contributes whole body basal metabolic rate addressed whether skeletal muscle metabolism depressed middle aged mice assessing activities two enzymes involved regulating mitochondrial metabolism 2a elevated middle aged compared young mice citrate synthase fig 2b followed similar upward trend suggesting -oxidation tca cycle activity directly compromised middle aged mice since mitochondrial number fig 2c function appear altered middle age next assessed whether peroxisome proliferator activated receptor ppar) responsive genes molecular signaling cascades known regulate skeletal muscle fatty acid flux fatty acid entry mitochondria associated overall reduction whole body basal metabolic rate observed middle age although comprehensive assessment multiple mediators fatty acid utilization may reveal additional mechanisms observe changes protein levels known ppar responsive genes involved lipid metabolism including malonyl coa decarboxylase acyl coa synthetase 1 data shown result also examined energy sensing kinase ampk known ability govern energy metabolism 23 agreement previous reports using older rodents 24,25 levels phosphorylated ampk were significantly reduced skeletal muscle middle aged mice compared young mice fig moreover phosphorylation status acetyl coa carboxylase acc downstream target ampk indirectly regulates fatty acid entry mitochondria ultimately -oxidation significantly decreased skeletal muscle middle aged mice fig although reduced ampk phosphorylation could result impaired activity upstream ampk kinases increased ampk phosphatase activity currently unknown contributes reduced ampk phosphorylation model however consistent decreased energy expenditure increased adiposity reduced ampk activity skeletal muscle middle aged mice levels skeletal muscle triglycerides significantly elevated middle aged mice compared young mice fig 2 g given lipid accumulation skeletal muscle proposed rodents 26 humans 17,27,28 one primary causes skeletal muscle insulin resistance next investigated whether glucose tolerance impaired middle aged mice despite elevated intramuscular triglycerides fig 2 g impaired basal insulin stimulated akt phosphorylation fig 2h respectively skeletal muscle middle aged mice whole body glucose tolerance fig 2k different middle aged compared young mice suggesting age induced alterations skeletal muscle fatty acid handling increased triglyceride storage precede development insulin resistance metabolic disease alterations fatty acid handling reduced insulin signaling skeletal muscle middle aged mice result impaired whole body glucose tolerance activity two mitochondrial enzymes -had citrate synthase cs b determined gastrocnemius muscle overnight fasted young 1214 weeks age middle aged 5258 weeks age mice immunoblot analysis using total oxphos complex antibody cocktail performed gastrocnemius muscle lysates immunoblots normalized tubulin control protein loading c phosphorylation status ampk threonine 172 acc serine 79 f detected using immunoblot analysis phospho specific antibodies immunoblots quantified densitometry normalized total protein levels ampk e acc f triglyceride tg levels g phosphorylation status akt h determined gastrocnemius muscle overnight fasted young middle aged mice gastrocnemius muscle collected separate group overnight fasted young middle aged mice following intraperitoneal injection either saline human recombinant insulin 10 units kg immunoblots performed detect phosphorylation status akt serine 473 gastrocnemius muscle lysates glucose tolerance test j ) was performed young middle aged mice following 6-h fast serum insulin detected young middle aged mice overnight fast k p 0.05 indicates comparisons performed young middle aged mice mann whitney u test since speculated middle aged mice susceptible young mice development insulin resistance young middle aged mice subjected high fat feeding 12 weeks although young mice fed high fat diet displayed weight gain fig 3a signs glucose intolerance compared young mice fed low fat diet fig in contrast middle aged mice fed high fat diet showed significant weight gain body weight low fat 30.18 0.70 g high fat 55.14 1.56 g p 0.05 displayed dramatically elevated insulin levels fig in addition whole body glucose tolerance middle aged mice fed high fat diet significantly impaired compared middle aged mice fed low fat diet fig although activation insulin signaling determined phosphorylation status akt impaired skeletal muscle young fig 3j mice fed high fat diet compared mice fed low fat diet likely due elevated levels circulating insulin fig 3e f observed respective high fat groups support glucose tolerance data homeostasis model assessment insulin resistance values significantly higher high fat fed middle aged mice fig 3k suggesting high fat feeding induces dramatic insulin resistance middle aged mice young mice interestingly young mice high fat diet weight middle aged mice low fat diet yet young mice high fat diet impaired glucose disposal data shown although discriminate effects aging increased adiposity variables coassociate findings suggest increased weight gain associated aging sufficient alter whole body glucose disposal factors high fat diet likely involved aging increases susceptibility development glucose intolerance insulin resistance mice fed high fat diet body weights fed fasted blood glucose b glucose tolerance test c phosphorylation status akt measured gastrocnemius muscle young 1214 weeks age mice following 12 weeks high fat hf feeding serum insulin levels fasted e fed f states obtained young 1214 weeks age middle aged 4852 weeks age mice fed low fat lf high fat diet 12 weeks fed fasted blood glucose levels g glucose tolerance test h area curve auc glucose tolerance test phosphorylation status akt gastrocnemius muscle j middle aged mice following 12 weeks high fat feeding homeostasis model assessment insulin resistance homa ir surrogate marker insulin resistance young middle aged mice fed high fat diet k immunoblot analysis using anti cd36 antibody performed gastrocnemius muscle lysates middle aged mice fed low- high fat diet immunoblots quantified densitometry normalized tubulin control protein loading l triglyceride tg long chain acyl coa lccoa n c18 ceramide levels gastrocnemius muscle overnight fasted middle aged mice fed low- high fat diet two way anova performed detect main effects age diet age diet interactions insulin levels e f homa ir k significant effect age diet age diet interaction p 0.05 observed e f k. p 0.05 indicates comparisons performed young middle aged mice low- high fat fed mice fed fasted state mann whitney u test high fat diet induced insulin resistance young rodents associated increased efficiency fatty acid uptake skeletal muscle 26 protein expression cd36 protein facilitates fatty acid transport determined skeletal muscle mice fed high fat diet consistent previous publications young mice 26,29,30 observed modest increase cd36 protein expression muscle young mice fed high fat diet well increase intramuscular triglyceride levels data shown consistent hypothesis cd36 expression significantly elevated skeletal muscle middle aged mice fed high fat diet compared mice fed low fat diet fig increased cd36 protein expression skeletal muscle triglyceride levels significantly elevated high fat fed middle aged mice compared low fat fed mice fig 3 long chain acyl coa esters fig data suggest increased cd36-mediated fatty acid transport may contribute lipid accumulation impaired insulin sensitivity skeletal muscle middle aged mice fed high fat diet to investigate whether inhibition fatty acid transport skeletal muscle could alter observed responses middle aged mouse high fat diet utilized cd36 ko mouse skeletal muscle fatty acid uptake rates 4070% wild type mice 31,32 interestingly striking difference weight gain middle aged wild type cd36 ko mice following 12 weeks high fat feeding fig 4a middle aged cd36 ko mice accumulating 51% less weight wild type mice period time fig 4d groups could account dramatic change weight gain indirect calorimetry indicated energy expenditure fig 4 g significantly increased middle aged cd36 ko mice fed high fat diet compared high fat fed middle aged wild type mice although increased activity middle aged cd36 ko mouse fed high fat diet could attributed absence obesity heat production also increased middle aged cd36 ko mice fed low fat diet compared low fat fed middle aged wild type mice fig 4h high fat fed middle aged ko mice normalized body weight fig 4i protection diet induced obesity middle aged cd36 ko mice fed high fat hf diet 12 weeks representative image middle aged 4852 weeks age wild type cd36 ko mice fed high fat diet 12 weeks weight gain b food intake adjusted body weight bw c wild type ko mice fed high fat diet respiratory exchange ratio rer oxygen consumption vo2 e carbon dioxide production vco2 f dark active light inactive phase following 12 weeks high fat feeding wild type ko mice total activity complete dark light cycle g heat production h heat production adjusted body weight wild type ko mice following 12 weeks high fat feeding values means sem n 610 mice group * p 0.05 indicates comparisons performed low fat lf)-fed mice high fat fed mice mann whitney u test b g anova bonferroni post hoc test pairwise comparison ( high quality digital representation figure available online issue gain comprehensive metabolic assessment muscle metabolism middle aged wild type cd36 ko mice fed low fat high fat diet used mass spectrometry measure broad range intermediary metabolites including acylcarnitines various chain lengths organic acids amino acids acylcarnitines products fuel catabolism respond changes substrate availability flux limitations specific mitochondrial enzymes 14,33,34 middle aged cd36 ko mice fed low fat diet elevated levels acetyl carnitine c2 -hydroxybutyryl carnitine c4oh compared wild type counterparts supplemental fig 1a supplemental table 1 whereas several short chain acylcarnitine species including c2 c4oh well propionyl carnitine c3 succinyl carnitine c4dc tended increase response high fat diet metabolites trended downward cd36 ko mice fed high fat diet supplemental fig 1a supplemental table 1 in addition several long chain acylcarnitine species reduced muscle wild type mice fed high fat diet time levels hydroxylated long chain acylcarnitine lcoh species increased resulting robust increase long chain lcoh acylcarnitine ratio fig c given long chain acylcarnitines accumulate production mitochondrial carnitine palmitoyl transferase cpt)1 exceeds flux -oxidation enzymes long chain acyl coa dehydrogenase lcad -had 35 pattern consistent diet induced shift flux limitation lcad -had notably levels many long chain lcoh acylcarnitines lower cd36 ko mice fed high fat diet wild type mice fed high fat diet fig 5a supplemental table 1 the organic acids less responsive diet genotype although subtle changes detected succinate fumarate citrate levels supplemental fig muscle levels amino acids higher wild type mice fed low fat diet dramatically decreased following high fat feeding comparison amino acid levels remained unchanged cd36 ko mice response high fat diet supplemental fig although metabolite measurements fully characterize mitochondrial substrate flux together data suggest ablation cd36 alters baseline mitochondrial intermediary metabolism also significantly impacts muscle response lipid exposure altered skeletal muscle lipid handling prevents development insulin resistance middle aged cd36 ko mice fed high fat hf diet 12 weeks acylcarnitine levels measured gastrocnemius muscle overnight fasted middle aged 4852 weeks age wild type wt cd36 ko mice fed low- lf high fat diet 12 weeks levels individual long chain lc lcoh species sum total long chain lcoh species b ratio total lcoh long chain species c phosphorylation status ampk thr172 acc ser 79 e detected gastrocnemius muscle using immunoblot analysis immunoblots quantified densitometry normalized total ampk acc e serum levels free fatty acids ffas high fat fed wild type cd36 ko mice determined 12 weeks diet f intramuscular levels triglyceride tg g lccoa h c18 ceramide determined gastrocnemius muscle obtained wild type ko mice fed high fat diet 12 weeks glucose tolerance testing j performed high fat fed wild type ko mice fasted 6 h. fasted blood glucose k serum insulin l levels obtained middle aged wild type ko mice fed high fat diet 12 weeks insulin tolerance test blood glucose levels expressed percent change blood glucose time zero middle aged wild type ko mice fed high fat diet 12 weeks immunoblots performed gastrocnemius muscle isolated middle aged wild type ko mice following high fat diet phosphorylation status akt measured normalized total akt levels n main effects genotype diet genotype diet interactions acylcarnitine levels c detected two way anova simplicity symbols indicate metabolites affected genotype diet genotype diet interaction detailed results statistical analysis acylcarnitine species presented supplemental table 1 * p 0.05 indicates comparisons performed low fat fed wild type low fat fed ko mice high fat fed wild type high fat fed ko mice mann whitney u test anova bonferroni post hoc test j interestingly despite changes muscle acylcarnitine levels activity -had altered data shown middle aged cd36 ko mice fed high fat diet protected decreased levels ampk acc phosphorylation fig 5d e compared young wild type mice fig 2d f suggesting alternate mechanisms responsible metabolic phenotype observed cd36 ko mice similarly absolute expression ampk acc skeletal muscle aged cd36 mice different groups data shown although serum free fatty acid levels elevated high fat fed cd36 ko mice fig 5f cd36 ablation resulted significant reduction skeletal muscle triglycerides fig by contrast ceramide levels remained similar high fat fed groups fig 5i suggesting accumulation lipid derived intermediates ceramides may contribute impaired insulin sensitivity indeed reduced intramuscular lipid accumulation middle aged cd36 ko mice associated improved whole body glucose tolerance fig 5k compared high fat fed middle aged wild type mice moreover fasted insulin levels significantly reduced fig 5 high fat fed middle aged cd36 ko mice compared high fat fed middle aged wild type mice suggesting insulin sensitivity restored preventing lipid accumulation skeletal muscle interestingly despite improved glucose utilization reduced plasma insulin levels mice phosphorylation status akt similar skeletal muscle middle aged wild type cd36 ko mice high fat diet fig furthermore found difference glycogen content livers cd36 ko mice fed low fat high fat diet data shown suggesting improved glucose tolerance observed mice result increased glucose uptake and/or glucose oxidation skeletal muscle cd36 ko mice alterations hepatic glucose metabolism to determine whether age related decline resting metabolic rate energy expenditure might contribute development insulin resistance c57bl6 mice 1214 young 5258 middle aged weeks age analyzed using indirect calorimetry mice aged body weight increased fig 1a substrate use altered slightly reductions rer indicating middle aged mice used fatty acid throughout day compared young mice fig in addition significant reductions oxygen consumption vo2 fig 1c carbon dioxide production vco2 fig 1d observed dark active light inactive phases middle aged mice compared young mice 1e decreased middle aged mice compared young mice whereas activity measurements significantly different age groups fig our data indicate middle aged mice lower metabolic rate young mice might increase susceptibility weight gain obesity metabolic disease body weight young 1214 weeks age middle aged 5258 weeks age mice fed standard laboratory diet indirect calorimetry performed measure respiratory exchange ratio rer b vo2 c vco2 heat production adjusted bodyweight e total activity f measured dark active light inactive phases p 0.05 indicates comparisons performed young middle aged mice either dark light phases mann whitney u test two way anova performed rer b indicated main effect age p 0.01 given skeletal muscle metabolism contributes whole body basal metabolic rate addressed whether skeletal muscle metabolism depressed middle aged mice assessing activities two enzymes involved regulating mitochondrial metabolism 2a elevated middle aged compared young mice citrate synthase fig 2b followed similar upward trend suggesting -oxidation tca cycle activity directly compromised middle aged mice since mitochondrial number fig 2c function appear altered middle age next assessed whether peroxisome proliferator activated receptor ppar) responsive genes molecular signaling cascades known regulate skeletal muscle fatty acid flux fatty acid entry mitochondria associated overall reduction whole body basal metabolic rate observed middle age although comprehensive assessment multiple mediators fatty acid utilization may reveal additional mechanisms observe changes protein levels known ppar responsive genes involved lipid metabolism including malonyl coa decarboxylase acyl coa synthetase 1 data shown result also examined energy sensing kinase ampk known ability govern energy metabolism 23 agreement previous reports using older rodents 24,25 levels phosphorylated ampk were significantly reduced skeletal muscle middle aged mice compared young mice fig moreover phosphorylation status acetyl coa carboxylase acc downstream target ampk indirectly regulates fatty acid entry mitochondria ultimately -oxidation significantly decreased skeletal muscle middle aged mice fig although reduced ampk phosphorylation could result impaired activity upstream ampk kinases increased ampk phosphatase activity currently unknown contributes reduced ampk phosphorylation model however consistent decreased energy expenditure increased adiposity reduced ampk activity skeletal muscle middle aged mice levels skeletal muscle triglycerides significantly elevated middle aged mice compared young mice fig 2 g given lipid accumulation skeletal muscle proposed rodents 26 humans 17,27,28 one primary causes skeletal muscle insulin resistance next investigated whether glucose tolerance impaired middle aged mice despite elevated intramuscular triglycerides fig 2 g impaired basal insulin stimulated akt phosphorylation fig 2h respectively skeletal muscle middle aged mice whole body glucose tolerance fig 2k different middle aged compared young mice suggesting age induced alterations skeletal muscle fatty acid handling increased triglyceride storage precede development insulin resistance metabolic disease alterations fatty acid handling reduced insulin signaling skeletal muscle middle aged mice result impaired whole body glucose tolerance activity two mitochondrial enzymes -had citrate synthase cs b determined gastrocnemius muscle overnight fasted young 1214 weeks age middle aged 5258 weeks age mice immunoblot analysis using total oxphos complex antibody cocktail performed gastrocnemius muscle lysates immunoblots normalized tubulin control protein loading c phosphorylation status ampk threonine 172 acc serine 79 f detected using immunoblot analysis phospho specific antibodies immunoblots quantified densitometry normalized total protein levels ampk e acc f triglyceride tg levels g phosphorylation status akt h determined gastrocnemius muscle overnight fasted young middle aged mice gastrocnemius muscle collected separate group overnight fasted young middle aged mice following intraperitoneal injection either saline human recombinant insulin 10 units kg immunoblots performed detect phosphorylation status akt serine 473 gastrocnemius muscle lysates glucose tolerance test j performed young middle aged mice following 6-h fast serum insulin detected young middle aged mice overnight fast k p 0.05 indicates comparisons performed young middle aged mice mann whitney u test since speculated middle aged mice susceptible young mice development insulin resistance young middle aged mice subjected high fat feeding 12 weeks 3a signs glucose intolerance compared young mice fed low fat diet fig in contrast middle aged mice fed high fat diet showed significant weight gain body weight low fat 30.18 0.70 g high fat 55.14 1.56 g p 0.05 displayed dramatically elevated insulin levels fig in addition whole body glucose tolerance middle aged mice fed high fat diet significantly impaired compared middle aged mice fed low fat diet fig although activation insulin signaling determined phosphorylation status akt impaired skeletal muscle young fig 3j mice fed high fat diet compared mice fed low fat diet likely due elevated levels circulating insulin fig 3e f observed respective high fat groups support glucose tolerance data homeostasis model assessment insulin resistance values significantly higher high fat fed middle aged mice fig 3k suggesting high fat feeding induces dramatic insulin resistance middle aged mice young mice interestingly young mice high fat diet weight middle aged mice low fat diet yet young mice high fat diet impaired glucose disposal data shown although discriminate effects aging increased adiposity variables coassociate findings suggest increased weight gain associated aging sufficient alter whole body glucose disposal factors high fat diet likely involved aging increases susceptibility development glucose intolerance insulin resistance mice fed high fat diet body weights fed fasted blood glucose b glucose tolerance test c phosphorylation status akt measured gastrocnemius muscle young 1214 weeks age mice following 12 weeks high fat hf feeding serum insulin levels fasted e fed f states obtained young 1214 weeks age middle aged 4852 weeks age mice fed low fat lf high fat diet 12 weeks fed fasted blood glucose levels g glucose tolerance test h area curve auc glucose tolerance test phosphorylation status akt gastrocnemius muscle j middle aged mice following 12 weeks high fat feeding homeostasis model assessment insulin resistance homa ir surrogate marker insulin resistance young middle aged mice fed high fat diet k immunoblot analysis using anti cd36 antibody performed gastrocnemius muscle lysates middle aged mice fed low- high fat diet immunoblots quantified densitometry normalized tubulin control protein loading l triglyceride tg long chain acyl coa lccoa n c18 ceramide levels gastrocnemius muscle overnight fasted middle aged mice fed low- high fat diet two way anova performed detect main effects age diet age diet interactions insulin levels e f homa ir k significant effect age diet age diet interaction p 0.05 observed e f k. * p 0.05 indicates comparisons performed young middle aged mice low- high fat fed mice fed fasted state mann whitney u test high fat diet induced insulin resistance young rodents associated increased efficiency fatty acid uptake skeletal muscle 26 protein expression cd36 protein facilitates fatty acid transport determined skeletal muscle mice fed high fat diet consistent previous publications young mice 26,29,30 observed modest increase cd36 protein expression muscle young mice fed high fat diet well increase intramuscular triglyceride levels data shown consistent hypothesis cd36 expression significantly elevated skeletal muscle middle aged mice fed high fat diet compared mice fed low fat diet fig 3l accordance increased cd36 protein expression skeletal muscle triglyceride levels significantly elevated high fat fed middle aged mice compared low fat fed mice fig 3 long chain acyl coa esters fig together data suggest increased cd36-mediated fatty acid transport may contribute lipid accumulation impaired insulin sensitivity skeletal muscle middle aged mice fed high fat diet to investigate whether inhibition fatty acid transport skeletal muscle could alter observed responses middle aged mouse high fat diet utilized cd36 ko mouse skeletal muscle fatty acid uptake rates 4070% wild type mice 31,32 interestingly striking difference weight gain middle aged wild type cd36 ko mice following 12 weeks high fat feeding fig 4a middle aged cd36 ko mice accumulating 51% less weight wild type mice period time fig 4d groups could account dramatic change weight gain indirect calorimetry indicated energy expenditure fig 4 g significantly increased middle aged cd36 ko mice fed high fat diet compared high fat fed middle aged wild type mice although increased activity middle aged cd36 ko mouse fed high fat diet could attributed absence obesity heat production also increased middle aged cd36 ko mice fed low fat diet compared low fat fed middle aged wild type mice fig 4h high fat fed middle aged ko mice normalized body weight fig 4i protection diet induced obesity middle aged cd36 ko mice fed high fat hf diet 12 weeks representative image middle aged 4852 weeks age wild type cd36 ko mice fed high fat diet 12 weeks weight gain b food intake adjusted body weight bw c wild type ko mice fed high fat diet respiratory exchange ratio rer oxygen consumption vo2 e carbon dioxide production vco2 f dark active light inactive phase following 12 weeks high fat feeding wild type ko mice total activity complete dark light cycle g heat production h heat production adjusted body weight wild type ko mice following 12 weeks high fat feeding * p 0.05 indicates comparisons performed low fat lf)-fed mice high fat fed mice mann whitney u test b g anova bonferroni post hoc test pairwise comparison ( high quality digital representation figure available online issue ) to gain comprehensive metabolic assessment muscle metabolism middle aged wild type cd36 ko mice fed low fat high fat diet used mass spectrometry measure broad range intermediary metabolites including acylcarnitines various chain lengths organic acids amino acids acylcarnitines products fuel catabolism respond changes substrate availability flux limitations specific mitochondrial enzymes 14,33,34 middle aged cd36 ko mice fed low fat diet elevated levels acetyl carnitine c2 -hydroxybutyryl carnitine c4oh compared wild type counterparts supplemental fig 1a supplemental table 1 whereas several short chain acylcarnitine species including c2 c4oh well propionyl carnitine c3 succinyl carnitine c4dc tended increase response high fat diet metabolites trended downward cd36 ko mice fed high fat diet supplemental fig 1a supplemental table 1 in addition several long chain acylcarnitine species reduced muscle wild type mice fed high fat diet time levels hydroxylated long chain acylcarnitine lcoh species increased resulting robust increase long chain lcoh acylcarnitine ratio fig 5a c given long chain acylcarnitines accumulate production mitochondrial carnitine palmitoyl transferase cpt)1 exceeds flux -oxidation enzymes long chain acyl coa dehydrogenase lcad -had 35 pattern consistent diet induced shift flux limitation lcad -had notably levels many long chain lcoh acylcarnitines lower cd36 ko mice fed high fat diet wild type mice fed high fat diet fig the organic acids less responsive diet genotype although subtle changes detected succinate fumarate citrate levels supplemental fig muscle levels amino acids higher wild type mice fed low fat diet dramatically decreased following high fat feeding comparison amino acid levels remained unchanged cd36 ko mice response high fat diet supplemental fig although metabolite measurements fully characterize mitochondrial substrate flux together data suggest ablation cd36 alters baseline mitochondrial intermediary metabolism also significantly impacts muscle response lipid exposure altered skeletal muscle lipid handling prevents development insulin resistance middle aged cd36 ko mice fed high fat hf diet 12 weeks acylcarnitine levels measured gastrocnemius muscle overnight fasted middle aged 4852 weeks age wild type wt cd36 ko mice fed low- lf high fat diet 12 weeks levels individual long chain lc lcoh species sum total long chain lcoh species b ratio total lcoh long chain species c phosphorylation status ampk thr172 acc ser 79 e detected gastrocnemius muscle using immunoblot analysis immunoblots quantified densitometry normalized total ampk acc e serum levels free fatty acids ffas high fat fed wild type cd36 ko mice determined 12 weeks diet f intramuscular levels triglyceride tg g lccoa h c18 ceramide determined gastrocnemius muscle obtained wild type ko mice fed high fat diet 12 weeks glucose tolerance testing j performed high fat fed wild type ko mice fasted 6 h. fasted blood glucose k serum insulin l levels obtained middle aged wild type ko mice fed high fat diet 12 weeks insulin tolerance test blood glucose levels expressed percent change blood glucose time zero middle aged wild type ko mice fed high fat diet 12 weeks immunoblots performed gastrocnemius muscle isolated middle aged wild type ko mice following high fat diet phosphorylation status akt measured normalized total akt levels n main effects genotype diet genotype diet interactions acylcarnitine levels c detected two way anova for simplicity symbols indicate metabolites affected genotype diet genotype diet interaction detailed results statistical analysis acylcarnitine species presented supplemental table 1 * p 0.05 indicates comparisons performed low fat fed wild type low fat fed ko mice high fat fed wild type high fat fed ko mice mann whitney u test anova bonferroni post hoc test j interestingly despite changes muscle acylcarnitine levels activity -had altered data shown middle aged cd36 ko mice fed high fat diet protected decreased levels ampk acc phosphorylation fig 5d e compared young wild type mice fig 2d f suggesting alternate mechanisms responsible metabolic phenotype observed cd36 ko mice similarly absolute expression ampk acc skeletal muscle aged cd36 mice different groups data shown although serum free fatty acid levels elevated high fat fed cd36 ko mice fig 5f cd36 ablation resulted significant reduction skeletal muscle triglycerides fig by contrast ceramide levels remained similar high fat fed groups fig 5i suggesting accumulation lipid derived intermediates ceramides may contribute impaired insulin sensitivity indeed reduced intramuscular lipid accumulation middle aged cd36 ko mice associated improved whole body glucose tolerance fig 5k compared high fat fed middle aged wild type mice 5 high fat fed middle aged cd36 ko mice compared high fat fed middle aged wild type mice suggesting insulin sensitivity restored preventing lipid accumulation skeletal muscle interestingly despite improved glucose utilization reduced plasma insulin levels mice phosphorylation status akt similar skeletal muscle middle aged wild type cd36 ko mice high fat diet fig furthermore found difference glycogen content livers cd36 ko mice fed low fat high fat diet data shown suggesting improved glucose tolerance observed mice result increased glucose uptake and/or glucose oxidation skeletal muscle cd36 ko mice alterations hepatic glucose metabolism consistent previous reports 17 data show significant decline metabolic rate middle aged mice compared young counterparts fig interestingly although mitochondrial function directly assessed study decline overall metabolic rate appear stem compromised mitochondrial function skeletal muscle middle aged mice compared young mice indeed whole body rer modestly decreased aging muscle activity -had increased suggesting shift substrate selection carbohydrates toward fatty acids however age associated reduction overall metabolic rate appear correlate changes maximal activities mitochondrial enzymes muscle young middle aged mice fig 2a 2b suggesting factors may influence substrate oxidation muscle well overall metabolic rate consistent ampk acc signaling axis significantly reduced skeletal muscle middle aged mice fig 2d 2f still unclear is whether reduced ampk phosphorylation older mice reflects cause consequence reduced metabolic rate although results recent study suggest acc mediated shifts fat oxidation per se impact whole body energy expenditure susceptibility diet induced obesity 36 ampk acts broad range enzymatic transcriptional targets could affect energy balance via mechanisms substrate selection 25,37 nonetheless cd36 deficiency raised metabolic rate without activating ampk indicating mechanisms operative model see although akt phosphorylation reduced skeletal muscle middle aged mice compared young mice fig 2h 2i whole body glucose tolerance plasma insulin levels remained normal fig 2j 2k suggesting impaired activation insulin signaling parameters skeletal muscle precede overt changes whole body glucose disposal may increase susceptibility aged mice diet induced insulin resistance determine whether middle aged mice indeed susceptible developing insulin resistance response high fat diet compared younger counterparts subjected middle aged mice 12 weeks low fat high fat diet as expected middle aged mice gained significantly weight young mice fed high fat diet weight gain middle aged 22.8 1.9 g versus young 12.0 1.1 g p 0.01 3c 3h 3i high fat diet induced hyperinsulinemia observed middle aged mice fig 3e 3f indicating increased -cell insulin secretion sufficient offset overt hyperglycemia age group fig 3 g given prolonged hypersecretion insulin -cells compensate peripheral insulin resistance contribute -cell failure 38 potentially type 2 diabetes 39 data suggest middle aged mice heightened susceptibility development insulin resistance however susceptibility might due aging per se since adiposity also increased older mice study design permit discriminate effects aging adiposity skeletal muscle metabolism development insulin resistance future experiments directed conducting weight loss food restriction studies exercise studies determine nevertheless aging increased adiposity co associate findings likely reflect majority middle aged humans western world risk developing insulin resistance although intramuscular lipid accumulation associated aging appear result mitochondrial dysfunction show significant twofold increase cd36 protein expression skeletal muscle high fat fed middle aged mice compared low fat fed middle aged mice fig 3l suggesting fatty acid transport muscle exceeded capacity oxidation although unknown caused increased cd36 expression study may resulted high levels plasma glucose levels shown regulate cd36 expression transcriptional and/or translational mechanisms rodents humans 40,41 determine whether reduced fatty acid transport metabolism could rescue high fat diet induced phenotype consistent prediction cd36 deficiency prevented decline metabolic rate energy expenditure middle aged mice fed high fat diet compared age matched wild type mice fig 4e 4f since food intake similar groups fig 4c propose increased energy expenditure high fat fed middle aged cd36 ko mice contributes protection diet induced obesity fig 4b blunted decline metabolic rate middle aged cd36 ko mice fed high fat diet fig 4e 4f accompanied alterations muscle concentrations several metabolic intermediates fig 1 improvement ampk acc phosphorylation fig 5d 5e respectively the impact diet muscle metabolites study differed extent compared previous report 14 tissue specimens harvested younger animals fed state herein tissues collected overnight fast sought evaluate state heightened fatty acid oxidation conditions the drop long chain acylcarnitines could reflect decreased fatty acid availability lower cpt1 activity increased long chain acyl coa flux lcad first high fat diet increases rather decreases lipid delivery muscle second two major products cpt1 palmitoylcarnitine c16 oleylcarnitine c18:1 unsaturated species reduced diet fig 5a suggesting upregulation isomerase enzyme catalyzes conversion double bond 42 5c response chronic lipid exposure suggest shift flux limitation earlier later steps -oxidation lastly diet resulted robust drop whole body rer indicative systemic increase fat oxidation notably cd36 deficiency altered baseline levels several muscle metabolites general tended mitigate diet induced changes several acylcarnitine amino acid species apparent resistance diet induced metabolic perturbations cd36 ko mice might directly related reduction fat delivery and/or secondary enhanced energy expenditure insulin sensitivity although work necessary fully understand implications results clear loss cd36 global impact muscle fuel metabolism in addition possible organs adipose tissue liver brain 43,44 also involved maintaining high level energy expenditure middle aged cd36 ko mice overall ablation cd36 associated improvement whole body glucose utilization insulin sensitivity fig although mechanisms responsible known excessive intramuscular lipid accumulation induced high fat feeding prevented skeletal muscle middle aged cd36 ko mice fig 5 g 5h whereas elevated intramuscular triglyceride levels associated insulin resistance young mice fig 2j2k preventing dramatic age- diet induced accumulation intramuscular triglyceride long chain acyl coa levels middle aged cd36 ko mice correlated improved whole body insulin sensitivity although ample evidence indicating cd36 ablation significantly reduces skeletal muscle fatty acid uptake 31,32 also possible effects report using cd36 ko mice secondary changes fatty acid metabolism notwithstanding later possibility data demonstrate limiting cd36-mediated skeletal muscle fatty acid transport guards whole body muscle insulin resistance middle aged mice fed high fat diet this finding suggests potential therapeutic strategy combating metabolic disease face age related abnormalities

objectivealthough advanced age is a risk factor for type 2 diabetes , a clear understanding of the changes that occur during middle age that contribute to the development of skeletal muscle insulin resistance is currently lacking . therefore , we sought to investigate how middle age impacts skeletal muscle fatty acid handling and to determine how this contributes to the development of diet - induced insulin resistance.research design and methodswhole - body and skeletal muscle insulin resistance were studied in young and middle - aged wild - type and cd36 knockout ( ko ) mice fed either a standard or a high - fat diet for 12 weeks . molecular signaling pathways , intramuscular triglycerides accumulation , and targeted metabolomics of in vivo mitochondrial substrate flux were also analyzed in the skeletal muscle of mice of all ages.resultsmiddle-aged mice fed a standard diet demonstrated an increase in intramuscular triglycerides without a concomitant increase in insulin resistance . however , middle - aged mice fed a high - fat diet were more susceptible to the development of insulin resistance a condition that could be prevented by limiting skeletal muscle fatty acid transport and excessive lipid accumulation in middle - aged cd36 ko mice.conclusionour data provide insight into the mechanisms by which aging becomes a risk factor for the development of insulin resistance . our data also demonstrate that limiting skeletal muscle fatty acid transport is an effective approach for delaying the development of age - associated insulin resistance and metabolic disease during exposure to a high - fat diet .

sarcopenia present approximately 513% persons age 60 years defined loss skeletal muscle mass strength progressive decline mobility function the pathogenesis sarcopenia associated many intrinsic extrinsic factors including proinflammatory cytokine accumulation oxidative stress mitochondrial dysfunction insulin resistance aging related loss anabolic hormones motor neuron end plates the loss skeletal muscle results imbalance protein metabolism dynamic balance protein degradation protein synthesis the protein degradation systems skeletal muscle modulated coordinated network signaling pathways activated suppressed hormones cytokines therefore catabolism stimulated variety proinflammatory cytokines glucocorticoids reactive oxygen species ros 5 6 it important note impaired cellular immune function combined low grade inflammation represents continuous impact aging process although aging associated prolonged inflammatory activity mainly attributed progressively worsening muscle weakness unclear whether processes cross talked molecular signals pathways connecting inflammatory system muscle degeneration may key reveal interactions responsible progression sarcopenia interplay seems exist mass loss skeletal muscle elevated systemic inflammation figure 1 sarcopenia complex process subclinical state inflammation driven proinflammatory cytokines oxidative stress increases infiltration immune cells injured muscles turn inflammation aggravates muscle loss fat accumulation aging skeletal muscle decreases muscle function physical activity the increase chronic inflammation response associated high level proinflammatory mediators extension age considered one diagnostic hallmarks significant contributor aging related atrophy skeletal muscle the transcription factor nuclear factor-b nf-b considered important mediator underlying relationship inflammation aging 10 11 the correlation inflammation sarcopenia exists possible linkage describing effect inflammation balance protein anabolism catabolism presence cd68 macrophage infiltration it worth noting substantial evidence also demonstrates connection obesity sarcopenia namely sarcopenic obesity in fact obesity always plays important role sarcopenia way adding inflammatory burden obesity adipose tissue characterized chronic inflammatory state release numerous proinflammatory cytokines including tumor necrosis factor alpha tnf- interleukin-6 il-6 interleukin-1 beta il-1 factors largely responsible insulin resistance obese adipose tissue combined aging related skeletal muscle loss moreover impaired mitochondria reason consequence inflammation aging increasing evidence shows mitochondria may contribute inflammation via ros production nf-b activation calcium homeostasis impaired autophagy atp deficiency 17 18 dysfunctional mitochondria able modulate aging related inflammatory processes direct activation nlrp3 inflammasome correspondingly result activation caspase-1 redox sensitive inflammatory signaling pathways thus leading production il-1 il-18 19 20 it noted increasing ros could stimulate activation nf-b via nf-b inducing kinase nik ib kinase ikk/ 21 22 since increased redox activation presence transcription factor nf-b excessive ros generation plays important role impaired mitochondrial function oxidative capacity accelerates aging process skeletal muscle described above sarcopenia common feature elderly mainly related release inflammatory mediators damaged tissue these responses controlled combination various cytokines responsible inflammatory pathways 10 24 given inflammatory response complex system cytokines important indicators mediating chronic inflammatory state increasing protein degradation reducing protein synthesis also mediators controlling muscle wasting directly targeting muscle tissue in particular proinflammatory cytokines well known impinge protein metabolism skeletal muscle result activation catabolism signals upregulate inflammatory pathways nf-b stat3 thus finally leading increased activation ubiquitin proteasome autophagy system 26 27 the chronic inflammatory aging process depends increased expression proinflammatory factors also reduced levels anti inflammatory factors il-10 one anti inflammatory cytokines since presence function cytokines demonstrated pathogenesis sarcopenia origins types must identified in fact cytokines secreted various types cells like inflammatory stromal cells well skeletal muscle cells skeletal muscle the constitutive expression cytokines generally stronger differentiated myotubes compared myoblasts usually results inconspicuous change cytokine release stimuli 29 30 accumulating evidences past decade have demonstrated proinflammatory cytokines tnf- il-6 c reactive protein crp cause significant increase aging skeletal muscle cells play key role complex network inflammatory signals charge muscle homeostasis connected aging related disability mortality 31 32 has originally classified prototypical proinflammatory cytokine exhibit marked pleiotropy anti inflammatory property also identified later 34 35 il-6 plays important role pathogenesis several chronic diseases including sarcopenia regulating inflammatory metabolic functions il-6 signaling involves binding membrane bound il-6 receptor skeletal muscle activation downstream signaling pathways including stat3 mapk erk p38 myostatin foxo3 pathways 3740 additionally il-6 confirmed function activating ampk and/or phosphatidylinositol-3-kinase pi3k regulating metabolism skeletal muscle 41 42 the overexpression il-6 result reduced body mass impaired insulin stimulated glucose uptake mouse skeletal muscle furthermore infusion il-6 skeletal muscle reduce phosphorylation s6k1 activated akt mtor associated inhibition anabolic process a comparative analysis cytokine levels confirmed upregulation proinflammatory il-6 crp elderly along increased risk loss skeletal muscle mass strength according recent study serum high sensitivity crp hs crp levels obesity sarcopenic obesity groups significantly higher normal group multivariate adjustments provides evidence obesity sarcopenic obesity associated increased levels serum hs crp among males tnf- cytokine implicated metabolic disturbance chronic inflammation formation il-1 identified circulatory factor increase gluconeogenesis lipolysis proteolysis accompanied decrease protein lipid glycogen synthesis skeletal muscle stages muscle regeneration tnf- il-1 observed injured muscle accumulation macrophages 48 49 also tnf- il-1 confirmed promote il-6 secretion activating nf-b cultured skeletal muscle cells several previous studies confirmed tnf- elevated level increase catabolism skeletal muscle suppressing akt mtor pathway tnf- soluble receptors described important contributors biomarkers loss mass strength aged skeletal muscle there strongly negative correlation protein breakdown tnf- concentration elderly injecting tnf- mice revealed activation ubiquitin proteasome system decrease skeletal muscle function vivo synthesis rate myosin heavy chain protein correlated negatively expression tnf- skeletal muscle tnf- induces skeletal muscle loss increased myofibrillar protein degradation cell apoptosis thus resulting muscle atrophy inhibition muscle regeneration following injury 55 56 additionally seems tnf- may antagonize anabolic effect insulin growth factor-1 igf-1 due development growth hormone resistance decreases circulating muscular igf-1 57 58 recent studies shown g a-308 tnf- polymorphism marker sarcopenia normal weight obese syndrome suggesting importance tnf- diagnosis sarcopenia it important note increase tnf- alone sufficient cause muscle atrophy the upregulation nf-b cause muscle atrophy rodents contribute progressive muscle loss advancing age other mediators interferon- ifn- produced microenvironment skeletal muscle play critical role myogenesis moreover il-15 usually mentioned among paracrine effectors cytokines irisin myonectin able induce anti inflammatory cytokines il-1 receptor antagonist il-10 especially contraction aging conditions the levels tlr4 protein il6 il10 il15 mrna expression increased short time bed rest healthy older adults levels ifn- macrophage inflammatory protein-1-beta mip-1 elevated aging skeletal muscle furthermore peroxisome proliferator activated receptor gamma coactivator-1-alpha pgc-1 regarded anti inflammatory function inhibiting function foxo3 could promote inflammatory cytokine expression downregulate antioxidant enzyme expression aging muscle the reduced expression pgc-1 results low level systemic inflammatory response exhibit negative impacts skeletal muscle inversely upregulated pgc-1 reduce activity nf-b contributes inhibition proinflammatory cytokines benefit prevention mass strength loss skeletal muscle functional decline organs well ultimate impact homeostasis human body 68 69 proinflammatory cytokines wide variety roles inflammation systems may important factor predisposing muscle catabolism response elderly however roles cytokines aging skeletal muscle still fully understood furthermore tissue specific inflammatory signaling pathways response cytokines along elevation systemic cytokines important elements considered mirnas short noncoding rnas approximately 22 nucleotides length involved complex posttranscriptional regulatory networks maintenance healthy cellular functions growth development metabolism skeletal muscle abundant tissue human body comprising 4050% body mass it estimated approximately 60% human genes regulated mirnas suggesting highly enriched mirnas skeletal muscle play important roles biological processes gene silencing including aging process the functions mirnas achieved either suppressing translation target messenger rnas mrnas promoting degradation mrnas thereby providing powerful sensitive regulator tune gene expression cell functions aging process skeletal muscle mirnas noncoding rna genes within protein coding genes transcribed primicrornas rna polymerase ii polymerase iii cases subsequently embedded premicrorna hairpins like rna duplex drosha 73 74 premicrorna hairpins exported nucleus exportin-5 processed double stranded mature mirnas dicer combination rna binding cofactor after dicer mediated maturation mirnas orient risc complex removal preservation one strand guide strand preferentially load risc complex position regulatory sequences target genes although precise mechanisms mirna targeting activity still remain fully explored mirna activity appears largely dependent binding capacity target mrna molecule 7779 generally mrnas contain predicted binding site 3 untranslated region utr less commonly 5 utr many mrnas contain multiple potential binding sites according binding complementarity seed sequence argonaute proteins ago-2 directly cleave messenger rna normally repress gene expression targeting mrna degradation complete match risc binds mrna perfect match mediating translation inhibition mrna deadenylation leading mrna destabilization condition mismatches mrna sequence risc incomplete match risc binds mrna mismatches however still unsettled questions regarding mirna binding rules thereby resulting lack consensus previous studies establishing direct cause effect links mirnas mrna targets key understand underlying molecular mechanisms behind health diseases develop effective targeted therapeutic strategies mirnas multiple gene targets target may regulated suite mirnas the roles mirnas inflammation sarcopenia initially explored future investigations unravel roles immunity metabolism according analysis mirna expression profiling mirnas critical regulators proinflammatory cytokines skeletal muscle function 82 83 order elucidate mirna important production proinflammatory cytokines aging related muscle wasting mrna targets specific roles regeneration protein synthesis skeletal muscle need established several tissue specific mirnas known associated aging skeletal muscle named myomirnas consistently identified including mir-1 mir-133 mir-206 mir-208 mir-486 mir-431 mir-499 8486 these myomirnas induce significant effects development myogenesis skeletal muscle targeting myogenic factors srf mef2 myostatin local injection mir-206 accelerate muscle regeneration mir-133 promote proliferation myoblasts mir-1 suppress proliferation myoblasts although obvious difference expression mature mir-1 mir-133 mir-206 skeletal muscle younger adults increased expression primary mirnas can observed aging effect anabolic stimulus levels mirnas perturbed elderly hand many studies implicated regulation inflammatory response inflammatory mirnas mir-155 mir-146a suggesting roles immune system since inflammation rather broad concept overlaps mirnas involved inflammation aging therefore cytokine associated mirnas appear central roles inflammation sarcopenia a recent rna sequencing study demonstrated differential expression mirnas skeletal muscle old young rhesus monkeys mir-181a role tuning threshold cell receptor tcr signaling originally described acts myomirna also impacts inflammatory system it downregulate sirtuin 1 sirt1 gene expression regulator expression mir-181a target gene disrupted aged skeletal muscle moreover based earlier reports showing proinflammatory cytokines tnf- il-6 il-1 il-8 proposed targets mir-181a reduction mir-181a responsible increase abovementioned proinflammatory cytokines skeletal muscle aging process besides tnf- il-1 significantly negatively correlated decreased expression myomirs suppress differentiation c2c12 myoblasts myocytes myotubes nf-b jak stat mapk p38 key pathways a newly discovered proinflammatory cytokine tnf like weak inducer apoptosis tweak belongs tnf family revealed function causing muscle atrophy one mechanisms proposed induction skeletal muscle wasting tweak regulating differential expression several growth related mirnas including mir-1 mir-23 mir-133a mir-133b mir-206 c2c12 myotubes however reduce mir-1 mir-133a mir-133b mouse skeletal muscle while treatment tweak regulates several mirnas involved growth skeletal muscle known whether regulation cause muscle wasting compensatory response prevent muscle wasting let-7 mirna first known human mirna reported critical promoting differentiation inhibiting cellular proliferation the elevation let-7 mirna may responsible damage repairing capability activation proliferation satellite cells skeletal muscle elderly therefore contributing attenuated regenerative capacity skeletal muscle elderly moreover let-7 mirna inhibit secretion inflammatory cytokine il-13 human myotubes recent study also found overexpression mirna let-7c inhibit lps induced production tnf- il-6 il-1 inhibiting phosphorylation stat3 compared younger individuals skeletal muscle older individuals shows significant elevation let-7b let-7e resting conditions suggesting involvement mirnas regulating cell cycle based let-7 target genes mir-146a negatively regulates expression il-1 il-6 highly expressed aged mice consequence aberrant nf-b binding mir-146a promoter result negative feedback regulation loop inducing downregulation inflammatory factors interrupted aged mice macrophages isolated aged mice both dna methyl transferase inhibitor histone deacetylase inhibitor able significantly upregulate mir-146a transcriptional activation altering dna binding activity nf-b reduced mir-146a oxldl activated macrophages linked increase target toll like receptor 4 tlr4 involved lipid uptake inflammatory cytokine secretion due upregulation inflammatory condition various primary disorders skeletal muscle mir-155 identified important regulator mef2a expression exhibits function myoblast differentiation also plays critical role regulation inflammation affects innate adaptive immunity the upregulation mir-155 characteristic feature mirna expression signature lps stimulated macrophages binding nf-b moreover inflammatory response mediated mir-155 induced tlr ligands enhance translation tnf- pathogenesis metabolic syndromes in addition mir-23a negatively regulates pgc-1 key activator mitochondrial biogenesis function another study level mir-696 upregulated skeletal muscle mice subjected hind limb immobilization level pgc-1 target mir-696 exhibits obvious decrease consistent observation overexpression mir-696 myocytes shows decrease pgc-1 suggesting involvement mitochondrial function metabolism importance controlling metabolism adaptation atrophy skeletal muscle since large number mirnas have identified skeletal muscle investigation mirnas promising relatively unexplored area understanding regulatory mechanisms wasting process associated cytokine expression secretion aging skeletal muscle clearly targeting mirnas could provide efficient noninvasive approach diagnosis prevention treatment sarcopenia regulation proinflammatory anti inflammatory factors potential interventions sarcopenia include nutritional supplements physical activity resistance exercise caloric restriction anabolic hormones anti inflammatory agents antioxidants a key question whether sarcopenia truly distinct syndrome milder form cachexia continuum it difficult estimate prevalence sarcopenia mostly practical difficulties assessing skeletal muscle mass sarcopenia associated difference production proinflammatory cytokines vivo shows prolonged inflammation activity remains lack understanding individual contributions various cytokines aging process skeletal muscle wide ranging effects cell proliferation differentiation migration survival apoptosis reviewed here mirnas play major roles inflammatory regulation pivotal regulators modulating cell functions critical factors affecting therapeutic outcome sarcopenia although central role inflammation sarcopenia proinflammatory cytokines including tnf- il-6 central mediators skeletal muscle atrophy documented roles inflammatory mirnas mass maintenance functional development skeletal muscle still need explored confirmed whether mirnas used diagnosis inflammatory involvement aging process skeletal muscle proinflammatory cytokine associated mirnas mir-146a mir-181 mir-21 frequently detected high level skeletal muscle however functions still fully clear therefore exploration targets regulatory networks functions highly desired conclusion discovery mirnas regulatory capacity inflammatory response aging process skeletal muscle open novel avenue diagnosis prevention therapy sarcopenia effectively modulating inflammatory signal pathways

sarcopenia has been defined as the aging - related disease with the declined mass , strength , and function of skeletal muscle , which is the major cause of frailty and falls in elders . the activation of inflammatory signal pathways due to diseases and aging is suggested to reveal the critical impact on sarcopenia . several proinflammatory cytokines , especially interleukin-6 ( il-6 ) and tumor necrosis factor - alpha ( tnf- ) , play crucial roles in modulation of inflammatory signaling pathway during the aging - related loss of skeletal muscle . micrornas ( mirnas ) have emerged as the important regulators for the mass and functional maintenance of skeletal muscle through regulating gene expression of proinflammatory cytokines . in this paper , we have systematically discussed regulatory mechanisms of mirnas for the expression and secretion of inflammatory cytokines during sarcopenia , which will provide some novel targets and therapeutic strategies for controlling aging - related atrophy of skeletal muscle and corresponding chronic inflammatory diseases .

temporary henna tattoos pseudotattoo become increasingly widespread among children adolescent safe economic alternative permanent tattoos it well known allergic skin reactions natural henna rare due extremely low rate sensitization india north africa china egypt it used weddings religious ceremonies occident used dye hair cosmetics paraphenylenediamine ppd powerful allergen added henna tattoo mixtures black henna tattoo decrease application time intensify color we describe case 7-year old boy reported erythematous papular bulls eye shaped lesions consolidated edema primarily upper lower extremities figure 1 he also showed erythematous eczematous lesion leg shaped like dolphin figure 2 lesions compatible erythema multiforme like reaction erythematous papular lesions contact eczema tattoo area dolphin shaped patch tests performed observed high sensitivity 48 h moderate 96 h. reported positive reaction ppd henna used paint skin adornment religious reasons 9000 years 60 countries christians jews muslims hindus buddhists used henna part religious customs the henna flowering plant native northern africa western southern asia semi arid zones used since antiquity dye skin it great affinity keratinocytes used create temporary tattoos without necessary puncture skin black henna contains ingredient addition pure henna achieve ebony color cases added ingredient ppd powerful sensitizer directly applied skin may cause mild contact dermatitis one dangerous applications chemical added henna dye applied ppd oxidation process potential allergen increased added henna concentration ppd often much higher approved use hair dyes the cause sensitivity ppd unknown believed mechanism involved pathogenesis may reaction mediated type iii immune complexes associated type iv retarded hypersensitivity various topicals allergens cause erythema multiforme including topical drugs corticosteroids nonsteroidal anti inflammatory drugs iodine povidone imiquimod rubber gloves nickel herbicides three possible causes residual hypopigmentation described reduction melanin synthesis selective destruction melanocytes photoleukomelanodermitis due pigment blocking as henna tattoos becoming increasingly popular prevention requires provision information consumers especially young people parents it important population aware circumstance risk entailed sensitization ppd to conclude believe temporary black henna tattooing controlled health authority legislation minimize appearance new cases reaction ppd serious permanent consequences presented it important population aware risk entailed sensitization ppd due popular henna tattoos

temporary henna tattoos or pseudotattoos have become increasingly widespread among children and adolescent . a generalized skin reaction , type erythema multiforme - like reaction is unusual , and rarely reported . we describe the case of a 7-year - old boy who reported erythematous papular bulls - eye shaped lesions and consolidated edema primarily in the upper and lower extremities . these lesions were compatibles with erythema multiforme - like reaction . he also showed an erythematous - eczematous lesion on his leg , shaped like a dolphin . in this area , a temporary henna tattoo was painted 1-month earlier . patch test was positive for paraphenylenediamine ( ppd ) . skin reactions due to henna are rare . most of the reactions are due to additives , especially ppd , an aniline derivative , which is added to speed up the process of skin dyeing and to give a darker brown to black color ( black henna ) . as henna tattoos are becoming increasingly popular , prevention requires the annual provision of information to consumers , especially young people and their parents .

romaleidae family accounts 200 species grasshoppers comprising three subfamilies romaleinae aucacrinae trybliophorinae it second diverse family superfamily acridoidea occurring semiarid regions tropical rainforests carbonell 1977 roberts carbonell 1982 carbonell 1984 1986 2002 the genus radacridium dispersed across northeast region brazil seems well adapted severely arid conditions carbonell 1984 two species found state pernambuco radacridium mariajoseae typical agreste region radacridium nordestinum typical caatinga biome carbonell 1984 1996 cytogenetic studies involving representatives romaleidae revealed great karyotypic conservation mesa et al 1982 2004 souza kido 1995 rocha et al 1997 pereira souza 2000 most analyzed species including r. mariajoseae r. nordestinum presented karyotypes 2n 23 male 24 female x0/xx sex chromosome system exclusively acrocentric chromosomes the constitutive heterochromatin ch romaleidae predominantly located pericentromeric regions chromosomes observed xyleus angulatus brasilacris gigas chromacris nuptialis radacridium nordestinum e phaeoparia megacephala souza kido 1995 rocha et al analyses dapi cma3 romaleids showed predominance gc rich cma3 regions xyleus angulatus xestotrachelus robustus in contrast gc rich ch regions observed loreto et al ( 2005 two chromacris species c. nuptialis one bivalent m6 pericentromeric cma3 block whereas c. speciosa presented cma3 blocks two autosomal bivalents proximal one m6 telomeric one l2 large part eukaryotic genome formed repetitive dna including tandem sequences mainly comprising satellite dna multigene families ribosomal dna histone gene families include variable number copies various genome locations charlesworth et al fluorescence situ hybridization fish rdna histone genes probes proven useful mapping location clarifying genome organization several organisms among invertebrates rdna gene mapping used several groups including worms vitturi et al 2002 mollusks colomba et al 2002 insects cabrero camacho 2008 cabral de mello et al 2011a panzera et al 2012 the studies involving histone genes mapping grasshoppers included species acrididae family cabrero et al 2009 oliveira et al 2011 four species proscopiidae family cabral de mello et al 2011b mapped this study aimed understanding pattern organization multigene families two species radacridium our results showed great variability number location rdna clusters species whereas histone h4 genes highly conserved number these results compared data grasshopper species discussed based possible mechanisms involved repetitive dna diversification we analyzed ten individuals r. mariajoseae gravat 081204 353353 w bezerros 081400 354749 w ten adult males radacridium nordestinum surubim 074959 354517 w located agreste region state pernambuco brazilian northeast specimens processed testes fixed carnoy solution 3:1 ethanol acetic acid chromosome preparations obtained testicular follicles squashing technique one drop 45% acetic acid the slides stained cma3 0.5 mg ml one hour washed distilled water stained da distamicine 0.1 mg ml 45 min the slides rewashed stained dapi 2 g ml 20 min mounted glycerol mcilvaine buffer mgcl2 probes obtained pcr performed according ayres 2002 modifications using genomic dna species primers 18s dnar sca18s1f f 5 ccc cgt aat cgg aat gag ta 3 sca18s1r r 5- gag gtt tcc cgt gtt gag tc -3 5srdna f(5- aac gac cat acc acg ctg aa -3 r 5- aag cgg tcc ccc atc taa gt 3 histone h4 f-1 5 tsc gig aya aca tyc agg gia tca c 3 r-1 5 cky tti agi gcr tai acc acr tcc 3 the pcr products analyzed electrophoresis 1% agarose gel expected sizes the 18s rdna histone h4 probes labeled biotin-16-dutp 5s rdna probe digoxigenin-11-dutp the chromosome preparations submitted alcohol series pretreatment treated rnase pepsin the hybridization mix contained 1 l probe denaturation performed humid chamber 75 c followed renaturation overnight 37 c immunodetection performed mouse anti biotin m743 dako rabbit anti mouse tritc r270 dako biotin sheep anti digoxigenin roche 1 207 741 sheep anti rabbit fitc dako f0135 digoxigenin chromosomes counterstained 4,6 diamidine-2-phenyl indole dapi slides mounted vectashield vector images obtained leica epifluorescence microscope captured cw4000 program leica adjusted adobe photoshop cs5 radacridium mariajoseae r. nordestinum presented 2n 23(male sex determination mechanism x0(male type exclusively acrocentric chromosomes chromosomes species grouped three large l1-l3 five medium m4-m8 three small s9-s11 pairs cma3/da dapi sequential staining showed gc rich cma3 positive constitutive heterochromatin ch blocks interstitial region one medium sized bivalent m5 pericentromeric region x chromosome r. mariajoseae figure 1a r. nordestinum cma3 blocks present interstitial region l2 bivalent pericentromeric region chromosomes except l1 bivalent figure 1c after fish 18s rdna probe labeled single site pericentromeric region x chromosome r. mariajoseae figure 2a three pericentromeric sites bivalents l2 s9 s10 r. nordestinum figure 2b the 5s rdna genes located pericentromeric region two largest bivalents l1 l2 x chromosome r. mariajoseae figure 2c bivalents l2 l3 m4 m5 r. nordestinumm figure 2d the histone h4 probe mapped proximal location medium sized autosome bivalent m5 species figure 2e f the karyotypic similarities detected conventional analysis two species radacridium extend cma3 dapi staining patterns our results showed gc richness ch heterogeneity r. mariajoseae one autosome pair x chromosome presented cma3 blocks resembled scarcity gc rich regions romaleidae two species chromacris single cma3 block loreto et al 2005 the presence large number cma3 blocks frequent romaleidae observed xyleus angulatus phaeoparia megacephala xestotrachelus robustus ch shown gc rich souza et al 1998 ; pereira souza 2000 souza et al 2003 great difference 18s 5s rdna distribution r. mariajoseae presented single 18s rdna site x chromosome confirming finding one active nucleolus organizer region silver nitrate impregnation agno3 rocha et al 1997 although three autosome bivalents showed 18s hybridization signals r. nordestinum l2 pair corresponding active identified rocha et al these data indicate possible dispersion 18s rdna sequences may caused structural chromosome rearrangements ectopic recombination transpositions cabrero camacho 2008 kind events observed insects nguyen et al 2010 cabral de mello et al ancestral rdna site could present m9 bivalent common ancestor two points support hypothesis presence 18s rdna site pair r. nordestinum considered megameric chromosome rocha et al ( 1997 preferential localization nors type chromosome several species grasshoppers rufas et al 1985 the 18s rdna probe location x chromosome r. mariajoseae could resulted chromosome rearrangement translocation transposition moved m9 x meiotic association chromosome megameric one described loreto et al 2008a 18s rdna sites restricted autosomes observed r. nordestinum also detected xestotrachelus robustus chromacris nuptialis c. speciosa souza et al on hand 18s rdna sites located autosomes sex chromosome described example xyleus discoideus angulatus souza et al 18s rdna sites frequently observed associated gc rich regions romaleidae pereira souza 2000 loreto et al 2005 2004 proscopiidae souza moura 2000 ommexechidae carvalho et al 2011 pattern also observed two species analyzed herein the histone h4 genes located single chromosome pair m5 species a single chromosome pair bearing histone genes also described species grasshoppers ( 2009 analyzed location histone h3 h4 genes 35 species grasshoppers acrididae family they observed great majority species analyzed showed one histone site located autosome pair work double fish performed 11 randomly chosen species revealed cases genes present chromosome site indicating great conservation histone gene location acrididae cabral de mello et al 2011b using histone h3 probe four species proscopiidae tetanorhynchus silvai scleratoscopia protopeirae s. spinosa stiphra robusta observed single site m4 bivalent species oliveira et al 2011 observed multiples sites histone h3 rhammatocerous brasiliensis acrididae concluded would derived condition presence single histone site observed species studied herein would ancestral form the 5s 18s genes co localized l2 chromosome r. nordestinum x chromosome r. mariajoseae similarly observed radacridium species extensive variation 5s rdna distribution found others grasshoppers species presenting single sites extending chromosome pairs described loreto et al 2008b cabral de mello et al 2011a the results obtained study indicate great level karyotypic differentiation r. mariajoseae r. nordestinum these data reinforce fact high conservation observed chromosome level including chromosome number morphology radacridium romaleids reflected genomic level our results also contribute understanding chromosome evolution patterns family romaleidae

in this study , two species of romaleidae grasshoppers , radacridium mariajoseae and r.nordestinum , were analyzed after cma3/da / dapi sequential staining and fluorescence in situ hybridization ( fish ) to determine the location of the 18s and 5s rdna and histone h4 genes . both species presented karyotypes composed of 2n = 23 , x0 with exclusively acrocentric chromosomes . cma3 + blocks were detected after cma3/da / dapi staining in only one medium size autosome bivalent and in the x chromosome in r. mariajoseae . on the other hand , all chromosomes , except the l1 bivalent , of r. nordestinum presented cma3 + blocks . fish analysis showed that the 18s genes are restricted to the x chromosome in r. mariajoseae , whereas these genes were located in the l2 , s9 and s10 autosomes in r. nordestinum . in r. mariajoseae , the 5s rdna sites were localized in the in l1 and l2 bivalents and in the x chromosome . in r. nordestinum , the 5s genes were located in the l2 , l3 , m4 and m5 pairs . in both species the histone h4 genes were present in a medium size bivalent . together , these data evidence a great variability of chromosome markers and show that the 18s and 5s ribosomal genes are dispersed in the radacridium genome without a significant correlation .

relation chronic subclinical low grade inflammation insulin resistance ir long known 1 2 ir major contributor mediating factor development type 2 dm t2 dm along concomitant hypertension ht cardiovascular disease cvd 3 4 the relationship development dm markers inflammation c reactive protein crp il-6 fibrinogen pai-1 described previously serum concentration crp increases impaired glucose tolerance igt overt t2 dm 3 510 hand studies reported elevation crp indicator development t2 dm compared conventional ogtt 2-hpg recommended gold standard fasting plasma glucose fpg hba1c convenient simpler cost effective diagnostic methods currently use diagnosis t2 dm 5 1217 however test recognizes people different metabolic features groups may diagnosed different tests overlap substantially high postchallenge plasma glucose strong predictor cvd fasting glucose independent predictor cvd to best knowledge previous report specifically comparing role hs crp people newly diagnosed dm criteria based 2-hpg fpg hba1c therefore aim study identify optimal cut points hs crp new onset previously undiagnosed people dm diagnosed based current 2-hpg fpg hba1c diagnostic criteria study hs crp results obtained nationally representative population based survey reported data derived turkish epidemiology survey diabetes hypertension obesity endocrine diseases turdep ii population based study included randomly assigned 26,499 adult people 270 urban 270 rural centers the field survey performed january june 2010 participation rate 85% the study approved local ethical board istanbul medical faculty ethical committee 16.4.2008/699 people known dm systemic diseases hs crp levels 10 mg l 95.2 nmol l excluded study due possible infection all biochemical tests including glucose insulin lipid profile measured fasting blood samples using roche diagnostics modular autoanalyzer system roche diagnostics germany central biochemistry laboratory istanbul medical faculty concentration hs crp analyzed immunoturbidimetric assay roche hitachi 912 modular p analyzers acn 210 crpl3 tina quant c reactive protein gen 3 hba1c turbidimetric inhibition immunoassay system laboratory regularly certified roche diagnostics tq hba1c gen 3 ngsp certificate traceability september 2010 2011 detailed medical history participant obtained measurements anthropometry height weight waist hip circumference systolic diastolic blood pressure sbp dbp done body mass index bmi homa ir (= fasting glucose fasting insulin/405 non hdl cholesterol (= total cholesterol hdl cholesterol calculated accordingly glomerular filtration rate egfr estimated using chronic kidney disease epidemiology collaboration ckd epi equation risk factors dm evaluated using chi square test mean values sex compared using nonparametric mann whitney u test homogeneity variance normal distribution variables tested kolmogorov smirnov test pearson correlation coefficients r values calculated assess association hs crp laboratory parameters mean levels hs crp new dm groups compared using univariate analysis adjusted age bmi smoking alcohol drinking sbp dbp an optimum cut point hs crp estimated using receiver operating characteristic roc curve area curve auc 95% cis calculated new dm groups diagnosed fpg 126 mg dl 7.0 mmol l 2-hpg 200 mg dl 11.1 mmol l hba1c 6.5% 48 mmol mol 13 17 optimum cut points hs crp defined men women separately raw data not normally distributed log transformed obtained square root transformation sqrt hs crp levels defining cut points recalculated squares data analyzed using spss windows version 21.0 spss ibm chicago il demographic characteristics laboratory findings women men turdep ii study presented table 1 brief men significantly older higher mean weight waist circumference sbp dbp triglycerides tg hdl cholesterol non hdl cholesterol values women women significantly higher bmi hip circumference heart rate fpg hba1c 1-hpg 2-hpg hdl cholesterol egfr values men median interquartile range iqr concentration hs crp women significantly higher men women 1.85 3.09 total serum cholesterol fasting serum insulin homa ir values differ men women table 1 there positive correlation hs crp levels age bmi waist hip sbp dbp pulse fpg hba1c 1-hpg 2-hpg tg non hdl cholesterol homa ir negative correlation hdl cholesterol egfr when repeated analysis controlling ht age sex smoking alcohol use bmi waist circumference positive correlations hs crp levels hba1c 1-hpg 2-hpg tg non hdl cholesterol egfr homa ir negative correlation hdl cholesterol creatinine remained significant table 2 among people new dm the highest hs crp level group detected hba1c criterion hs crp median iqr hba1c 3.45 3.82 mg dl 32.9 36.4 nmol l 2-hpg 2.7 3.14 mg dl 25.4 29.9 nmol l fpg 2.4 3.0 mg dl 22.4 28.5 nmol l data shown high sensitive crp level significantly higher women men newly diagnosed dm groups based 2-hpg fpg hba1c criteria among newly diagnosed dm groups median iqr level hs crp highest detected hba1c genders hba1c group women 4.0 4.1 mg dl 38.4 39.1 nmol l men 2.7 3.1 mg dl 25.9 29.1 nmol l fpg group women 3.3 4.1 mg dl 31.1 39.3 nmol l men 2.4 3.0 mg dl 22.4 28.5 nmol l 2-hpg group women 2.8 3.3 mg dl 26.5 31.3 nmol l men 2.4 2.8 mg dl 23.3 26.9 sex differences hs crp change data adjusted respect age bmi waist circumference ht mean hs crp highest newly diagnosed patients based hba1c criterion sexes again average hs crp levels women higher men table 3 women newly diagnosed dm based fpg mean hs crp level comparable diagnosed 2-hpg lower group diagnosed hba1c p 0.000032 women newly detected dm based 2-hpg also lower mean hs crp detected hba1c p 0.000001 in contrast men newly detected dm based fpg criterion lower mean hs crp diagnosed 2-hpg p 0.017 hba1c p 0.003 mean hs crp levels comparable 2-hpg hba1c based new dm groups table 3 the specificity sensitivity optimal cut points hs crp detect dm women fpg group 60% 57% 2.5 mg l 23.6 nmol l 2-hpg group 60% 54% 2.1 mg l 19.7 nmol l 65% 64% hba1c group 2.9 mg l 27.5 nmol l men corresponding specificity sensitivity values follows fpg group 60% 57% 1.8 mg l 16.9 nmol l 2-hpg group 60% 57% 1.8 mg / l 16.9 nmol l hba1c group 65% 60% 2.0 mg l 19.0 nmol l roc curves figure 1 table 4 largest auc value hs crp detect dm found women men using hba1c women 0.700 men 0.656 positive negative predictive values ppv npv corresponding mentioned cut points hs crp women were calculated 58% 59% fpg 57% 58% 2-hpg 64% 65% hba1c men 58% 59% fpg 58% 59% 2-hpg 61% 61% hba1c our current population based study identified 1,727 people newly diagnosed dm based least one three methods however people identified dm substantially different three methods in words concordance rate dm among different methods glycaemia testing low characteristics people dm risk factors may vary method used detection dm several studies suggested inflammation associated ir takes part pathogenesis t2 dm atherosclerotic disease 14 6 environmental factors infections overnutrition lack physical activity believed contribute serum crp levels although mechanism properly understood hand hyperglycaemia per se may induce inflammation may enhance development dm 21 22 demonstrated people developed dm detected ogtt higher baseline serum crp levels develop dm there linear increasing trend incidence dm baseline crp quartile increased in pizarra prospective study people baseline hs crp 3 mg l 28.6 nmol l developed dm previous report demonstrated linear increasing trend hs crp levels normal glucose tolerance impaired fasting glucose ifg igt new dm recent meta analysis including 18 prospective studies demonstrated high baseline crp levels associated future t2 dm diagnosed based fpg and/or 2-hpg criteria all findings support chronic low grade inflammation hypothesis development dm study found positive correlation hs crp levels glycaemia ir parameters however adjustment age sex smoking bmi waist ht positive correlations maintained hba1c 1-hpg 2-hpg fasting insulin homa ir fpg later report festa et al stated postchallenge glucose fpg strongly correlated baseline crp other studies also shown association crp dm remained significant adjusting bmi covariates our findings others suggested adiposity sufficient explain relationship high levels inflammatory markers increased dm risk the predictive value hs crp seem fully independent obesity several 3 23 24 27 28 studies 7 9 10 22 our results showed among people new dm highest hs crp levels obtained identified hba1c criterion hba1c elevation diagnosis indication overt dm advanced stage compared new onset dm detected fpg 2-hpg criteria as show positive correlation hs crp hba1c reported people dm poorer glycaemic control higher crp levels some commonly used medications like aspirin statin may synergistically reduce serum crp concentrations 29 30 present study we excluded people known systemic disease self reported regularly using medications however may ascertain people using aspirin and/or statin aronson et al reported crp levels among middle aged people higher dm ifg compared healthy subjects similar findings showing women higher hs crp levels men regardless dm adopt investigators reported hs crp levels women higher men without metabolic syndrome ms they reported positive correlation hs crp hba1c bmi homa ir number ms components people new dm in women health study incidence dm four times higher women hs crp levels upper quartile comparison hs crp levels lowest quartile wu coworkers reported high levels hs crp correlated high levels hba1c fpg men fpg women other studies reported strong correlations hs crp fasting insulin homa ir fpg 21 34 inverse correlation crp hdl cholesterol 3 21 confirmed study we estimated optimal cut hs crp auc crp 95% cis dm three diagnostic methods separately best knowledge this first study aiming determining hs crp cut points indicating new dm compared three methods assessing hyperglycaemia the highest cut point hs crp obtained hba1c based new dm detection compared fpg 2-hpg methods in fact previously showed new dm group detected hba1c advanced metabolic disorder higher bmi waist blood pressure non hdl cholesterol triglycerides insulin lower hdl cholesterol new dm groups detected fpg 2-hpg den engelsen et al attempted find cut point hs crp would indicate presence ms hs crp cut point set 3 mg l 28.6 nmol l sensitivity specificity 72% 37% point ppv npv 42% 67% another study performed japanese population cut point hs crp 0.65 mg l 6.2 nmol l fpg 100 mg dl 5.6 mmol l higher capable defining ms 100% sensitivity 77% specificity women 65% sensitivity 63% specificity men study optimum cut point hs crp 2.5 mg / l 23.6 nmol l women 1.8 mg l 16.9 nmol l men fpg 126 mg dl 7.0 mmol l higher capable defining new dm 60% sensitivity 57% specificity genders optimum cut point hba1c 6.5% and over 2.9 mg l 27.5 nmol l women 65% sensitivity 64% specificity 2.0 mg l 19.0 nmol l men 60% sensitivity 62% specificity largest auc value hs crp detect new dm found women men using hba1c women 0.700 men 0.656 these high cut points crp may related advanced diabetic state compared fpg 2-hpg based detected cases one greatest strengths present study national representative sampling large sample size wide age range in addition first study three currently proposed methods 2-hpg fpg hba1c used define dm compared inflammation marker hs crp the major limitations cross sectional design somewhat higher participation rate women controlled data analyses brief an hs crp level 1.8 mg l 16.9 nmol l generally detects half people new dm external validation findings needs carried additional studies populations reasonably large sample size findings generalized our results revealed hs crp may strengthen diagnosis new onset dm however highest hs crp among people new dm found identified hba1c criterion this suggests high hba1c may recognize new dm cases advanced stage fpg 2-hpg ogtt would important find people newly detected dm high hs crp require intensive therapy low hs crp

fasting plasma glucose ( fpg ) and hemoglobin a1c ( hba1c ) have been used to diagnose new - onset diabetes mellitus ( dm ) in order to simplify the diagnostic tests compared with the 2-hour oral glucose tolerance test ( ogtt ; 2-hpg ) . we aimed to identify optimal cut - off points of high sensitive c - reactive protein ( hs - crp ) in new - onset dm people based on fpg , 2-hpg , or hba1c methods . data derived from recent population - based survey in turkey ( turdep - ii ) . the study included 26,499 adult people ( 63% women , response rate 85% ) . the mean serum concentration of hs - crp in women was higher than in men ( p < 0.001 ) . the people with new - onset dm based on hba1c had higher mean hs - crp level than fpg based and 2-hpg based dm cases . in hba1c , 2-hpg , and fpg based new - onset dm people , cut - off levels of hs - crp in women were 2.9 , 2.1 , and 2.5 mg / l [ 27.5 , 19.7 , and 23.5 nmol / l ] and corresponding values in men were 2.0 , 1.8 , and 1.8 mg / l ( 19.0 , 16.9 , and 16.9 nmol / l ) , respectively ( sensitivity 6065% and specificity 5464% ) . our results revealed that hs - crp may not further strengthen the diagnosis of new - onset dm . nevertheless , the highest hs - crp level observed in new - onset dm people diagnosed with hba1c criterion supports the general assumption that this method might recognize people in more advanced diabetic stage compared with other diagnostic methods .

caused mutations nuclear genes either relating mitochondrial components mitochondrial dna mtdna the prevalence mitochondrial diseases due mutations mtdna related nuclear genes estimated 1 5000 mutations mtdna much higher related nuclear genes probably mitochondrial genome exposed reactive oxygen species(ros lacked protection structure 1990 adenine guanine transition mtdna position 3243 encoding trna found molecular basis mitochondrial encephalomyopathy lactic acidosis stroke like episodes melas epidemiological studies showed m.3243a g mutation frequent pathogenic mutation mtdna the prevalence m.3243a g mutation mtdna 3.5/100,000 adults north east england approximately 1/6000 adult population finland seizures encephalopathy stroke like episodes found 80% patients melas short stature deafness cognitive impairment exercise intolerance migraines depression cardiomyopathy cardiac conduction defects diabetes mellitus also found melas cases summarized clinical spectrum m.3243a g mutation chinese pediatric patients define common clinical manifestations study correlation heteroplasmic degree mutation clinical severity disease clinical data 100 chinese pediatric patients first diagnosed mitochondrial diseases gene test m.3243a g mutation peking university first hospital 2007 2013 retrospectively reviewed this study approved medical ethics committee peking university first hospital a total ten clinical characteristics including vision impairment hearing loss encephalopathy myopathy gastrointestinal disturbances collected patients short stature defined body height less two standard deviations mean height normal children the peripheral blood samples collected patients first screened gene mutation detection m.3243a g mutation ratio performed polymerase chain reaction pcr)-restriction fragment length polymorphism method the pcr product digested restriction enzyme apa separated 2% agarose gel the patients divided three groups based mutation ratio low level 030% middle level 3160% high level 61100% age mutation ratio inconsistent gaussian distribution presented median q1 q3 correlation m.3243a g mutation ratio age evaluated spearman rank correlation method the differences clinical symptom frequency patients low middle high levels mutation ratio analyzed chi square test clinical data 100 chinese pediatric patients first diagnosed mitochondrial diseases gene test m.3243a g mutation peking university first hospital 2007 2013 retrospectively reviewed this study approved medical ethics committee peking university first hospital a total ten clinical characteristics including vision impairment hearing loss encephalopathy myopathy gastrointestinal disturbances collected patients short stature defined body height less two standard deviations mean height normal children the peripheral blood samples collected patients first screened gene mutation detection m.3243a g mutation ratio performed polymerase chain reaction pcr)-restriction fragment length polymorphism method the pcr product digested restriction enzyme apa separated 2% agarose gel the patients divided three groups based mutation ratio low level 030% middle level 3160% high level 61100% age mutation ratio inconsistent gaussian distribution presented median q1 q3 correlation m.3243a g mutation ratio age evaluated spearman rank correlation method the differences clinical symptom frequency patients low middle high levels mutation ratio analyzed chi square test the age diagnosis mitochondrial disease ranged 2 months 18 years median age 9 years 5.8 years 12.0 years the m.3243a g mutation ratio varied 5% 93% median level 44% 36% 54% there significant difference m.3243a g mutation ratio males females 0.691 p 0.491 patients onset one symptoms including seizures 54% muscle weakness 29% headache complicated vomiting 25% decreased vision 18% hearing loss 10% impaired verbal communication 6% heart preexcitation syndrome 5% the prevalent symptom patients seizures 76% followed short stature 73% elevated plasma lactate 70% abnormal magnetic resonance imaging computed tomography mri ct changes 68% vomiting 55% decreased vision 52% headache 50% muscle weakness 48% most patients multisymptomatic two patients one symptom five patients manifested two symptoms seizures present 76 patients 76% 13 patients stroke shortly seizures recurrent headaches found 50 patients 50% complicated vomiting and/or vision loss sixty eight patients 68% found mri ct abnormalities including abnormal asymmetric signals occipital area 51/68 75% temporal area 21/68 31% parietal area 20/68 29% bilateral basal ganglia calcification 16/68 24% cerebral atrophy 10/68 15% thalamus brainstem lesions 5/68 7% slurred speech present 16 patients 3 progressively worsening speech 2 delayed speech development 1.5 3.0 years age seventy three patients 73% short stature 69 patients 69% weight loss fifty five patients 55% experienced recurrent vomiting 38 patients 38% diarrhea constipation plasma lactate ranged 1.4 19.0 mmol l normal range 0.72.0 mmol l elevated plasma lactate detected 70 patients 70% 90% plasma lactate 5 mmol l vision impairment found 52 patients 52% 33 experienced blurred vision 16 decreased visual acuity reduced muscle strength reported 48 patients 48% 31 minimal muscle weakness upper limbs shoulders 17 manifested muscle weakness lower limbs 2 walk difficulties thirty seven patients 37% complained difficulties maintaining stability 18 experienced frequent tumbling 38 patients 38% compromised exercise tolerance appeared running going upstairs cases walk flat places two cases heart diseases detected 35 patients 35% 17 found abnormal electrocardiogram st changes arrhythmias left ventricular hypertrophy found eight patients right ventricular hypertrophy five patients preexcitation syndrome five patients twenty one patients 21% hearing impairment presenting tinnitus hearing loss mild deafness 14 patients moderate deafness 5 patients severe deafness 2 patients the m.3243a g mutation ratio peripheral leukocytes determined patients 32% mutation ratio 50% the relationship m.3243a g mutation ratio onset age analyzed spearman rank correlation method showed m.3243a g mutation ratio correlated negatively onset age r 0.470 p 0.001 figure 1 correlation m.3243a g mutation ratio peripheral leukocytes onset age r=0.470 n=100 the differences clinical symptom frequency among patients low middle high levels mutation ratio analyzed chi square test table 1 there significant differences frequencies hearing loss decreased vision myopathy gastrointestinal disturbance among three groups however patients low middle level m.3243a g mutation ratio likely suffer hearing loss decreased vision gastrointestinal disturbance high level group analysis clinical symptom frequency different distributions 3243a g mutation ratio n low level mutation ratio range 030% middle level mutation ratio range 3160% high level mutation ratio range 61100% mri magnetic resonance imaging ct computed tomography patients onset one symptoms including seizures 54% muscle weakness 29% headache complicated vomiting 25% decreased vision 18% hearing loss 10% impaired verbal communication 6% heart preexcitation syndrome 5% the prevalent symptom patients seizures 76% followed short stature 73% elevated plasma lactate 70% abnormal magnetic resonance imaging computed tomography mri ct changes 68% vomiting 55% decreased vision 52% headache 50% muscle weakness 48% most patients multisymptomatic two patients one symptom five patients manifested two symptoms seizures present 76 patients 76% 13 patients stroke shortly seizures recurrent headaches found 50 patients 50% complicated vomiting and/or vision loss sixty eight patients 68% found mri ct abnormalities including abnormal asymmetric signals occipital area 51/68 75% temporal area 21/68 31% parietal area 20/68 29% bilateral basal ganglia calcification 16/68 24% cerebral atrophy 10/68 15% thalamus brainstem lesions 5/68 7% slurred speech present 16 patients 3 progressively worsening speech 2 delayed speech development 1.5 3.0 years age seventy three patients 73% short stature 69 patients 69% weight loss fifty five patients 55% experienced recurrent vomiting 38 patients 38% diarrhea constipation plasma lactate ranged 1.4 19.0 mmol l normal range 0.72.0 mmol l elevated plasma lactate detected 70 patients 70% 90% plasma lactate 5 mmol l vision impairment found 52 patients 52% 33 experienced blurred vision 16 decreased visual acuity reduced muscle strength reported 48 patients 48% 31 minimal muscle weakness upper limbs shoulders 17 manifested muscle weakness lower limbs 2 walk difficulties thirty seven patients 37% complained difficulties maintaining stability 18 experienced frequent tumbling 38 patients 38% compromised exercise tolerance appeared running going upstairs cases walk flat places two cases heart diseases detected 35 patients 35% 17 found abnormal electrocardiogram st changes arrhythmias left ventricular hypertrophy found eight patients right ventricular hypertrophy five patients preexcitation syndrome five patients twenty one patients 21% hearing impairment presenting tinnitus hearing loss mild deafness 14 patients moderate deafness 5 patients severe deafness 2 patients the m.3243a g mutation ratio peripheral leukocytes determined patients 32% mutation ratio 50% the relationship m.3243a g mutation ratio onset age analyzed spearman rank correlation method showed m.3243a g mutation ratio correlated negatively onset age r 0.470 p 0.001 figure 1 correlation m.3243a g mutation ratio peripheral leukocytes onset age r=0.470 n=100 the differences clinical symptom frequency among patients low middle high levels mutation ratio analyzed chi square test table 1 there significant differences frequencies hearing loss decreased vision myopathy gastrointestinal disturbance among three groups however patients low middle level m.3243a g mutation ratio likely suffer hearing loss decreased vision gastrointestinal disturbance high level group analysis clinical symptom frequency different distributions 3243a g mutation ratio n low level mutation ratio range 030% middle level mutation ratio range 3160% high level mutation ratio range 61100% mri magnetic resonance imaging ct computed tomography the m.3243a g mutation shown lead reduced levels trna decrease aminoacylation absence normal modification 5-taurinomethyl group wobble base mitochondrial disease caused mutation may result reduction mtdna encoded proteins oxidative phosphorylation activity mitochondrial translation several clinical syndromes including melas myoclonic epilepsy ragged red fibers chronic progressive external ophthalmoplegia leigh syndrome may associate m.3243a g mutation patients m.3243a g mutation without clinical symptoms uncommon define spectrum clinical manifestations due m.3243a g mutation retrospectively reviewed clinical data 100 chinese pediatric patients m.3243a g mutation regardless clinical presentations central nervous system cns frequently involved mitochondrial diseases higher energy demand seizures may result neuronal energy depletion oxidative stress impaired calcium signaling immune disturbances deficiencies vitamins cofactors amino acids study the prevalence seizures high 76% nearly 100% previous study similar prevalence 70.5% report pediatric mitochondrial disease taiwan china cns symptoms therefore common severe children adults prevalence seizures ranged 9% 20% adults melas patients recurrent stroke like episodes frequent m.3243a g mutation without mutation we found stroke like episodes 22% patients higher prevalence patients mitochondrial mutations m.3243a g mutation most patients showed abnormal brain image findings probably due vascular injuries bilateral basal ganglia vulnerable site disease followed temporal parietal occipital area similar previous report chae et al also observed tendency basal ganglia frequently involved patients without m.3243a g mutation vomiting frequent constipation diarrhea 68% vomiting cases complicated headaches higher prevalence 42% symptoms therefore mitochondrial diseases considered clinically children unexplained vomiting headaches the prevalence cardiac involvement highly variable patients mtdna mutations ranging 17% 40% in study 35% patients exhibited cardiac involvement main manifestations abnormal electrocardiogram 17% left ventricular hypertrophy 8% the prevalence left ventricular hypertrophy less patients patients m.3243a g mutation 56% reported majamaa voltti et al pediatric patients may reason lower prevalence cardiac involvement present study patients suspected mitochondrial disease routine electrocardiogram ultrasonocardiography the m.3243a g mutation ratio peripheral leukocytes negatively correlated patients onset age myopathy frequently seen patients high level m.3243a g mutation ratio however patients low middle level m.3243a g mutation ratio likely suffer hearing loss decreased vision gastrointestinal disturbance conclusion study summarized common symptoms onset symptoms large cohort chinese pediatric patients m.3243a g mutation view fact diagnosis 66% patients delayed average 2 years suggested examination m.3243a g mutation mtdna considered children one symptoms including seizures short stature muscle weakness headache complicated vomiting decreased vision hearing loss although mutation ratio blood sample available test diagnosis mitochondrial disease m.3243a g mutation ratio usually higher muscle urine sample therefore mutation ratio tissues muscle urine cell included future study this study supported grants national natural science foundation china this study supported grants national natural science foundation china 81271256

background : mitochondrial diseases are a group of energy metabolic disorders with multisystem involvements . variable clinical features present a major challenge in pediatric diagnoses . we summarized the clinical spectrum of m.3243a > g mutation in chinese pediatric patients , to define the common clinical manifestations and study the correlation between heteroplasmic degree of the mutation and clinical severity of the disease.methods:clinical data of one - hundred pediatric patients with symptomatic mitochondrial disease harboring m.3243a > g mutation from 2007 to 2013 were retrospectively reviewed . detection of m.3243a > g mutation ratio was performed by polymerase chain reaction ( pcr)-restriction fragment length polymorphism . correlation between m.3243a > g mutation ratio and age was evaluated . the differences in clinical symptom frequency of patients with low , middle , and high levels of mutation ratio were analyzed by chi - square test.results:sixty-six patients ( 66% ) had suffered a delayed diagnosis for an average of 2 years . the most frequent symptoms were seizures ( 76% ) , short stature ( 73% ) , elevated plasma lactate ( 70% ) , abnormal magnetic resonance imaging / computed tomography ( mri / ct ) changes ( 68% ) , vomiting ( 55% ) , decreased vision ( 52% ) , headache ( 50% ) , and muscle weakness ( 48% ) . the mutation ratio was correlated negatively with onset age ( r = 0.470 , p < 0.001 ) . myopathy was more frequent in patients with a high level of mutation ratio . however , patients with a low or middle level of m.3243a > g mutation ratio were more likely to suffer hearing loss , decreased vision , and gastrointestinal disturbance than patients with a high level of mutation ratio.conclusions:our study showed that half of chinese pediatric patients with m.3243a > g mutation presented seizures , short stature , abnormal mri / ct changes , elevated plasma lactate , vomiting , and headache . pediatric patients with these recurrent symptoms should be considered for screening m.3243a > g mutation . clinical manifestations and laboratory abnormalities should be carefully monitored in patients with this point mutation .

prolonged exposure microgravity significant effects physiological conditions many studies investigated effects microgravity neuromuscular system most studies focused skeletal muscle changes microgravity however best knowledge limited research regarding effects microgravity peripheral nervous system one study examined conduction velocity cv branching axon terminals following space mission bed rest identified decreased cv however measure velocity main trunk nerve fibers for example one study investigated manifestation somatosensory evoked potentials hypokinesia included peripheral central sensory nervous systems however conditions hypokinesia bed rest different compared microgravity therefore effect microgravity peripheral nervous system evaluated ground based models suitable alternative space flights induce similar modifications neuromuscular system the hindlimb unloading hu model characterized absence weightbearing reduced motor activity typically applied rats moreover 6 head tilt hdt another experimental model used simulate space flight environment humans determine changes nerve conduction simulated microgravity current study aimed investigate nerve conduction characteristics rhesus monkeys prolonged exposure hdt all experimental procedures conducted rhesus monkeys approved ethical committee china astronaut research training center accordance principles association assessment accreditation laboratory animal care international aaalac approved institutional animal care use committee iacuc the hdt model rhesus monkeys selected model peripheral nervous system primates similar humans compared species six rhesus monkeys age 34 years three males three females laid beds tilted backward 6 horizontal the head animals wore special cloth enabled fixed bed however arms legs free move provided access food water the hdt model functions reduce mechanical loading hindlimbs provides similar condition microgravity the rhesus monkeys provided regular dietary program included primate biscuits fresh fruits vitamin syrup the animals housed one per cage bed rooms air temperature maintained 23 2c standard 12:12 h dark light cycle lights turned 8:00 a.m. 8:00 p.m. general health condition animals carefully monitored the monkeys provided toys example drum shaped rattle chinese traditional toy housing throughout duration study toys available time except experimental procedures nerve conduction studies ncss performed using surface electrodes median ulnar tibial fibular nerves right side assess motor function upper lower limbs using key point electromyography system 31a06 medoc ltd the motor conduction velocities proximal distal amplitudes compound muscle action potentials cmaps proximal distal latencies median ulnar tibial fibular nerves recorded representative images ncs tibial nerve shown figure 1 the ncs performed order median ulnar tibial fibular nerves hdt 7 21 42 days hdt procedure toys provided researchers accompanied monkeys reduce pain suffering all animal housing experiments occurred animal facility china astronaut research training center ncs nerve conduction studies hdt head tilt statistical analysis performed using spss software version 19.0 ibm chicago il usa analysis variance anova using randomized block design conducted compare differences ncs hdt 7 21 42 days hdt post hoc analyses including least significant difference student newman keuls performed significant differences identified anova one rhesus monkey died day 21 hdt inadaptation simulated microgravity one monkey injured upper limbs result rigorous movement thus anova randomized block design anova median ulnar nerve parameters performed using data collected remaining four rhesus monkeys data tibial fibular nerves obtained five remaining rhesus monkeys all experimental procedures conducted rhesus monkeys approved ethical committee china astronaut research training center accordance principles association assessment accreditation laboratory animal care international aaalac approved institutional animal care use committee iacuc the hdt model rhesus monkeys selected model peripheral nervous system primates similar humans compared species six rhesus monkeys age 34 years three males three females laid beds tilted backward 6 horizontal the head animals wore special cloth enabled fixed bed however arms legs free move provided access food water the hdt model functions reduce mechanical loading hindlimbs provides similar condition microgravity the rhesus monkeys provided regular dietary program included primate biscuits fresh fruits vitamin syrup the animals housed one per cage bed rooms air temperature maintained 23 2c standard 12:12 h dark light cycle lights turned 8:00 a.m. 8:00 p.m. the monkeys provided toys example drum shaped rattle chinese traditional toy housing throughout duration study toys available time except experimental procedures nerve conduction studies ncss performed using surface electrodes median ulnar tibial fibular nerves right side assess motor function upper lower limbs using key point electromyography system 31a06 medoc ltd the motor conduction velocities proximal distal amplitudes compound muscle action potentials cmaps proximal distal latencies median ulnar tibial fibular nerves recorded representative images ncs tibial nerve shown figure 1 the ncs performed order median ulnar tibial fibular nerves hdt 7 21 42 days hdt procedure toys provided researchers accompanied monkeys reduce pain suffering all animal housing experiments occurred animal facility china astronaut research training center ncs tibial nerve hdt 42 days hdt rhesus monkeys hdt statistical analysis performed using spss software version 19.0 ibm chicago il usa analysis variance anova using randomized block design conducted compare differences ncs hdt 7 21 42 days hdt post hoc analyses including least significant difference student newman keuls performed significant differences identified anova one rhesus monkey died day 21 hdt inadaptation simulated microgravity one monkey injured upper limbs result rigorous movement thus anova randomized block design anova median ulnar nerve parameters performed using data collected remaining four rhesus monkeys data tibial fibular nerves obtained five remaining rhesus monkeys the parameters ncs hdt normal conditions 7 21 42 days hdt presented table 1 the proximal amplitude cmap median nerve significantly decreased 21 42 days hdt compared amplitude hdt 4.38 2.83 vs. 8.40 2.66 mv f 4.85 p 0.013 3.30 2.70 vs. 8.40 2.66 mv f 5.93 p 0.004 respectively the proximal amplitude cmap median nerve 42 days hdt significantly decreased compared 7 days hdt 3.30 2.70 vs. 7.70 1.50 mv f 4.40 p 0.022 ncs 7 21 42 days hdt rhesus monkeys n 6 data represent means sds median nerve statistically different versus proximal cmap hdt median nerve statistically different versus distal cmap hdt tibial nerve statistically different versus proximal cmap hdt median nerve statistically different versus proximal cmap 7 days hdt median nerves statistically different versus distal cmap 7 days hdt tibial nerve statistically different versus proximal cmap 7 days hdt ncs nerve conduction study hdt head tilt mcv motor conduction velocity cmap compound muscle action potential sds standard deviations the distal amplitude cmap median nerve significantly decreased 7 21 42 days hdt compared amplitude hdt 7.28 1.27 vs. 10.25 3.40 mv f 4.03 p 0.039 5.05 2.01 vs. 10.25 3.40 mv f 6.25 p 0.04 3.95 2.79 vs. 10.25 3.40 mv f 7.35 p 0.01 respectively the distal amplitude cmap median nerve 42 days hdt significantly decreased compared 7 days hdt 3.95 2.79 vs. 7.28 1.27 mv f 3.33 p 0.08 the proximal amplitude cmap tibial nerve significantly decreased 42 days hdt compared amplitude hdt 6.14 1.94 vs. 11.87 3.19 mv f 5.02 p 0.039 the proximal amplitude cmap tibial nerve 42 days hdt significantly decreased compared 7 days hdt 6.14 1.94 vs. 12.98 4.99 mv f 6.84 p 0.008 the proximal distal latencies nerves nerve cvs prolonged decreased slightly compared parameters hdt significantly different previous studies regarding effects microgravity neuromuscular system mainly focused muscle atrophy induced muscle disuse few studies investigated electrophysiological characteristics peripheral nervous system prolonged microgravity the current investigation focused electrophysiological characteristics peripheral nervous system identified significant decrease proximal distal amplitudes cmap median tibial nerves early day 7 hdt previous research identified longer duration slower falling rate action potentials muscle fibers thereby reflecting change motor fiber impulses nerve may contribute decreased amplitude furthermore atypical combinations myosin heavy chain mrna isoforms demonstrated transiently increased soleus fibers rats experienced 7 days hu suggests disruption transcriptional translational activity these changes present early stage may explain cmap amplitude decrease ncs identified current study furthermore recording surface electrodes attached muscle belly decrease muscle power muscle atrophy may contribute cmap amplitude decrease median tibial nerves however significant differences proximal distal amplitudes cmap ulnar fibular nerves 42 days hdt the reason finding may 42 days hdt sufficient produce dramatic differences studies rats microgravity typically lasted 14 days less significant changes multiple parameters nerve cv axon diameter identified humans primates closely resemble humans however 42 days hdt likely sufficient induce similar changes moreover one study demonstrated equilibrium state rats shifted different level 14 days hu the transitional period two equilibrium states may marked transitory disorganization we infer electrophysiological characteristics peripheral nerves transitory disorganization day 42 hdt thus amplitudes cmap ulnar peroneal nerves exhibit significant decreases significant decrease cv muscle fibers reduction cv branching axon terminals previously identified study the latencies nerves nerve cvs significantly different hdt the mechanisms modulate cv nerve fibers clear changes membrane properties nodes ranvier may represent one factor plays role modulation changes membrane properties may induced modifications synthesis voltage gated membrane channels excitable muscle membranes wittwer et al demonstrated gene expression alterations following prolonged unloading rat soleus muscles there increase mrnas coded ion channels may elucidate increased shortening velocity soleus muscle following spaceflight study the likely explanations lack change latencies nerves nerve cvs following hdt 42 days exposure hdt sufficient generate significant changes electrophysiological characteristics peripheral nerve fibers transitory disorganization furthermore best knowledge nerve cv depends axonal diameter myelin sheath thickness internodal distance previous research indicates although myelin thinner following hu mean axonal diameter small fibers slightly decreased hu rats contrast significantly different large fibers charge motor function distances nodes ranvier global structure nerve fibers significantly different moreover current findings consistent previous research regarding fatigue cv along nerve fibers substantially reduced study rhesus monkeys subjected hdt resemble space flight environment model substantial value investigation microgravity effects astronauts experiments involve astronauts including ground based experiments expensive impact microgravity motor function astronauts often minimized countermeasures furthermore pretest conditions astronauts challenging control thus potential heterogeneity may impact reliability findings moreover although studies evaluated changes muscle fibers axon terminals microgravity studies investigated variables nerve trunks the current findings provide novel evidence related electrophysiological characteristics nerve trunks microgravity despite importance experimental model findings identified study thus future studies larger sample size longer duration hdt necessary confirm findings conclusively study demonstrates cmap amplitudes nerves decreased hdt rhesus monkeys moreover results present study suggest rhesus monkeys exposed hdt might used experimental model study ncs microgravity

background : few studies have focused on peripheral nerve conduction during exposure to microgravity . the 6 head - down tilt ( hdt ) comprises an experimental model used to simulate the space flight environment . this study investigated nerve conduction characteristics of rhesus monkeys before and after prolonged exposure to hdt.methods:six rhesus monkeys ( 34 years old ) were tilted backward 6 from the horizontal . nerve conduction studies ( ncss ) were performed on the median , ulnar , tibial , and fibular motor nerves . analysis of variance with a randomized block design was conducted to compare the differences in the ncs before and 7 , 21 , and 42 days after the 6 hdt.results:the proximal amplitude of the cmap of the median nerve was significantly decreased at 21 and 42 days of hdt compared with the amplitude before hdt ( 4.38 2.83 vs. 8.40 2.66 mv , f = 4.85 , p = 0.013 and 3.30 2.70 vs. 8.40 2.66 mv , f = 5.93 , p = 0.004 , respectively ) . the distal amplitude of the cmap of the median nerve was significantly decreased at 7 , 21 , and 42 days of hdt compared with the amplitude before hdt ( 7.28 1.27 vs. 10.25 3.40 mv , f = 4.03 , p = 0.039 ; 5.05 2.01 vs. 10.25 3.40 mv , f = 6.25 , p = 0.04 ; and 3.95 2.79 vs. 10.25 3.40 mv , f = 7.35 , p = 0.01 ; respectively ) . the proximal amplitude of the cmap of the tibial nerve was significantly decreased at 42 days of hdt compared with the amplitude before hdt ( 6.14 1.94 vs. 11.87 3.19 mv , f = 5.02 , p = 0.039).conclusions : this study demonstrates that the compound muscle action potential amplitudes of nerves are decreased under simulated microgravity in rhesus monkeys . moreover , rhesus monkeys exposed to hdt might be served as an experimental model for the study of ncs under microgravity .

55 year old man visited emergency department increasing frequency chest pain he undergone pump coronary artery bypass grafting cabg 10 years ago unstable angina associated three vessel coronary artery disease initial operation situ right internal thoracic artery ita in situ left ita situ right gastroepiploic artery rgea grafts used revascularize left anterior descending coronary artery two obtuse marginal coronary branches posterior descending coronary artery respectively an excess segment distal right ita connected side left ita composite graft anastomosed first diagonal coronary artery coronary angiography myocardial single photon emission computed tomography spect performed 5 years surgery follow study the 5-year angiography showed patent grafts myocardial spect demonstrated perfusion decrease exertional chest pain recurred 7 years surgery repeated coronary angiography showed patent previous grafts including faint visualization situ rgea graft associated significant stenosis os celiac axis the computed tomographic angiogram also demonstrated 90% stenosis celiac os without stenosis abdominal angiography taken surgery fig redo pump cabg performed 10 years initial surgery increasing frequency angina aggravated finding follow myocardial spect newly developed reversible perfusion decrease inferior wall fig great saphenous vein harvested lower leg interposed middle part situ right ita distal part situ rgea grafts used previously supply blood flow right ita graft posterior descending coronary artery one year redo surgery patient symptoms angina coronary angiogram performed revealed patent grafts including interposed saphenous vein graft fig 3a myocardial spect test also performed demonstrated perfusion decrease including inferior wall fig reoperations coronary artery disease increased due increased number isolated cabg the society thoracic surgeons statistics indicated nearly 5% current cabg procedures done us repeat surgical revascularization angiographic indications reoperation progression native coronary atherosclerosis previous graft failure combination one previous study demonstrated 4 400 patients underwent cabg using rgea graft needed percutaneous interventions due rgea graft failure postoperative follow 2211 months one 4 patients required angioplasty newly developed stenosis celiac trunk present case indication reoperation the patient free angina angiographic myocardial spect follow studies revealed abnormal findings postoperative 5 years when patient suffered recurred angina postoperative 7 years coronary angiography showed faint visualization situ rgea graft associated significant stenosis os celiac axis the 10-year follow myocardial spect test demonstrated newly developed reversible perfusion decrease inferior wall the prevalence celiac axis stenosis 7.3% korean population although lower previously reported incidence celiac axis stenosis western populations ranged 12.5% 24% present case celiac artery stenting could alternative option case however performed redo operation celiac axis stenting associated high incidence late restenosis the aorta another situ arterial graft could chosen blood source alternatively patent situ grafts used previously may used inflow conduit regards patient 3 situ arterial grafts already used the saphenous vein graft interposed middle part right ita distal part situ rgea grafts used previously

we report a redo coronary artery bypass grafting ( cabg ) in a 55-year - old man . angina recurred 7 years after the initial surgery . coronary angiography showed all patent grafts except a faint visualization of the in situ right gastroepiploic artery ( rgea ) graft , which was anastomosed to the posterior descending coronary artery , associated with celiac axis stenosis . redo - cabg was performed at postoperative 10 years because of aggravated angina and decreased perfusion of the inferior wall in the myocardial single photon emission computed tomography . the saphenous vein graft was interposed between the 2 in situ grafts used previously ; the right internal thoracic artery and rgea grafts . angina was relieved and myocardial perfusion was improved .

report case inadvertent anterior chamber cornea stromal injection high dose antibiotics steroids cataract operation during cataract operation 78 year old female patient high dose gentamicin 20 mg/0.5 ml dexamethasone 2 mg/0.5 ml inadvertently injected anterior chamber cornea stroma making cornea edema sealing incision sites on postoperative day one extensive cornea edema noted best corrected visual acuity 0.2 postoperatively corneal edema fully resolved best corrected visual acuity 0.8 however descemet membrane folds still remained decrease number endothelial cells noted specular microscope in case involving anterior chamber cornea stromal injection high dose antibiotics steroids immediate anterior chamber irrigation balanced salt solution seemed appropriate management patient long term visual acuity appears good prevent mistakes precise labeling solutions use different syringe needles considered a 78 year old woman underwent extracapsular cataract extraction phacoemulsification via temporal clear corneal single superior side port incision an intraocular lens inserted bag viscoelastic materials removed irrigation aspiration without complications end operation nurse inadvertently handed wrong syringe high dose antibiotics steroids inadvertently injected anterior chamber corneal stroma 19 g needle stromal hydration procedure wound closure incision sites antibiotics steroids given gentamicin 20 mg/0.5 ml dexamethasone 2 mg/0.5 ml originally prepared subconjunctival injection about 10 seconds injection recognized mistake anterior chamber irrigated 100ml balanced salt solution cytosol ophthalmicstm one minute postoperative day one patient complained blurred vision foreign body sensations severe corneal edema descemet membrane folds invading visual axis seen extending 12 4 o'clock position fig best corrected visual acuity 0.2 intraocular pressure 18 mmhg noncontact tonometer postoperatively cravit levofloxacin 0.5% santen osaka japan 1% prednisolone 5% nacl administered every two hours oral prednisolone 20 mg ofloxacin 300 mg used well pressure patch ofloxacin dexamethasone ointment the corneal edema persisted postoperative day three best corrected visual acuity decreased 0.15 the vision improved 0.4 two weeks corneal edema persisted without improvement the patient continued original medications dosages third postoperative week best corrected visual acuity stabilized 0.4 corneal edema began resolve the visual acuity continued improve 0.7 corneal edema finally resolved four weeks postoperatively however linear descemet membrane folds persisted postoperative week 16 fig 2 3 at site descemet membrane fold corresponding endothelial damage also observed manifesting definite dark acelluar area specular microscopy fig 4 preoperative endothelial cell density specular microscopy 2717 cells mm mean cell size 368 postoperative month three the mean cell size 424 endothelial cell density decreased 2358 cells mm no changes observed best corrected visual acuity improved 0.8 postoperative month four almost every ocular drug potentially toxic corneal endothelium risk endothelial toxicity increased used anterior chamber direct contact endothelium corneal endothelium vulnerable even osmotic change ph change irrigating fluid easily damaged electrolyte imbalance moreover permanent endothelial dysfunction cystoid macular edema pupil dilation glaucoma due destruction trabecular meshwork occur reported severe cases.8 10 therefore important control concentration solution antibiotics added irrigating solution order prevent postoperative endophthalmitis.1,2,4 however exact nontoxic concentrations antibiotics steroids fully investigated montan et al.11 studied doses exposure durations cefuroxime injected anterior chamber reporting 1 mg/0.1 ml cefuroxime safe maintains high concentration one hour postoperatively kang et al.12 studied gentamicin toxicity different concentrations three types human corneal cells culture suggested safe local concentration gentamicin endothelial stromal cell 1 mg ml human eye increasing concentration gentamicin 2 mg ml 4 mg ml the toxicity gentamicin corneal cells direct proportion concentration duration incubation petroutsos et al.13 reported endothelial toxicity occurred 1 mg ml gentamicin injected anterior chamber rabbit eyes medin14 used weight recording system demonstrate possible toxic effect gentamicin endothelium rabbit corneas stored organ culture lin et al.15 reported 15% cell damage found tissue cultured bovine endothelial cells exposed 1.6 mg ml gentamicin when concentration gentamicin doubled cell damage reached 40% recovery cellular morphology much slower mester stein16 studied effect gentamicin concentration rabbit endothelial cells reported 0.50% gentamicin toxic endothelium 0.25% gentamicin significantly different compared control besides irreversible damage corneal endothelium corneal edema high concentrations gentamicin solutions induce retinal hemorrhage edema obliteration retinal vasculature injected vitreous resulting optic atrophy retinal pigment degeneration neovascular glaucoma.17,18 case toxicity gentamicin corneal endothelium expected significant due fact concentration gentamicin injected anterior chamber corneal stroma 40 times previously mentioned studies wang et al.19 tested cytotoxicity five antibiotics amphotericin b colistin sulbenicillin amikacin cephradine steroid betamethasone cultured porcine corneal endothelial cells demonstrated steroid less toxic endothelium antibiotics case the inadvertent injection antibiotics steroids resulted severe corneal edema 12 4 o'clock position involving visual axis along extensive descemet membrane folds we used hypertonic solution 1720 osm l 5% nacl topically reduce stromal edema this concentration known nontoxic,20,21 solution effective case on postoperative week 12 descemet membrane folds observed specular microscopy persisted 16 weeks operation case corneal edema descemet membrane fold probably due inadvertent corneal stromal injection high dose gentamicin dexamethasone rather injection directly anterior chamber the duration exposure concentration drugs negligible due prompt irrigation anterior chamber balanced salt solution we found localized endothelial defect specular microscopy manifesting definite dark acelluar area corresponded area descemet membrane fold site inadvertent stromal injection also irrigation balanced salt solution might play role causing corneal edema postoperative week four corneal edema resolved best corrected visual acuity improved 0.7 our case showed relatively good visual prognosis despite high concentration injected antibiotics steroids this favorable outcome might due immediate irrigation anterior chamber balanced salt solution as long term endothelial exposure high dose antibiotics steroid avoided the immediate irrigation possible balanced salt solution prepared operation hansany basu22 demonstrated 0.1 mg ml concentration gentamicin toxic corneal endothelium seven days postop seven days corneal endothelial toxicity demonstrated concentration this study suggested duration drug exposure rather drug concentration also important factor corneal endothelial damage therefore considering case study conclude immediate irrigation anterior chamber important preventing corneal endothelial damage high dose antibiotics steroids injected anterior chamber mistake cataract intraocular surgery dilute intrastromal antibiotics steroids considered stromal injection balanced salt solution performed separation descemet membrane stroma occur mcdonald et al.23 insisted clear communication surgeon nursing staff addition precise labeling every injectable solution necessary prevent accidents in addition wise draw injectable antibiotics injection use different gauge needles different solutions could easily recognized physician microscope case reported favorable visual outcome immediate irrigation anterior chamber balanced salt solution inadvertent injection high dose antibiotics steroids however prevent accident surgery strict precautions mentioned previously clear communication surgeons nursing staff including scrub nurses considered great importance

purposeto report a case of inadvertent anterior chamber and cornea stromal injection with high dose antibiotics and steroids during cataract operation.methodsduring cataract operation on a 78 year - old female patient , high dose gentamicin ( 20 mg/0.5 ml ) and dexamethasone ( 2 mg/0.5 ml ) were inadvertently injected into the anterior chamber and cornea stroma when making cornea edema for sealing of the incision sites . anterior chamber irrigation with balanced salt solution ( bss ) was immediately administered . on postoperative day one , extensive cornea edema was noted , and best - corrected visual acuity was 0.2 . descemet 's membrane folds were observed around the corneal incision sites . topical 5% nacl and 1% prednisolone were started.resultsfour weeks postoperatively , corneal edema began to reduce significantly . at four months postoperatively , corneal edema fully resolved , and best - corrected visual acuity was 0.8 . however , some descemet 's membrane folds still remained , and a decrease in the number of endothelial cells was noted by specular microscope.conclusionsin this case involving anterior chamber and cornea stromal injection with high dose antibiotics and steroids , immediate anterior chamber irrigation with balanced salt solution seemed an appropriate management , and the patient 's long - term visual acuity appears good . to prevent such mistakes , precise labeling of all solutions and use of different syringe needles should be considered .

autosomal dominant polycystic kidney disease adpkd characterized cyst formation occurs primarily kidneys due replacement normal renal parenchyma adpkd results end stage renal failure 45% patients approximately 711% patients receiving renal replacement therapy western world due adpkd the underlying cause adpkd mutation polycystin-1 -2 plasma proteins located primary cilia this mutation leads abnormal function renal tubular epithelia inadequate calcium influx followed cyst formation cardiovascular disease frequent cause 36% mortality patients adpkd patients adpkd often develop hypertension earlier age general population impairment kidney function it hypothesized renin aldosterone system endothelial dysfunction caused impaired nitric oxide release important factors development hypertension adpkd patients we describe uncommon case middle aged man spontaneous coronary artery dissection cad adpkd a 41-year old caucasian man presented emergency department acute chest pain chest pain began 2 h presentation medical history recorded subdural haematoma result trauma according family history our patient non smoker history hypertension diabetes mellitus hypercholesterolaemia physical examination blood pressure 155/102 mmhg pulse 72 beats minute vital parameters normal electrocardiography showed sinus rhythm 65 beats minute st elevation precordial leads figure 1 / l creatine kinase mb 17.4 u l troponin 0.21 ng ml laboratory test results normal echocardiography revealed hypokinetic septum slightly impaired left ventricular function ejection fraction 4560% electrocardiography presentation shows sinus rhythm 65 beats minute st elevation v3 ii iii based results presumptive diagnosis acute septal myocardial infarction made coronary artery angiography cag revealed transient occlusion left anterior descending lad coronary artery probably result myocardial bridging figure 2a the cag shows compression lad coronary artery systole resulting narrowing b performed second chest pain attack demonstrating dissection distal left anterior descending coronary artery however chest pain returned 3 days presentation a second electrocardiography showed persistent inverted waves precordial leads without st elevation it disclosed open lad dissection distal part double lumen observed first angiography figure 2b the definitive diagnosis non q wave anterior infarct result spontaneous lad dissection made based cysts kidneys combined family history adpkd diagnosis adpkd made ravine criteria since cerebral aneurysms one extrarenal manifestations adpkd computerized tomography angiography brain performed negative result vascular anomalies exercise stress test performed 16 days onset chest pain normal the lad patent without significant infarction still double lumen appearance 2-year follow nephrologist our patient relatively young man negative cardiovascular profile history subdural haematoma developed myocardial infarction secondary dissection lad the cad recognized first cag relevant coronary artery obturate dissection acute phase this condition found segmental coronary artery intramyocardial course compressed systole restored diastole therefore one would require difference coronary artery contraction systolic diastolic phase observed first cag four cases reported occurrence spontaneous cad middle aged adpkd patients predisposing factors cad adpkd patients still undetermined especially absence traditional cardiovascular risk factors furthermore known arterial dissection extrarenal manifestation adpkd secondary hypertension the estimated prevalence spontaneous cad 0.7% 2% cases cause acute coronary syndrome lad affected 80% patients cad 8 9 the majority patients cad often lack classical risk factors cardiovascular disease female de maio et al identified three groups patients cad patients atherosclerotic cardiovascular disease ii women postpartum period iii idiopathic group several underlying conditions idiopathic group suggested polyarteritis nodosa lupus erythematosus marfan syndrome ehlers danlos syndrome intense physical exercise use cocaine cyclosporin oral contraceptives the tunica media middle layer elastic arteries include smooth muscles interposing layers elastic lamellae the connection intracellular contractile filaments extracellular elastic fibres provided dense plaque sites localization dense plaques assigns significant function polycystins maintaining vascular integrity furthermore qian et al suggested abnormal intracellular calcium concentration vascular smooth muscle cells linked vascular phenotype case inactivation polycystin-2 protein literature also confirms observation intracranial aneurysms myocardial infarction secondary coronary aneurysms certain families occurrence vascular rupture haemorrhage homozygous polycystic kidney disease pkd)-1 knockout mice 4 11 considering results high plasma renin activity impaired nitric oxide release adpkd patients we speculate vascular abnormalities likely direct result pkd mutations rather secondary cause hypertension conclusion polycystins seem play main role stability arterial vasculature therefore spontaneous cad considered extrarenal manifestation adpkd the clinician aware cad adpkd patients present chest pain discomfort cag inconclusive respect mechanism coronary occlusion acute phase repeated especially complaints persist

little is known about the association between autosomal - dominant polycystic kidney disease ( adpkd ) and coronary artery dissection ( cad ) . we suggest that the genetic disorder in adpkd is the main cause of instable artery vasculature . our case also shows that cad can be missed in the acute phase . therefore , we recommend additional investigation in patients with adpkd presenting with acute chest pain . we report a case of a patient who developed a myocardial infarction due to a spontaneous dissection of the left anterior descending coronary artery . adpkd was diagnosed during the additional investigation . the patient received medical management .

optimal treatment cancers children often requires combined modality therapy including chemotherapy surgery and/or radiotherapy chemotherapy always sufficient achieve cure solid tumors children either resection radiation may needed local tumor control well 1 children radiosensitive malignant tumors typically require radiation therapy number sessions period several weeks although procedure painless young children need sedated anesthetised order provide motionless state procedure short period sedation analgesia general anaesthesia the patient anaesthesia equipment observed continuously closed circuit television monitors mirrored remote observation site outside treatment room different anesthesia methods anesthetics recommended provide safe optimal situation motionless short recovery period children undergoing general anaesthesia sedation external beam irradiation 37 this report describes accidental detection missed complication anesthetist time radiotherapy previous chemotherapy preliminarily unduly attributed anesthesia a 2.5 year old 13-kg boy asa american society anesthesiologists class ii acute lymphoblastic leukaemia scheduled radiotherapy anesthesia planned anesthetist physical examination normal radiotherapy routine monitoring established peripheral pulse monitoring distal portion right upper limb child rested covers after 5 minutes anesthetic effect ketamine began noticed lack right radial pulse anesthesia related hemodynamic instability expected however manifestation hypoxia hypo perfusion detected furthermore carotid pulsation normal examination left radial pulse peripheral pulses showed normal pulsation the patient showed scar swelling right antecubital area detailed history taken child parents showed history chemotherapy during extravasation chemotherapy drug resulted severe inflammation edema site injection a colour doppler ultrasound antecubital area showed deep edema chronic compression antecubital tissue confirmed diagnosis permission obtained patient parents use patient reports however patient information remain confidential the incidence range extravasations cytostatic drugs cancer patients reported 0.2 1.4% five year study 8) extravasations cytostatic treatment may cause wide range symptoms patients discomfort severe complications necrosis amputation ( 9 eccrine squamous syringometaplasia rare also occurred patients received chemotherapy treatment 10 yeung et al described case metastatic ovarian carcinoma repeated thrombosis femoral arteries following intravenous carboplatin based combination chemotherapy persistent withdrawal occlusion pwo frequently caused fibrin sheath formation around venous access devices small doses thrombolytic drugs urokinase could manage pwo could also serious complicate chemotherapy drug extravasation 12 keratolytic ointment applied old lesions whereas new lesions multiple subcutaneous injections hydrocortisone solution used application betamethasone ointment application conservative agents radiotherapy induced extravasation areas may avoid tissue necrosis consequently reconstructive surgery 13 management cytotoxic drug extravasation humans based experimental evidences available case reports lack randomized trials for instance topical dimethylsulfoxide dmso cooling extravasation anthracyclines mitomycin local injection hyaluronidase extravasation vinca alkaloids local injection sodium thiosulfate sodium hyposulfite extravasation chlormethine mechlorethamine mustine empirically recommended case failed conservative treatment history physical examination injection anesthetic agents could useful preventing patient mismanagement a weak pulse child significant problem anesthesiologist case shown critically misleading factor increased emphasis clinical evaluation pulse checking necessary especially children history chemotherapy providing thorough pulse evaluation work children avoiding immediate aggressive intervention certain cause weak pulse additional issues importance shown case report

treatment of cancer in children often requires a combination of chemotherapy , surgery , and/or radiotherapy . radiotherapy and chemotherapy are not painful processes , but children undergoing these procedures must be made motionless through anesthesia or sedation . there are a few reports of complications during these procedures in relation to the procedures themselves or to the anesthesia given . this report describes an unexpected pulseless radial artery which was preliminarily and unduly attributed to anesthesia . a 2.5 year - old male pediatric patient with an acute lymphoblastic leukaemia was scheduled for radiotherapy . anesthesia with intramuscular ketamine was induced before starting radiotherapy . about 5 minutes after injection of ketamine we found the right radial pulse undetectable . there was no other manifestation of hypoxia or hypo - perfusion . carotid pulsation was normal . examination of the left radial pulse and other peripheral pulses showed normal pulsation . the procedure was continued uneventfully . the next follow - up after radiotherapy , showed a scar and swelling on the right antecubital area , caused by extravasation of chemotherapeutic agent in the prior period of chemotherapy . doppler ultrasonography of the antecubital vein confirmed the diagnosis . this case study therefore demonstrates that proper intravenous cannula establishment before chemotherapy is of great importance . furthermore , accurate history and physical examination before induction of anesthesia or sedation may be useful in preventing mismanagement in pediatric cancer procedures .

annually 2.5 million muslims 140 countries go hajj pilgrimage largest mass gathering world the presence vast number people holy places especially cities mecca medina massive pilgrim crowds certain places certain times causes infectious diseases spread easily racial cultural health differences well level access health medical welfare services time stay places important factors increase risk communicable diseases viral bacterial respiratory tract infections common among pilgrims age sex groups regarded common disease among pilgrims reports some studies also reported prevalence different types infections 85.3% prevent infections some preventive measures recommended pilgrims mandatory injection tetravalent meningococcal meningitis vaccine recommendation inject seasonal flu vaccine using surgical masks hand each country plans implements specific measures prevent control diseases among pilgrims more 100,000 iranians 600 caravans undertook hajj 2010 according current policies hajj medical center iran traveling caravan common diseases detected among pilgrims treated caravan referred medical center needed the reports show conflicting results effects preventive measures respiratory tract infections fact precise study effects one preventive measures rarely done this research trying examine effects general preventive measures respiratory tract infections nested case control study precise design ordinary case control studies we used nested case control design based risk set sampling the studied cohort consist two caravans 338 pilgrims one first enter mecca first enter medina the outcome study types respiratory tract infections common cold including tonsillitis pharyngitis laryngitis sinusitis otitis media bronchitis pneumonia influenza as soon patient caravans identified data collection form completed individual considering level presence saudi arabia amount contact types viruses bacteria regarded risk day identifying patient two pilgrims caravan randomly selected control group each control pilgrim affected mentioned outcome time investigation although pilgrims may enrolled case future days every pilgrim become ill studied disease consent participate enrolled study all pilgrims get studied disease time selection consent participate could enrolled controls body mass index bmi calculated dividing weight kilograms height square meter another patient studied disease existed room pilgrim considered room contacty if pilgrims used face masks crowding even occasionally considered using face mask pilgrims considered vaccinated influenza vaccinated vaccine since two years traveling saudi arabia pilgrims washed mouth throat salt water least day considered salt water gargling pilgrims past history least one systemic diseases including asthma diabetes mellitus hypertension copd cardiovascular diseases considered systemic diseases present past smoker type amount smoking considered smokers if pilgrims used personal prayer carpet holy places considered using personal prayer carpet the effect preventive measure occurrence respiratory tract infections studied univariable model next stage variables significant first stage p 0.2 entered multiple models adjusted odds ratio obtained one variables we used nested case control design based risk set sampling the studied cohort consist two caravans 338 pilgrims one first enter mecca first enter medina the outcome study types respiratory tract infections common cold including tonsillitis pharyngitis laryngitis sinusitis otitis media bronchitis pneumonia influenza as soon patient caravans identified data collection form completed individual considering level presence saudi arabia amount contact types viruses bacteria regarded risk day identifying patient two pilgrims caravan randomly selected control group each control pilgrim affected mentioned outcome time investigation although pilgrims may enrolled case future days every pilgrim become ill studied disease consent participate enrolled study all pilgrims get studied disease time selection consent participate could enrolled controls body mass index bmi calculated dividing weight kilograms height square meter another patient studied disease existed room pilgrim considered room contacty if pilgrims used face masks crowding even occasionally considered using face mask pilgrims considered vaccinated influenza vaccinated vaccine since two years traveling saudi arabia pilgrims washed mouth throat salt water least day considered salt water gargling pilgrims past history least one systemic diseases including asthma diabetes mellitus hypertension copd cardiovascular diseases considered systemic diseases present past smoker type amount smoking considered smokers if pilgrims used personal prayer carpet holy places considered using personal prayer carpet the effect preventive measure occurrence respiratory tract infections studied univariable model next stage variables significant first stage p 0.2 entered multiple models adjusted odds ratio obtained one variables during hajj pilgrimage 32 people 9.5% cohort 338 pilgrims affected respiratory tract infections according explained method description cases controls terms age sex education factors influence incidence respiratory tract infections presented table 1 distribution factors affecting respiratory tract infections hajj pilgrims 2010 sixty nine percent patients treated symptomatic treatment oral antibiotics 27.5% required treatment intravenous antibiotics well in addition 79.3% patients fully recovered treatment administered caravan 17.2% referred hajj medical center finally 3.4% total patients hospitalized center univariable logistic regression analysis showed among variables studied gargling salt water presence patients room age level education p 0.2 associated respiratory tract infections among variables gargling salt water 2.4 p 0.08 strongest relationship table 2 the role protective measures individual factors respiratory tract infections among hajj pilgrims 2010 multivariable logistic regression model showed none factors listed significantly associated outcome studied for example presence patient room increases risk outcome 2.67 times effect significant according confidence intervals table 2 the results also showed current preventive measures including wearing face masks seasonal flu vaccination use personal prayer carpet effective enough prevention infections however seasonal flu vaccination recommended especially high risk individuals 65 years age the influenza vaccine proved researchers effect prevention respiratory infections even seen use seasonal influenza vaccine prolongs period sore throat however methodological problems studies applied methods including laboratory demographic studies considered comparing results it also noted recommendations take seasonal influenza vaccine due preventive effect incidence flu reduction risk pandemic swine flu other studies like results study shown wearing face masks effect respiratory infections although cdc recommend wearing saudi ministry health recommends pilgrims wear face masks the recommendation wear masks probably role prevention tuberculosis studied among pilgrims the effect using personal prayer carpet studied reports probably close contact pilgrims presence crowded places main causes transmission respiratory infections hinders possible protective role played personal prayer carpet although effect action prevention respiratory infections significant multiple logistic model seems reason relatively small sample size study in words studies larger sample size may concluded lack gargling salt water increases risk respiratory infections 2.3 times similarly said staying patients room increases risk respiratory infections 2.67 times seen table 2 factors age sex level education area room smoking systemic diseases obesity average daily hours gathering together holy places effect respiratory tract infections in words age sex group different individual conditions likely get exposed viral bacterial causes infections mentioned relatively small sample size one limitations study an increase sample size would make possible study role factors associated respiratory infections holy places mecca medina mina etc study the cases diagnosed clinically caravan physician rapid test diagnosis applied along acceptable sensitivity specificity diagnose cases accuracy study increase flu vaccinations wearing face masks personal prayer carpet smoking obesity etc affect incidence respiratory infections hajj study undertaken larger sample size according appropriate selected methodology evidence obtained showing prophylactic effect gargling salt water prevention infections

background : respiratory tract infections are very common among the hajj pilgrims . some preventive measures including influenza vaccination , using face mask and salt water gargling have been considered to control these infections and the reports show conflicting results about the effects of each one of these measures . this study is trying to assess the effects of these recommendations on respiratory tract infections.methods:according to nested case - control design , in a cohort consisting of 338 iranian pilgrims , the outcome examined , was all types of respiratory tract infections other than common colds . with occurrence of any patient in convoy , data collection form was completed for that person . on the same day , two people were randomly selected as control group from among pilgrims who have not affected so far.results:during hajj , 32 pilgrims ( 9.5% ) were affected by respiratory tract infections other than common colds . in univariable logistic regression analysis , salt water gargling ( or = 2.4 , p = 0.08 ) , existence of other patient in the room ( or = 2.14 , p = 0.19 ) , age over 60 years ( or = 1.84 , p = 0.15 ) and the education more than or equal to 3 years ( or = 1.93 , p = 0.16 ) were effective in the respiratory tract infections ( p < 0.2 ) . however , multivariable logistic regression analysis showed that none of the above mentioned factors are significantly associated with these infections.conclusions:this study showed that measures such as seasonal influenza vaccination , use of face masks and personal prayer carpet have no effect on the incidence of respiratory tract infections . however , washing throat and mouth with salt water can be considered the most effective preventive measures .

care coordination important aspect nursing care especially elderly patients admitted acute care setting singapore care coordination transitional care nursing new concept care nevertheless important unexplored the objective paper explore characteristics elderly patients receiving care coordination determine care gaps intervention home visit telephonic review a designed questionnaire used collect information patient demography social clinical profile determine post discharge activities using eric coleman four pillars tool the retrospective data patient index admission last six months nov 08april 09 analyzed using spss version 16 majority 69% 70 years old 57% female 76% lives children clinical information demonstrates 53% 36 co morbidities 58% taking five medications the abbreviated mental test score 6.2 6% depressed delirium present 14% patients only 65 patients 0.1% home visits telephonic review done whilst 97% remaining telephonic review done those telephonic home visit review medications advice compliance checked 0.8% one week 1.6% one month whilst home visit done 12.2% patients medication discrepancy apparent home appointment compliance compilation done 0.8% one week 51% four weeks telephonic review compared home visit 4.8% caregivers education emphasized 14% patients home visit 2% one week 4% one month telephonic review the result showed home visit effective exploring medication compliance advice emphasizing caregiver education managing appointments effectively done telephone review this study demonstrates vital role home visit elderly patient safely transit hospitals home

introductioncare coordination is an important aspect of nursing care especially for elderly patients admitted to an acute care setting . in singapore care coordination and transitional care nursing is a new concept of care nevertheless important but unexplored.aim/objectivesthe objective of this paper is to explore the characteristics of elderly patients receiving care coordination , determine care gaps and intervention during home visit and telephonic review.research design and samplinga designed questionnaire was used to collect information on the patient s demography , social and clinical profile and determine post discharge activities using eric coleman s four pillars tool . a pilot study of ten questionnaires was conducted . the retrospective data from the patient s index admission from the last six months ( nov 08april 09 ) was analyzed using spss version 16.resulttotal of 517 patients were recruited from october 2008 to march 2009 . majority , 69% were above 70 years old of which 57% female and 76% lives with their children . clinical information demonstrates that 53% had 36 co - morbidities and 58% were taking more than five medications . the abbreviated mental test score were 6.2 , 6% were depressed and delirium was present in 14% of patients.only 65 patients ( 0.1% ) had home visits and telephonic review done whilst 97% of the remaining had only telephonic review done . those who had both telephonic and home visit review , medications advice and compliance were checked only in 0.8% ( at one week ) and 1.6% ( at one month ) whilst during home visit this was done in 12.2% of patients as medication discrepancy were apparent at home . as for appointment compliance and compilation were done in 0.8% at one week and 51% at four weeks of telephonic review compared to during home visit only 4.8% . caregivers education was emphasized in 14% of patients at home visit , 2% at one week and 4% at one month of telephonic review.discussionthe result showed that home visit is effective in exploring medication compliance , advice and emphasizing caregiver education , managing appointments can be effectively done through telephone review.conclusionthis study demonstrates the vital role of home visit for elderly patient to safely transit between hospitals to home .

irrevocable aim endodontics three dimensional unblemished seal root canal system achieved perfect designing canal diameter canal form the biomechanical preparation one major steps removal bacteria debris root canal achieve successful endodontic treatment root canal instrumentation there complications perforations ledge formation transportation canal formation cracks root dentin times zeal biomechanical preparation canal inevitably end damaging root dentin becomes gateway dentinal cracks minute intricate fractures thereby causing failure treatment result craze lines microcracks might occurrence root fracture propagates due repeated application stress occlusal forces shemesh et al observed dentinal defects teeth obturated spreader teeth obturated without spreader different degrees dentinal damage occur due procedures like biomechanical preparation obturation retreatment complexities preparation root canal may attributed variation design cutting instrument taper composition material made hand instrumentation milestone endodontic practice past though lost popularity still remain integral part canal preparation rotary instrument innate behavior canal may result friction may increase dentinal defects microcracks formation comparison hand instruments possible relationship design niti rotary instruments incidence vertical root fractures found kim et al concluded design file affects strain concentration apical stress instrumentation root canal recently protaper next ptn dentsply maillefer files introduced family niti rotary instruments completely new design comprising unique swaggering movement greater flexibility wire technology 5 generation continuous improvement offset design whether rotary hand files hfs assumed cause limited frictional forces within canal hence creating dentinal defects so need study behavior different niti rotary instruments newly developed rotary system ptn root dentin teeth curved roots calcified canals extracanals teeth developmental anomaly resorption excluded study the teeth decoronated coronal portions using diamond disc leaving roots approximately 10 mm length all roots inspected transmitted light detecting preexisting cracks craze lines using stereomicroscope 12 exclude teeth findings study patency canal established using 10 k file mani japan canal the specimens divided four groups group containing 15 specimens hfs upto file 40 used canal preparation pt dentsply maillefer hs micro mega besancon france ptn dentsply maillefer groups preparation canals done using speed torque controlled motor x smart dentsply maillefer hand files group step back technique used upto file 40 pt group the following sequence pt rotary niti files used preparation canals 300 rpm shaping file x coronal enlargement s1 s2 f1 f2 f3 files corresponding apical size 30 used working length hs group hs niti files used upto file 30 300 rpm crown sequence ptn group the ptn rotary system files used 300 rpm following sequence x1 x2 x3 corresponding apical size 30 the ptn rotary files used constant rotation speed 300 rpm light apical pressure recommended torque 2.0 ncm adjustable 5.2 ncm according practitioner experience flutes instruments cleaned frequently check signs distortion wear the ptn instruments recommended used mechanically manually severe curvatures clockwise continuous motion brushing motion away external root concavities facilitate flute unloading apical file progression experimental groups sectioning roots done perpendicular long axis 9 6 3 mm using diamond disc water cooling digital images sectioned root captured using 40 stereomicroscope using digital camera olympus tokyo japan roots classified defect fracture defects described table 1 classification identification defects specimens results expressed number percentage defects group chi square test used statistical analysis groups level significance set p 0.05 using statistical package social sciences spss 20.0 sectioning roots done perpendicular long axis 9 6 3 mm using diamond disc water cooling digital images sectioned root captured using 40 stereomicroscope using digital camera olympus tokyo japan roots classified defect fracture defects described table 1 classification identification defects specimens the level significance set p 0.05 using statistical package social sciences spss 20.0 figure 1 bar chart representing number root defects group hfs group showed lowest defect 1/15 followed pt 6/15 hs 10/15 ptn 4/15 statistical significant difference seen hfs hs group hs ptn groups p 0.05 no significant difference found pt hs p 0.05 bar chart representing number root defects group stereomicroscopic images group ii iii iv shown figure 2 stereomicroscopic images showing dentinal defects seen groups ii iii iv showing craze lines seen group i. fracture defects group ii craze lines partial crack group iii craze lines group iv in present study hfs pt hs ptn number incidence defects observed root dentin found 1/15 6.67% 6/15 40% 10/15 66.67% 4/15 26.7% respectively group hfs showed lowest incidence defects 6.67% whereas hs group showed maximum incidence defects 66.67% compared groups the results study accordance imam reported lowest number defects 1/20 hfs yold et al observed highest incidence defects 12/20 hss rotary files present study number percentage defects shown ptn rotary files 4/15 26.7% the results present study accordance results bier et al hfs showed defect pt rotary files showed highest incidence dentinal damage 16% excess removal root dentin root canal preparation obturation canal spreader may create fracture teeth the important goal endodontics resistance tooth fracture fractures might cause decrease long term survival rate presents the number rotations required complete root canal preparation niti rotary instruments hfs kim et al stated taper files responsible increase stress walls root canal whereas bier et al stated taper files one contributing factor crack formation root dentin pt taper 0.07 0.08 0.09 respectively hss 0.04 0.06 ptn x1 x2 x3 0.04 0.06 0.07 respectively this explains formation cracks pt group reported earlier bier et al liu et al barreto et al liu et al furthermore relatively low flexibility hs may contributed maximum number defects hs group present study rotational force applied canals root niti rotary instruments thus creating craze line microcracks root dentin formation defects may associated design tip cross sectional geometry taper type constant progressive flute form pitch constant variable the pt files triangular cross sectional geometry hs triple helix cross sectional geometry whereas ptn rectangular thus stated design rotary files factor defect formation root dentin lam et al stated forces shaping root dentin affected file design risk root fracture increased due forces generated root canal preparation ptn files wire technology centered rectangular cross section giving file snake like swaggering movement moves along root canal thus reducing screw effect unwanted taper lock torque given file thus decreasing file root dentin contact m wire alloy niti material controlled memory niti wire flexible made conventional niti wire thus flexibility ptn rotary files may contributed less number dentinal defects formation compared pt hs capar et al concluded swaggering motion less taper ptn instruments could change root canal volume extent higher tapered instruments use different speed torque settings rotary system could limitation study increase rotational speed associated increased cutting efficiency.simulation periodontal ligament done present study capar et al stated simulation periodontal ligament necessary investigating influence forces formation crack fracture strength it plays important role stress dissipation created application load teeth use different speed torque settings rotary system could limitation study capar et al stated simulation periodontal ligament necessary investigating influence forces formation crack fracture strength it plays important role stress dissipation created application load teeth use different speed torque settings rotary system could limitation study increase rotational speed associated increased cutting efficiency.simulation periodontal ligament done present study capar et al stated simulation periodontal ligament necessary investigating influence forces formation crack fracture strength it plays important role stress dissipation created application load teeth use different speed torque settings rotary system could limitation study capar et al stated simulation periodontal ligament necessary investigating influence forces formation crack fracture strength it plays important role stress dissipation created application load teeth within limitations vitro study ptn rotary system induce less dentinal defects pt hs

introduction : the objective of this study was to evaluate dentinal defects formed by new rotary system protaper next ( ptn).materials and methods : sixty single - rooted premolars were selected . all specimens were decoronated and divided into four groups , each group having 15 specimens . group i specimens were prepared by hand k - files ( mani ) , group ii with protaper universal ( pt ; dentsply maillefer ) , group iii with hero shaper ( hs ; micro - mega , besancon , france ) , and group iv with ptn ( dentsply maillefer ) . roots of each specimen were sectioned at 3 , 6 , and 9 mm from the apex and were then viewed under a stereomicroscope to evaluate presence or absence of dentinal defects.results:in roots prepared with hand files ( hfs ) showed lowest percentage of dentinal defects ( 6.7% ) ; whereas in roots prepared with pt , hs , and ptn it was 40 , 66.7 , and 26.7% , respectively . there was significant difference between the hs group and the ptn group ( p < 0.05).conclusion : all rotary files induced defects in root dentin , whereas the hand instruments induced minimal defects .

batch processes used production many low volume high value added products speciality chemicals health care food agrochemicals, etc operation flexibility today market driven environment in addition two products require similar processing steps set equipment considered least economical reason a batch plant producing multiple products categorized either multiproduct plant multipurpose plant in plant products follow path process one product manufactured time processing products carried using equipment successive production runs campaigns multipurpose plant each product follows one distinct processing paths one product may produced simultaneously plants the present work directed toward optimal design problems multiproduct batch plants conventional optimal design multiproduct plant production requirements product total production time products available specified the number required volume size parallel equipment units stage determined minimize investment it emphasized batch plantsdesign long identified key problem chemical engineering reported literature 29 formulation batch plant design generally involves mathematical programming methods linear programming lp nonlinear programming nlp mixed integer linear programming milp mixed integer nonlinear programming minlp mathematical programming different optimization techniques branch bound heuristics genetic algorithm simulated annealing are thoroughly used derive optimal solutions however reality multiproduct design problem formulated multiobjective design optimization problem one seeks minimize investment operation cost total production time simultaneously maximize revenue recall much work reported literature multiobjective optimal design multiproduct batch plant huang wang introduced fuzzy decision making approach multiobjective optimal design problem multiproduct batch plant monotonic increasing decreasing membership function used define degree satisfaction objective function problem represented augmented minmax problem formulated minlp models obtain unique solution presented development two stage methodology multiobjective batch plant design retrofit according multiple criteria the authors used multiobjective genetic algorithm based combination single objective genetic algorithm pareto sort procedure proposing several plant structures discrete event simulator evaluating technical feasibility proposed configurations case multiple objectives optimum solution respect objectives may exist cases the objective functions conflict order decrease objective functions need increase objective functions recently solimanpur et al developed sophisticated multiobjective integer programming model objectives considered maximization total similarity parts minimization total processing cost minimization total processing time minimization total investment needed acquisition machines the presence multiple objectives problem usually gives rise family nondominated solutions largely known pareto optimal solutions objective component solution along pareto front improved degrading least one objective components since none solutions nondominated set absolutely better one acceptable solution difficult choose particular solution multiobjective optimization problem without iterative interaction decision maker dm one general approach establish first entire set pareto optimal solutions external decision maker dm direct intervention gives interactive information multiobjective optimization loop so satisfactory solution problem found soon knowledge acquired promethee ii preference ranking organisation method enrichment evaluations2nd version popular decision method successfully applied selection final solution multiobjective optimization problems it generates ranking available points according dm preferences best ranked one considered favourite final solution it based concept outranking relation binary relation defined every pair b alternatives way preferred b according dm interests said outranks b. relations defined pairs alternatives exploited according rules order rank solutions best worst this nonpareto based approach based selection several relevant groups individuals group associated given objective it reported method tends crowd results extremes solution space often yielding poor convergence pareto front recent algorithm based scalarization weighted sum function many successful evolutionary multiobjective optimization algorithms developed based two ideas suggested goldberg pareto dominance niching pareto dominance used exploit search space direction pareto front niching technique explores search space along front keep diversity well known algorithms category include multiobjective genetic algorithm moga niched pareto genetic algorithm npga strength pareto evolutionary algorithm spea multiobjective evolutionary algorithm moea nondominated sorting genetic algorithm nsga proposed srinivas deb one first evolutionary algorithm solving multiobjective optimization problems although nsga successfully applied main criticisms approach high computational complexity nondominated sorting lack elitism need specifying tuneable parameter called sharing parameter recently deb et al reported improved version nsga called nsga ii address issues the purpose study extend methodology solution multiobjective optimal control problems framework nsga ii the problem multiproduct batch plant covered paper defined assuming plant consists sequence batch processing stages used manufacture n different products stage j there nj identical units parallel operating phase size vj batches transferred one stage next without delay consider zero wait operating policy conventional design multiproduct batch plant one seeks minimize investment cost determining optimal number required volume size parallel equipment units stage specified production requirement product total production time however reality designer considers minimizing investment also minimizing operation cost total production time maximizing revenue simultaneously 1)maxnj vj bi tli qi h revenue f1=i=1ncpiqi 2)minnj vj bi tli qi hinvestment cost f2=j=1mnjjvjbj 3)minnj vj bi tli qi h operation cost f3=i=1n j=1mcejqjbi+coiqi 4)minnj vj bi tli qi h total production time f4=h so multiobjective problem consists determining following parameters nj number parallel units stage j vj required volume unit stage j bi size batch product end stages tli cycle time product qi production requirement product h total production time satisfying certain constraints volume time forth volume vj able process products 2 time constraint the summation available production time products net total time production 6)i=1nqibitlih ( 3 limiting cycle time product 7)ijnjtli i=1, ,n j=1, ,m every unit restricted allowable range 8)vjlvjvju j=1, ,m bjlbjbju j=1, ,n in contrast simple genetic algorithms look unique solution multiobjective genetic algorithm tries find many elements pareto set possible case nsga ii one provided operators allow know level nondominance every solution well grade closeness solutions allows explore widely inside feasible region brief form functioning multiobjective genetic algorithm nsga ii described following steps fast nondominated sorta efficient procedure used arrange solutions fronts nondominated arranging accordance aptitude values a domination count np number solutions dominates solution p set sp contains solutions dominated p. solutions first front higher status nondominance pareto sense efficient procedure is used arrange solutions fronts nondominated arranging accordance aptitude values a domination count np number solutions dominates solution p set sp contains solutions dominated p. solutions first front higher status nondominance pareto sense diversity preservationthis achieved means calculation crowding degree closeness solutions inside population this quantity obtained calculating average distance two points either side particular solution along objectives this quantity serves estimate cuboid perimeter formed using nearest neighbours vertices there also operator called crowded comparison n guides genetic algorithm towards pareto optimal front accordance following criterion 9)in j irank jrank),or irank jrank ididtance jdistance accordance previous criterion two nondominated solutions prefer solution better rank otherwise solutions belong front prefer solution located lesser crowded region this achieved means calculation crowding degree closeness solutions inside population this quantity obtained calculating average distance two points either side particular solution along objectives this quantity serves estimate cuboid perimeter formed using nearest neighbours vertices there also operator called crowded comparison n guides genetic algorithm towards pareto optimal front accordance following criterion 9)in j if irank jrank),or irank jrank ididtance jdistance accordance previous criterion two nondominated solutions prefer solution better rank otherwise solutions belong front prefer solution located lesser crowded region initial loopinitially random parent population po size n created then usual binary tournament selection recombination mutation operators used create new population q0 size n. initially random parent population po size n created then usual binary tournament selection recombination mutation operators used create new population q0 size n. main loopthe nsga ii procedure explained describing th generation showed figure 1 the procedure begins combination pt qt forming new population called rt population rt sorted using nondomination criterion since previous current population members included rt the population rt size 2n later different fronts nondominated solutions created f1 front contains better rank solutions figure 4 shows process forming new population pt+1 algorithm takes members fronts f1 f2 elements front f3 n solutions needed exactly new population pt+1 find exactly n solutions last front ordained description number 3 arranging solutions descending order means crowded comparison n selecting best solutions needed fill population slots population pt+1 genetic operators selection crossing mutation used create new population qt+1 size n. finally mentioned selection process crowded comparison operator used the nsga ii procedure explained describing th generation showed figure 1 the procedure begins combination pt qt forming new population called rt population rt sorted using nondomination criterion since previous current population members included rt the population rt size 2n later different fronts nondominated solutions created f1 front contains better rank solutions figure 4 shows process forming new population pt+1 algorithm takes members fronts f1 f2 elements front f3 n solutions needed exactly new population pt+1 find exactly n solutions last front ordained description number 3 arranging solutions descending order means crowded comparison n selecting best solutions needed fill population slots population pt+1 genetic operators selection crossing mutation are used create new population qt+1 size n. finally mentioned selection process crowded comparison operator used to demonstrate effectiveness nsga ii batch plant processes two examples given the first example batch plant consisting three processing stages mixer reactor centrifuge manufacture two products b. second example treats four processing stages mixer reactor extraction centrifuge manufacture three products b c. data examples 1 2 illustrated respectively tables 1 2 processing times size factor units cost product the set decision variables consists batch size total production time number parallel units stage cycle time product required volume unit stage since number parallel units stage integer decision variable code variable binary variable in addition constraints expressed 5)(8 consider bounds objective functions additional constraints generate feasible nondominated solutions range desired decision maker 19 constraints 10)filfifiu 1 ,4 then nsga ii employed solve optimization problem following parameters maximum number generation 200 population size 500 probability crossover 0.85 probability mutation 0.05 distribution index simulated crossover operation 10 distribution index simulated mutation operation 20 the revenue f1 increases increase operation cost f3 investment cost f2 decreases when four objective functions considered simultaneously solutions obtained present study show improvement huang wang results problem for example let us consider solution presented huang wang unit reference membership level objectives f1 121 350 f2 171 624 f3 77 299 f4 5667 solution 1 presented table 3 present study improves solution f1 f3 f4 f2 comparable the large set multiple optimal solutions provides decision maker immediate information relationship among several objective criteria set feasible solutions thus helps decision maker select highly confident choice solution the fixed optimal plant structure 221 corresponds two mixers two reactors one centrifuge design the batch plant case consists four processing stages manufacture three products b c four objective optimization problem expressed 1)(4 but deal 4 integer variables 14 real variables 31 constraints includes bounds objective functions the model equations example 1 used except processing time ij 7 the time required process one batch product stage j expressed 11)ij=ij+cijbij j ij 0 cij 0 j constants bi batch size product i. thus processing time constant depends decision parameters batch size the constrained multiobjective minlp problem solved nsga ii set nsga ii parameters used example 1 example 1 revenue f1 increases operation cost f3 increases investment cost f2 decreases following operation cost f3 let mention four objective functions considered simultaneously solutions obtained present study improve significantly results presented huang wang problem for example solution presented huang wang unit reference membership level objectives f1 274 312 f2 375 688 f3 175 688 f4 5639 solution 1 presented table 4 present study improves solution f1 f3 f4 f2 comparable example plant structure evolved optimal two mixers two reactors two extractors one centrifuge presented figure 7 implementation trade analysis dependent upon availability decision maker preferences a multiobjective decision batch plant process design considered non dominating sorting genetic algorithm nsga ii developed get optimal zone containing solutions concept pareto set nsga ii capability proved evolving entire set nondominating solutions along pareto front single run algorithm thus decision maker dm provided best trade operating zone furthermore better confident choice design among several compromises decision maker achieved decision variables effects objective functions known finally large set solutions presents useful base alternative approaches fulfil dm targets the inherent dynamic nature batch processes allows ability handle variations feedstock product specifications provides flexibility required multiproduct multipurpose facilities they thus best suited manufacture low volume high value products specialty chemicals pharmaceuticals agricultural food consumer products recently constantly growing spectrum biotechnology enabled products reduced time market lower production costs improved flexibility critical success factors batch processes

optimal design problem are widely known by their multiple performance measures that are often competing with each other . in this paper , an optimal multiproduct batch chemical plant design is presented . the design is firstly formulated as a multiobjective optimization problem , to be solved using the well suited non dominating sorting genetic algorithm ( nsga - ii ) . the nsga - ii have capability to achieve fine tuning of variables in determining a set of non dominating solutions distributed along the pareto front in a single run of the algorithm . the nsga - ii ability to identify a set of optimal solutions provides the decision - maker dm with a complete picture of the optimal solution space to gain better and appropriate choices . then an outranking with promethee ii helps the decision - maker to finalize the selection of a best compromise . the effectiveness of nsga - ii method with multiojective optimization problem is illustrated through two carefully referenced examples .

since introduction extra oral implants reconstruction craniofacial defects achieving proper prosthesis retention become promising these problems include ulceration hard and/or soft tissues used retention lack retention due prosthesis movement tissue irritation caused adhesives the ideal position number implants restoring orbital defects would three non linear implants lateral supraorbital infra orbital rims however implant arrangement always conceivable considering extension defect bone quality quantity defect walls two common retention systems used reconstruction orbital defects include freestanding abutments magnetic retention bar clip retention magnetic abutments common resolve potential problems associated bar clip attachment including difficulty insertion removal prosthesis patient difficulty regular hygiene measurements rigidity attachment resulting implant overloading however magnetic attachment might provide sufficient retention implants placed adjacently the presence implant defective area might complicate usual impression taking procedures used fabrication conventional craniofacial prostheses accuracy impression affected defect shape retention system number divergence implants moreover anatomical undercuts defect proximity remoteness implants could complicate impression taking procedure use multiple trays elastomeric impression materials dual impression technique suggested overcome problems 2,1214 the purpose article present case treated implant supported prosthesis reconstruct relatively large orbital defect using three adjacent implants lateral orbital rim a 60-year old woman left orbital defect due removal periocular basal cell tumor referred implant department tehran university medical sciences school dentistry prosthetic reconstruction eye three implants superline dentium seoul south korea 8 mm length 3.6 mm diameter placed lateral rim orbit although suitable sites orbital implants superior lateral rims present case implants placed adjacently due insufficient bone thickness superior inferior orbital rims the defect relatively deep undercuts medial wall could complicate impression making the preferred prosthesis design implant supported prosthesis custom bar containing properly distributed magnetic components the healing abutments unscrewed three hexed direct casting abutments implantium dentium seoul south korea 4.5 mm diameter directly secured implants the medial undercuts blocked using gauze pack avoid penetration acrylic resin auto polymerizing acrylic resin pattern resin gc tokyo japan pattern was formed directly abutments manner cobalt samarium co5sm magnets implantium dentium seoul south korea 5.5 mm diameter retention force 700 gram could placed proper distances superior inferior lateral segments acrylic bar fig the acrylic resin bar casted using base metal alloy aalba dent inc ; cordelia c.a usa magnet keepers cemented corresponding sites panavia f 2.0 resin cement kurary medical inc japan acrylic resin pattern bar containing indentations magnets try metal bar implants magnet keepers place b the space beneath superstructure also undercuts defect walls blocked gauze packs the final impression made order pick magnets simultaneously record rest orbital defect light viscosity addition silicone panasil kettenbach germany used first layer cover entire defect well intact side midface afterwards regular viscosity addition silicone panasil kettenbach germany used light viscosity material create mechanical retention projections gypsum layer herostone vigodent inc the wax pattern orbit formed containing ocular prosthesis simulated properties healthy eye the pattern tried patient modifications made improve esthetic adaptation the prosthesis made combination heat cured acrylic resin holding magnets high temperature vulcanizing silicone internal external staining characterizations skin wrinkles eye brow eye lashes the final prosthesis delivered patient necessary home care instructions provided removing prosthesis night cleaning eye defect damp gauze need regular biannual follow ups 69 tissue side prosthesis three magnets delivery prosthesis b ) the patient presented treated implant supported orbital prosthesis bar magnetic attachment this retention mechanism might minimize risk mechanical overload implants compared conventional bar clip attachment cantilever arms despite proximity implants the mentioned distribution magnetic attachments increased retention creating tripod furthermore since acrylic resin pattern bar made directly defective area implant abutment analogues used final impression procedure prolonged chair side time disadvantage stated method could justified considering mentioned advantages

implant - supported craniofacial prostheses are made to restore defective areas in the face and cranium . this clinical report describes a technique for fabrication of an orbital prosthesis with three adjacent implants in the left lateral orbital rim of a 60-year - old woman . selection of appropriate attachment system ( individual magnetic abutments versus bar - clip attachment ) for implant - supported orbital prostheses depends upon the position of implants . bar - magnetic attachment has been selected as the retention mechanism in the present case .

hepatocellular carcinoma hcc one common cancers worldwide especially china 13 the high hcc rates china largely reflect elevated prevalence chronic hepatitis b virus hbv infection developed countries united states nonalcoholic fatty liver disease nafld associated obesity less study focused effect obesity hcc especially relationship bmi hcc no study focused effect waistline surgical outcome hcc patients so study influence body mass index bmi waistline complications postoperative death long time survival patients undergoing surgery hcc between january 2007 december 2012 retrospectively reviewed database 136 patients underwent hepatic resection hcc department surgery fourth affiliated hospital zhejiang university school medicine this retrospective study performed approval ethics committee fourth affiliated hospital zhejiang university school medicine compliance helsinki declaration written informed consent given participants clinical records used study we enrolled 136 patients divided 4 groups group bmi 25 group b bmi 25 group c waistline 90 cm males waistline 80 cm females group waistline 90 cm males waistline 80 cm females there 61 patients 44.9% group 75 patients 55.1% group b 58 patients 42.6% group c 78 patients 57.4% group d. patients followed preoperative evaluation protocol including blood biochemistry ultrasonography computed tomography liver the criteria resection included good general condition absence essential organ dysfunction distant metastasis liver function child b icg r15 15% follow data obtained direct communication patients underwent hepatic resection survival analysis including overall survival disease free survival estimated kaplan meier survival method compared using log rank test all statistical analyses performed using statistical software spss 13.0 windows spss chicago il significant level p<0.05 there 110 80.9% men 26 19.1% women underwent hepatectomy the median age 43 years 118 86.8% patients ages 60 years 18 13.2% patients older 60 years there 61 44.9 patients normal bmi 25 75 55.1% patients overweight obese bmi 25 fifty eight patients 42.6% belong group c 78 patients 57.4% belong group d. ninety seven 71.3% patients positive hepatitis b 39 28.7% patients without hbv histopathology hcc confirmed vascular invasion 41 patients 30.1% liver cirrhosis 65 47.8% patients surgical results confirmed capsular formation 54 39.7% patients 51 37.5% patients solitary hcc table 1 the intraoperative postoperative data including major complications 136 patients hcc shown table 2 supplementary table 1 the median hospital stay 11 days group 12 days group b significant difference 2 groups p=0.373 a 23 37.7% patients blood loss 1000 ml compared 29 38.7% patients group b. hospital death group 1 1.3% hospital death group b. however significant difference found 2 groups significant differences overall postoperative complication rate group group b although pulmonary infection showed significant difference 2 groups p=0.017 seven 11.5% patients complications group compared 9 12% patients group b. common complications group ascites wound infection common complications group b pulmonary infection wound infection variables might affect overall survival patients hcc hepatic resection analyzed study on univariate analysis prognostic factors found patients bmi 25 waistline 90 cm 80 cm women vascular invasion poor overall survival without variables p=0.032 p=0.017 p=0.009 the variables sex afp level blood loss significant prognostic factors overall survival on multivariate analysis however vascular invasion waistline significantly associated overall survival p=0.031 p=0.039 the variables including bmi independent prognostic factors overall survival multivariate analysis table 3 the overall survival curves hcc patients according bmi shown figure 1 the 1- 3- 5-year overall survival rates group 95% 81% 16% respectively the 1- 3- 5-year disease free survival rates patients 78% 38% 4% respectively figure 1 however significant difference 2 groups disease free survival p=0.235 the overall disease free survival curves hcc patients affected waistline shown figure 2 the 1- 3- 5-year overall survival rates group c 97% 88% respectively 15% compared 96% 68% 15% respectively group d. 1- 3- 5-year disease free survival rates group c 84% 40% 6% respectively group c significant better overall survival disease free survival group p=0.028 p=0.048 there 110 80.9% men 26 19.1% women underwent hepatectomy the median age 43 years 118 86.8% patients ages 60 years 18 13.2% patients older 60 years there 61 44.9 patients normal bmi 25 75 55.1% patients overweight obese bmi 25 fifty eight patients 42.6% belong group c 78 patients 57.4% belong group d. ninety seven 71.3% patients positive hepatitis b 39 28.7% patients without hbv histopathology hcc confirmed vascular invasion 41 patients 30.1% liver cirrhosis 65 47.8% patients surgical results confirmed capsular formation 54 39.7% patients 51 37.5% patients solitary hcc table 1 the intraoperative postoperative data including major complications 136 patients hcc shown table 2 supplementary table 1 the median hospital stay 11 days group 12 days group b significant difference 2 groups p=0.373 a 23 37.7% patients blood loss 1000 ml compared 29 38.7% patients group b. hospital death group 1 1.3% hospital death group b. however significant difference found 2 groups significant differences overall postoperative complication rate group group b although pulmonary infection showed significant difference 2 groups p=0.017 seven 11.5% patients complications group compared 9 12% patients group b. common complications group ascites wound infection common complications group b pulmonary infection wound infection variables might affect overall survival patients hcc hepatic resection analyzed study on univariate analysis prognostic factors found patients bmi 25 waistline 90 cm 80 cm women vascular invasion poor overall survival without variables p=0.032 p=0.017 p=0.009 the variables sex afp level blood loss significant prognostic factors overall survival on multivariate analysis however vascular invasion waistline significantly associated overall survival p=0.031 p=0.039 the variables including bmi independent prognostic factors overall survival multivariate analysis table 3 the overall survival curves hcc patients according bmi shown figure 1 the 1- 3- 5-year overall survival rates group 95% 81% 16% respectively the 1- 3- 5-year disease free survival rates patients 78% 38% 4% respectively figure 1 however significant difference 2 groups disease free survival p=0.235 the overall disease free survival curves hcc patients affected waistline shown figure 2 the 1- 3- 5-year overall survival rates group c 97% 88% respectively 15% compared 96% 68% 15% respectively group d. 1- 3- 5-year disease free survival rates group c 84% 40% 6% respectively group c significant better overall survival disease free survival group p=0.028 p=0.048 there many reports relationship bmi size waistline cancer risk 714 research conducted cancer council victoria australia shows waist measurement 100 cm men 85 cm women significantly increase risk cancer including breast bowel aggressive prostate cancer however reports relationship bmi waistline hcc the high hcc rates china largely due prevalence chronic hepatitis b virus infection however increase prevalence obesity nafld progress cirrhosis subsequently development hcc recognized one common liver diseases china although many reports affirmed patient higher bmi tend show higher incidence liver cirrhosis reports relationship bmi surgical outcome hepatectomy hcc 1517 regarding relationship bmi waistline obesity hypothesized waistline might related surgical outcome hepatectomy hcc well study significant differences postoperative complication rate postoperative death group group b. however pulmonary infection 13.3% showed significant difference 2 groups p=0.017 observation obese patients pulmonary infection hepatectomy hcc can explained fact obesity reduce pulmonary function diminishing exercise capacity lung volume increasing resistance breathing vascular invasion waistline bmi independent prognostic factors long term survival group c better overall disease free survival group group better overall survival group b. result showed bmi waistline independent prognostic factors long term survival waistline may important bmi predicting prognosis hcc hepatectomy obesity lead nafld finally progress cirrhosis thought account majority hcc 1821 increase prevalence obesity we recommend individuals whose bmi waistline exceeds normal limits cultivate healthy lifestyle eating foods help lose weight regular physical exercise getting enough sleep in conclusion overweight obesity shown significant predictors adverse long time survival hepatectomy hcc waistline important bmi predicting disease free survival hcc hepatectomy

backgroundhepatocellular carcinoma ( hcc ) is one of the most common cancers worldwide especially in china . this article aimed to evaluate the influence of body mass index ( bmi ) and waistline on complications , postoperative death , and long - term survival in patients undergoing surgery for hcc.material/methods136 patients were enrolled and divided into 4 groups : group a , bmi < 25 ; group b , bmi 25 ; group c , waistline < 90 cm in males or waistline < 80 cm in females ; group d , waistline 90 cm in males or waistline 80 cm in females . clinical pathological features and surgical outcomes of these patients were analyzed retrospectively.resultsthere were no significant differences in postoperative complication rate and postoperative death between group a and group b , although pulmonary infection showed a significant difference between 2 groups ( p=0.017 ) . vascular invasion , waistline , and bmi are the independent prognostic factors for long - term survival . the disease - free survival curves after hepatectomy showed no statistically significant difference between group a and group b. group c had the better overall survival than group d , and group a had the better overall survival than group b.conclusionsbmi and waistline are both independent prognostic factors for long - term survival of hcc after hepatectomy . waistline is more important than bmi in predicting the disease - free survival of hcc after hepatectomy .

professional mononuclear phagocytes polymorphonuclear neutrophils pmn monocytes macrophages considered first line defence early host innate immune response 1 2 their main function classically understood kill invasive pathogens variety potent intracellular microbicidal effector mechanisms 37 after first contact pathogens mononuclear phagocytes engulf internalize phagosomes fusion intracellular granules formation phagolysosomes pathogens may killed intracellularly combination non oxidative oxidative mechanisms 1 8 actions potent antimicrobial peptides defensins cathelicidins cathepsins pentraxin lactoferrin parts non oxidative killing mechanisms oxidative killing relies exclusively production antimicrobial reactive oxygen species ros via nadph oxidase nox complex within blood circulating phagocytes pmn far abundant cell population representing 5080% total white blood cells different vertebrates moreover released bone marrow blood circulation pmn highly mobile short lived phagocytes densely packed secretory granules 4 8 pmn granules categorized three different types based contents primary azurophilic secondary specific tertiary gelatinase granules the types granules found circulating pmn depend maturation stage thus pmn maturation starts formation primary granules followed secondary tertiary granules 4 9 10 the content primary granules includes myeloperoxidase mpo neutrophil elastase ne cathepsin g proteinase 3 defensins lysozyme secondary granules contain collagenase gelatinase cystatin lysozyme lactoferrin tertiary granules comprise gelatinase lysozyme arginase amongst others following granule maturation pmn possess three types granules displaying full killing capacity blood also tissues organs gut lumen in addition pmn act pathogens actively participating complex inflammatory networks release broad panel proinflammatory chemokines cytokines survival- growth factors trigger downstream proinflammatory effects transition adaptive immune reactions such several proinflammatory cytokines chemokines found enhanced activated pmn response apicomplexan parasites tnf- il-1 cc cxc chemokines e.g. il-8 ip-10 gro- rantes mip-1 1115 several pmn derived immunomodulatory molecules augment production various chemokines cytokines regulate phagocyte functions 16 17 more importantly means activated pmn recruit innate immune cells also cells site infection 1820 even induce sterile inflammation 21 22 beginning landmark study brinkmann et al paradigm pmn fight kill pathogenic bacteria profoundly changed the discovery dna based antimicrobial neutrophil extracellular traps nets changed current knowledge innate immune reactions level pathogen killing also pathophysiology metabolic autoimmune reproductive inflammatory diseases well cancer progression 3237 nets released activated pmn novel cell death process called netosis stimulated variety molecules invasive pathogens microorganisms bacteria 31 3941 fungi 4244 viruses 4549 parasites 5055 identified net inducers also different molecules cellular structures gm csf complement factor 5a 56 57 activated platelets 40 58 pma zymosan 24 26 31 59 singlet oxygen lps 31 61 fc receptor trigger netosis addition il-8 well known chemoattractant pmn demonstrated net inducer 31 62 efficient netosis requires mature pmn cases nox mpo ne peptidylarginine deiminase type iv pad4 activities 14 24 59 6365 furthermore process netosis obviously requires intracellularly signalling pathways raf mek erk kinases well p38 mapk frequently reported involved process 14 23 33 6669 in addition calcium release needed optimal net formation different vertebrate species 14 23 7072 upon stimulation pmn nuclear envelope disintegrates permitting mixture chromatin granular proteins peptides ne mpo degrade histones h1 h2a h2b h3 h4 promote chromatin decondensation mediated pad4 via hypercitrullinating specific histones allow electrostatic coiling chromatin 64 73 74 the total dna complexes decorated granular proteins peptides specific histones h1 h2a h2b h3 h4 finally extruded nets extracellular environment dying pmn net formation primarily nox dependent mechanism 14 24 59 75 76 however nox independent netosis also reported 29 60 67 68 77 this mode netosis accompanied substantially lower level erk activation rather moderate level akt activation whereas activation p38 similar kinds net formation 67 68 example irrespectively nox dependency pathogens may either immobilised within sticky dna fibres 55 78 79 killed via local high concentration effector molecules 31 42 51 53 meanwhile types leukocytes innate immune system macrophages 8083 monocytes 26 28 mast cells 84 85 eosinophils 55 86 87 also basophils reported release net like structures collectively entitled extracellular traps ets described already many years ago enucleated pmn may remain vital even capable killing invasive microbes more recent studies corroborated findings proving leukocytes necessarily die et extrusion 56 68 86 context yousefi et al 56 86 demonstrated eosinophils certain pmn subpopulations release ets mitochondrial origin without dying furthermore yipp et al verified pmn released nets still viable retained capability engulf bacteria via phagocytosis however appears nonlethal pmn faster nox dependent net formation rely vesicular based pathway releasing nuclear dna 33 68 additionally different molecular pathways lead stimulus dependent manner extrusion different types ets vitro vivo different morphological forms ets first time described human gout disease vivo proving monosodium urate crystals msu induced aggregated aggets spread sprets diffused diffets et formation as parasitic nematode haemonchus contortus larvae triggered ruminant pmn eosinophils aggets spreets diffets while net- et related studies focused bacterial viral fungal pathogens little attention paid protozoan parasites first ever published study parasite triggered netosis published 2008 baker et al 4 years discovery novel effector mechanism reported plasmodium falciparum triggered net formation parasites mosquito borne pathogens cause malaria serious public health disease worldwide tropic subtropics globally estimated 3.3 billion people risk infected malaria approximately 1.2 billion high risk 1 1000 chance developing malarial disease the first report p. falciparum induced nets referred p. falciparum infected children demonstrated vivo net entrapped trophozoite infected erythrocytes blood samples moreover baker colleagues provided first evidence involvement parasite triggered nets pathogenesis malaria since high levels anti dsdna antibodies predictive levels autoimmunity interestingly recent study also indicates capacity p. falciparum inhibit net formation may relevance immunopathogenesis thus mosquito derived salivary protease inhibitor agaphelin induced p. falciparum infection inhibited vertebrate elastase net formation whether represents true anti net mechanism remains elucidated parasites genus eimeria worldwide high veterinary economic importance livestock especially chicken cattle small ruminants 95100 coccidiosis disease high morbidity animals ages nonetheless inducing pathogenicity especially young animals occasionally causing death heavily infected animals 99 102 103 several studies showed pmn infiltrate intestinal mucosa response eimeria infections occasionally found close contact parasitic stages vivo 102 104107 pmn also shown directly interact e. bovis stages antigens vitro resulting release proinflammatory cytokines chemokines inos additionally phagocytic oxidative burst activities enhanced response eimeria stages vitro vivo first indications eimeria spp potent net inducers came behrendt colleagues reported sporozoites entangled extracellular network delicate dna fibres extruded pmn vitro figure 1(a using extracellular dna measurements dnase treatments other studies confirmed typical characteristics nets colocalization ne mpo histones dna backbone eimeria induced net like structures meanwhile also pathogenic ruminant eimeria species shown induce netosis e. arloingi figures 2(a 2(b 24 27 e. ninakohlyakimovae prez personal communication importantly muoz caro colleagues proved nets also occur vivo eimeria infected gut mucosa the current data suggest eimeria induced netosis species- stage independent mechanism since induced sporozoites merozoites oocysts different eimeria species 23 24 given pmn described act even intestinal lumen via different effector mechanisms 27 108 109 appears likely interactions luminal pmn ingested eimeria oocysts newly excysted sporozoites may occur 6 23 24 particular net related reactions oocysts would high impact ongoing infection since may hamper proper excystation infective stages sporozoites consequence dampen degree infection earliest possible time point host since e. arloingi sporozoites must egress oocyst circumplasm micropyle nets covering area oocyst detrimental effect proper excystation 6 24 explanation seems feasible e. bovis e. ninakohlyakimovae regardless fact excystation occurs rupture oocyst walls prior sporozoites egress sporocysts although eimeria species tested far equally induced nets significant differences entrapment effectivity reported amongst different host species parasite species stages thus caprine nets immobilised high proportion e. arloingi sporozoites 72% whilst bovine system considerably less parasite stages e. bovis sporozoites 43% b. besnoiti tachyzoites 34% found entrapped net structures 23 59 so far remains elucidated whether varying effectivity nets based pmn origin goats generally considered strong immune responders parasite species the molecular basis eimeria induced netosis entirely understood far enzyme activity measurements inhibition studies revealed key role nox ne mpo eimeria triggered net formation see table 1 agreement bacterial fungal parasitic pathogens 14 25 59 65 75 110 referring signal cascades analyses grade phosphorylation revealed key role erk1/2 p38 mapk sporozoite exposed bovine pmn since respective inhibitor experiments led decreased parasite mediated net formation muoz caro et al this finding agreement data t. gondii mediated net formation referring ca influx inhibition experiments proved e. bovis mediated netosis dependent intracellular ca mobilization since 2-abp inhibitor store operated ca entry bapta binding intracellular ca muoz caro unpublished data egta inhibitor ca influx extracellular compartment muoz caro unpublished data significantly blocked parasite triggered netosis far reported enhanced cd11b surface expression pmn following e. bovis sporozoite exposure antibody mediated cd11b blockage leading significant reduction parasite triggered netosis bacteria fungi netosis reported lethal effector mechanism 31 42 however killing effects nets observed case eimeria spp far given eimeria spp are obligate intracellular parasites main function nets rather seems extracellular immobilisation infective stages hampering host cell invasion accordingly reduced host cell infections rates reported e. bovis e. arloingi sporozoites previously exposed pmn 23 24 feature reported monocyte preexposed e. bovis sporozoites indicating leukocyte cell type also casts ets response parasite stage etosis impact parasite invasion besides e. bovis e. arloingi silva unpublished data e. ninakohlyakimovae prez et al submitted manuscript also shown induce monocytes derived ets furthermore e. ninakohlyakimovae induced monocytes etosis showed rapid induction ets release upon viable sporozoites sporocysts oocysts encounters corroborating stage independent process monocyte derived etosis in addition found caprine monocyte derived etosis nox dependent upregulation genes transcription encoding il-12 tnf- relevant immunoregulatory cytokines transition properties adaptive immunity were also demonstrated e. ninakohlyakimovae exposed caprine monocytes prez et al submitted manuscript since reduction infection rates early infection automatically results decreased proliferation parasite indirect et mediated effect beneficial impact outcome disease despite advantageous properties ets ineffective clearance and/or poor regulation might also bear adverse pathological implications leading tissue damage addition enhanced local proinflammatory reactions 112 113 toxoplasmosis caused facultative heteroxenous apicomplexan polyxenous protozoan t. gondii representing one common parasitic zoonoses worldwide toxoplasma gondii well known affect almost warm blooded mammals including wide range domestic animals wild mammals marine mammals marsupials humans 115 116 response t. gondii infections pmn are promptly recruited site infection producing variety proinflammatory cytokines chemokines 11 117 in addition pmn capable killing t. gondii tachyzoites via phagocytosis 118 119 besides effector mechanism human murine bovine harbour seal phoca vitulina pmn additionally perform netosis reaction t. gondii tachyzoites figures 1(c 1(d 25 26 abi abdallah et al showed netosis triggered tachyzoites parasite strain independent fashion invasion phagocytosis independent process interestingly murine toxoplasmosis model tachyzoites induced nets result random cell lysis controlled dna release process since lysozyme still present pmn performing netosis 25 120 in contrast eimeria spp t. gondii triggered netosis modest toxoplasmacidal effects killing 25% parasites considering obligate intracellular life style t. gondii enormous proliferative capacity mammalian host cells parasite entrapment via nets might particular importance vivo based interference host cell invasion consistently harbour seal pmn promoted nets significantly hampered host cell invasion t. gondii tachyzoites vitro in vivo evidence t. gondii induced netosis reported murine pulmonary infection model revealing increase dsdna contents bronchoalveolar lavage fluids t. gondii infected mice equally reported several coccidian parasites 14 23 t. gondii induced nets were also proven nox- ne- mpo- ca- soce dependent mediated erk 1/2-related signalling pathway pmn see table 1 25 26 additionally earlier studies pivotal role pmn also important role monocytes toxoplasmosis clearly demonstrated 121123 however capacity also induce ets response tachyzoite stages recently demonstrated exposure harbour seal derived monocytes viable t. gondii tachyzoites resulted significant induction monocyte ets tachyzoites firmly entrapped immobilised within harbour seal monocyte et structures hampering parasite replication bovine besnoitiosis caused besnoitia besnoiti endemic disease africa asia 124126 considered emergent europe acute phase cattle besnoitiosis b. besnoiti tachyzoites mainly replicate host endothelial cells different organs 28 128 upon release may exposed circulating leukocytes besnoitia besnoiti tachyzoites recently reported effective inducers pmn- monocyte derived ets figures 1(e 1(g 1(h 28 59 latter case a high proportion pmn found involved netosis since 76% encountered pmn found participate netosis leading immobilisation approximately one third parasites besnoitia besnoiti triggered netosis furthermore proved vitality independent process even induced soluble parasite molecules homogenates though lower levels regarding pmn derived effector molecules nox ne mpo proved essential efficient b. besnoiti triggered netosis thus respective enzyme activities encountered tachyzoite exposed pmn chemical blockage enzymes via inhibitors blocked parasite triggered netosis 28 59 in contrast tachyzoites t. gondii entrapped b. besnoiti tachyzoites neither killed nets ets since host cell infectivity entirely restored upon dnase treatments 28 59 given that b. besnoiti tachyzoites mainly proliferate within endothelial cells acute phase parasitic stages released via cell lysis close proximity endothelium exposed blood contents leukocytes several reports shown nets interact endothelium may cause endothelial damage dysfunction 129131 since activated endothelial cells may produce broad panel immunomodulatory molecules il-8 p selectin identified potent net inducers 129 132 interactions infected endothelial cells b. besnoiti tachyzoites nets quite likely recently reported infection induced upregulation endothelial derived il-8 p selectin gene transcription furthermore presented indications net formation occurring adjacent infected endothelium pmn adhesion assays performed physiological flow conditions ones present small vessels recent net related investigations closely related cyst forming apicomplexan protozoa neospora caninum shown bovine pmn exposed viable tachyzoites also result strong netosis figure 1(f regard molecular mechanisms n. caninum triggered netosis seems p2y2- nox- soce- mpo- ne- erk1/2- p38 mapk- pad4-dependent villagra blanco et al submitted manuscript cryptosporidium parvum euryxenous apicomplexan parasite worldwide distribution high zoonotic potential mainly affecting young children immunocompromised humans neonatal livestock typically cryptosporidiosis water- food borne enteric disease causes diarrhoea dehydration weight losses abdominal pain leads significant economic losses livestock industry 133 134 after ingestion sporozoites released oocysts intestinal lumen infect small intestine epithelial cells recent studies reported significant contribution pmn macrophages inflammatory responses cryptosporidiosis vivo 136 137 muoz caro colleagues reported nets cast bovine human pmn response c. parvum stages parasite triggered netosis proved stage independent since induced sporozoites oocysts figure 1(b especially latter case parasite stages occasionally entirely covered net structures thereby probably hampering proper sporozoite excystation given pmn shown active even within intestinal lumen 108 109 138 139 reactions significant impact ongoing vivo infection vitro infection experiments additionally showed negative impact nets host cell invasion since infection rates significantly reduced using pmn preexposed c. parvum stages the fact reactions entirely reversible via dnase treatments rather argued cryptosporidicidal effects nets the colocalization ne histones mpo dna parasite mediated extracellular fibres proved classical characteristics nets inhibitor experiments emphasized key role ne nox mpo efficient net formation agreement findings eimeria induced netosis inhibition experiments revealed c. parvum triggered net formation dependent intracellular ca release erk 1/2 p38 mapk mediated signalling pathways interestingly c. parvum sporozoite exposed bovine pmn showed increased gene transcription proinflammatory molecules recently shown potent net inducers e.g. il-8 tnf- 140 141 may potentiated net reactions infections leishmania spp represent major health problem according 10% human world population risk infection meaning approximately 12 million people 98 countries infected 2 million new cases occur year 142 143 leishmaniasis vector transmitted zoonosis caused 25 different obligate intracellular protozoan leishmania species 142144 particularly pmn implicated immunopathogenesis leishmaniasis 145149 recent studies examined potential role nets early phase disease different leishmania species showed first time promastigotes leishmania amazonensis l. major l. chagasi capable triggering net formation additionally leishmania triggered netosis seems entirely stage specific since promastigotes l. amazonensis l. major l. chagasi l. donovani l. mexicana l brasiliensis amastigotes l. amazonensis l. braziliensis promoted net formation vitro vivo 51 147 150152 importantly guimares costa et al provided first indications possible parasite specific ligands responsible leishmania mediated netosis thus leishmania derived lipophosphoglycans lpg suggested main trigger net release since molecules also induced nets purified form the former authors showed nets possessed detrimental effects parasites net entrapped l. amazonensis promastigotes exhibited decreased viability authors also demonstrated extracellular dna histones found nets involved parasite inactivation killing process the leishmanicidal effects histones proven promastigotes cocultures purified h2a histones leading killing parasites significant reduction leishmanicidal effects cocultured presence anti histone antibodies demonstrated also histone h2b could directly efficiently kill promastigotes l. amazonensis l. major l. braziliensis l. mexicana case l. donovani gabriel et al reported netosis ros dependent process equally triggered human murine pmn see table 1 however leishmania lipophosphoglycan- lpg- dependent net induction reported guimares costa et al was observed l. donovani using genetically modified l. donovani promastigotes gabriel et al nonetheless infection system lpg appeared involved resistance nets mediated killing since wild type l. donovani maintained viability presence nets whilst mutant parasites lacking lpg efficiently killed extracellular structures a recent study revealed leishmania parasites trigger classical ros dependent netosis previously demonstrated also ros independent form named early rapid vital netosis early rapid leishmania triggered netosis in net formation takes place 515 min activation without affecting pmn viability 29 68 parasites also efficiently entrapped regarding net related evasion strategies trypanosomatidae parasites leishmania spp seem capable evading net killing firstly blocking oxidative burst activity pmn even resisting microbicidal activity nets 145 150 moreover guimares costa et al showed l. infantum promastigotes express enzyme 3-nucleotidase nuclease previously described involved parasite nutrition infection proven part ability promastigotes escape net mediated killing a recent investigation shown salivary component sand fly insect transmits leishmaniasis may also play role survival leishmania definitive hosts modulating innate immune system a molecule named lundep salivary gland lutzomyia longipalpis recently described endonuclease net destroying properties humans presence lundep measured ne release nets indicator net destruction since ne normally decorating nets backbone structures found low concentrations culture supernatants previously demonstrated lundep responsible significant increase ne concentration supernatants compared negative controls in conclusion experiments showed degradation dna scaffold nets destroying functional integrity increasing promastigote survival exacerbating l. major infection approximately eight million people affected tropical disease americas average 12,000 deaths per year known occur due american trypanosomiasis it well known macrophages eosinophils monocytes pmn implicated control early infection 30 155 demonstrated vitro t. cruzi able trigger nets dose- time- ros dependent manner agreement reports eimeria spp b. besnoiti 23 24 59 contrast observations t. gondii leishmania spp 25 51 viability t. cruzi stages affected nets netosis significantly impaired parasite host cell infectivity in fact nets components ne may affect t. cruzi infectivity since enzyme appears involved increased trypanocidal activity reduction trypomastigote release prestimulated infected macrophages 30 156 additionally authors showed via antibody mediated blockage t. cruzi triggered netosis tlr2- tlr4-dependent process moreover study showed viable t. cruzi trypomastigote forms also soluble antigens killed t. cruzi parasites induced net release human pmn in vivo murine studies indicated relevance netosis outcome trypanosomiasis since significantly decreased parasites numbers found blood system animals previously infected nets pretreated parasites during last years vast amount data protozoan mediated etosis published strengthening role effector mechanism defence parasitic infections several vivo data proven existence importance early host innate effector mechanism however still total lack information parasite derived ligands triggering etosis taking account cases et formation considered species- stage independent process rather ubiquitary occurring molecules may represent parasite derived target molecules ets moreover recent data revealed leukocytes monocytes macrophages basophils mast cells eosinophils also perform etosis upon pathogen encounter furthermore et related research mainly focused leukocytes aptitude impact parasites life cycle propensity parasitic stages develop counter mechanisms ets avoidance bunch data available bacterial nucleases counter mechanisms taken together call parasite related studies exciting field etosis

professional mononuclear phagocytes such as polymorphonuclear neutrophils ( pmn ) , monocytes , and macrophages are considered as the first line of defence against invasive pathogens . the formation of extracellular traps ( ets ) by activated mononuclear phagocytes is meanwhile well accepted as an effector mechanism of the early host innate immune response acting against microbial infections . recent investigations showed evidence that etosis is a widely spread effector mechanism in vertebrates and invertebrates being utilized to entrap and kill bacteria , fungi , viruses , and protozoan parasites . ets are released in response to intact protozoan parasites or to parasite - specific antigens in a controlled cell death process . released ets consist of nuclear dna as backbone adorned with histones , antimicrobial peptides , and phagocyte - specific granular enzymes thereby producing a sticky extracellular matrix capable of entrapping and killing pathogens . this review summarizes recent data on protozoa - induced etosis . special attention will be given to molecular mechanisms of protozoa - induced etosis and on its consequences for the parasites successful reproduction and life cycle accomplishment .

national tb prevalence survey eritrea conducted february october 2005 6 40 selected villages a census included information sex age taken 875 persons village all persons 15 years age asked provide morning spot sputum sample persons 2 positive sputum samples informed test results referred treatment those 1 positive sputum sample referred nearby healthcare facility smear examination if results smear examination negative thoracic radiographs taken evaluated 2 experienced radiologists case definition sputum smear positive case least 2 sputum specimens positive acid fast bacilli ziehl neelsen staining microscopy least 1 sputum specimen positive acid fast bacilli radiographic abnormalities consistent active pulmonary tb classification national tuberculosis control program eritrea using prevalence estimate obtained survey 2 different models calculated cdr 2004 model 1 described styblo cdr notification rate prevalence rate 0.5 0.83 notification rate prevalence rate 7,8 model 2 described dye et al cdr notification rate prevalence rate notification rate prevalence rate 0.5 9,10 we compared calculated cdr cdr estimated world health organization evaluate whether comparable conclusions tb case detection would obtained a total 38,047 persons included prevalence survey 15 years age 18,152 94.6% provided least 1 sputum sample figure the prevalence new smear positive tb estimated 90/100,000 95% confidence interval ci 35145/100,000 persons 15 years age 2005 44.7% of the eritrean population 15 years age 11 resulted overall new smear positive tb prevalence 50/100,000 95% ci 1980/100,000 assumption cases persons 15 years age summary tuberculosis prevalence survey eritrea 2005 2004 17/100,000 new smear positive cases reported 2 for eritrea cdr provided considerably lower calculated results national tb prevalence survey estimates indicate eritrea reached 70% target case detection however estimate suggests program needs improve case detection factor 5 whereas survey estimate suggests case detection needs improved factor 1.6 two explanations may account large difference 1 cdr derived tb prevalence survey high underestimation prevalence smear positive tb 2 cdr estimate published low overestimation incidence smear positive tb national tb prevalence survey measures taken ensure high quality results e.g. training data collectors repeat census taking reexamination slides found positive fluorescence microscopy reexamination 5% random sample negative slides persons smear positive tb may missed provide specimen however 5% eligible persons provide specimen explain slight underestimation furthermore recorded reasons providing specimen seem unrelated higher chance tb the quality provided specimens may suboptimal instructing motivating persons provide sputum sample challenging diagnosis tb microscopic examination saliva is less sensitive examination sputum however 50% saliva samples patients positive sputum sample bacilli demonstrated 12,13 27,647 samples appeared saliva smear assuming 50% detected maximum 12 smear positive tb patients may undetected taking account results prevalence 87/100,000 using estimate model 1 provides cdr 30% model 2 cdr 28% the possibility persons provided saliva sample able produce sputum sample pathologic pulmonary changes also taken consideration estimation incidence smear positive tb eritrea complicated fact data tuberculin prevalence surveys available the data available eritrea reporting data experts assessed low quality 14 use limited information result uncertain incidence estimate may result unreliable cdr countries africa little information available estimating prevalence disease progress towards millennium development goals http://unstats.un.org/unsd/mi/mi_goals.asp accessed 2006 aug 30 basis case reporting tb rightly declared emergency african health ministers africa regional committee maputo 2005 15 able fight emergency reliable information prevalence tb africa needed furthermore global tb control reliable information tb epidemic africa needed 28% incident smear positive cases occurred african region 2004 2 conclusion example eritrea shows large gap may exist available estimates tb prevalence actual tb prevalence africa national tb prevalence surveys africa would help provide better information tb prevalence case detection

we used results from a national tuberculosis prevalence survey in eritrea to calculate case detection rate ( cdr ) and compared it with the published cdr . the cdr obtained from the survey was 40% , whereas the cdr published by the world health organization was 3 lower ( 14% ) .

spermatogenesis complex process development occurs mammals throughout adulthood period this process happens seminiferous tubules lined epithelial tissue contains sertoli cells sertoli cells surrounded thin septum peritubular cells hold keep germ cells 1 2 spermatogonia undergo mitotic divisions meiotic alternations morphologically transform highly developed cells spermatozoa unique function structure 3 such complex process needs unique program control regulate involved genes this gene regulation accomplished cell surface molecules participate cell cell cell extracellular matrix interactions 4 5 hand when sperm passing male female genital tracts gains fertilization ability capacitation adopts maturity characteristics maturity initiated epididymis sperm communicates cell surface molecules pathway 6 therefore investigation stage and/or cell specific molecular expression testis post testicular maturation system improve understanding germ cell differentiation sperm formation 7 first identified 38kda protein mtex101 adult mouse testis detectable surface spermatocytes spermatids testis absent somatic cells including sertoli interstitial cells like leydig cells 3 there temporary expression mtex101 oogonia molecule disappears mature ovary embryonic testis mtex101 detected prosperm atogonia 8) upon puberty mtex101 mrna expressed spermatocytes steps 1 9 spermatids spermatogenesis spermatogonia the tex101 protein remains cell surfaces steps 10 16 spermatids testicular sperm hides epididymal sperm passing caput epididymis 6 the expression mtex101 homologous protein reported leukemia cell line lung cancer rats humans respectively 9 10 the exact structure function mtex101 completely understood yet speculated protein associated several transmembrane proteins like ly6k 11 cellubrevin 12 transduce extra cellular signals intracellular molecules the present study undertaken produce recombinant mtex101 might pave way production specific antibodies structural functional characterization molecule total rna isolated male gonadal organs four 6 week old mice pasteur institute iran rna concentration measured biophotometer eppendorf hamburg germany 260 nm one microgram total rna reversetranscribed cdna using 200u molony murine leukemia virus rtm mulv reverse transcriptase enzyme fermentas vilnius lithuania 20pmol random hexamer primers cybergene stockholm sweden pcr amplifications mtex101 transcript performed volume 25l using 10 20ng testis cdna forward reverse primers 10pmol specific mtex101 transcript 10x pcr buffer 2.5l dntp mixture 0.2 mm 1 mm mgcl2 1 unit taq dna polymerase roche mannheim germany pcr reactions carried using thermal cycler eppendorf mastercycler gradient indicated preheating cycle 95c 3min 35 cycles denaturation 95c 30sec annealing 60c 30sec extension 72c 60sec finally 7-min cycle 72c the forward reverse mtex101 orf primers used forward 5ccg aat tca tgg gag cct gcc gca tcc ag 3 reverse 5 agg gaa gtg ggt gag ggg gga gca gag cgg ccg c 3. contained ecori noti restriction enzyme sites respectively the pcr products resolved ethidium bromide stained 1.5% agarose gel electrophoresis revealed single distinct band 750bp figure 1 the 750bp band purified using qia quick gel extraction kit qiagen germantown md usa pcr optimization mouse testis cdna mgcl2 gradients 1 4 mgcl2 concentrations 1 4 mm respectively 5 1 kb dna ladder 6 negative control dna the pgem easy vector promega madison wi usa used cloning purified pcr product ligation reac tion set 50ng pgem easy vector promega three units t4 dna ligase 75ng mtex101 purified fragment 6l rapid 2x ligation buffer promega competent cells e. coli jm109 strain used transformation heat shock method 17 the transformed bacteria left 1 hr lb broth 37c recovery later 100l transformation culture plated onto ampicillin 100mg ml sigma louis mo usa iptg sigma 0.5 mm x gal sigma 80g ml containing lb agar plate cultured 16hrs 37c the recombinant plasmids isolated confirmed colonies miniperp kit qiagen digested ecori noti restriction enzymes plasmid dna 800ng used 25l total volume including noti 15units invitrogen carlsbad ca usa ecori 15 units invitrogen 2.5l 10 x reaction buffer 3 invitrogen incubated 1.5 hr 37c mtex101 fragment pgem t easy extracted form agarose gel subcloned pet-28a expression vector merck darmstadt germany digested restriction enzymes ligation reaction performed 125ng digested pet-28a 0.5pmol mtex101 purified fragments 2l rapid 2x ligation buffer pro mega 3 units t4 dna ligase promega 10l total volume incubated overnight 4c ligation products used transformation e. coli jm109 strain heat shock method 17 recovery time 1 hour lb broth transformed bacteria cultured lb agar kanamycin 50g ml sigma usa containing plates 16 hrs 37c the obtained colonies screened colony pcr one confirmed dna sequencing recombinant plasmid purified used transformation bl21 de3 protease deficient strain e. coli a single transformed colony inoculated 50ml lb broth including kanamycin 50g ml sigma usa untransformed bl21 de3 bacteria cultured 50 ml lb medium incubation performed shaking 37c optical density od 600 nm reached 0.6 iptg sigma added remainder final concentration 1 mm incubation continued 2 3 hours cell lysates prepared sonication pellets pbs buffer including 1% protease inhibitor roche protein solutions obtained bacteria boiling sample buffer contained tris hcl ph=6.8 0.5 sds 10% w v glycerol 50% v v bromo phenol blue 0.5% w v 5min samples 50l separated sds page 8% bio rad hercules ca usa non reducing conditions the protein constituents electro phoretically blotted onto polyvinylidene difluoride pvdf membrane millipore billerica usa described towbin et al ( the membrane blocked 5% skim milk 0.1% tween 20 pbs ph 7.4 reactivity transferred protein(s 1g ml anti mtex101 pab avicenna research institute iran assessed using sheep anti rabbit ig hrp avicenna research institute iran finally membranes visualized using ecl system ge healthcare biotech bucking hamshire uk total rna isolated male gonadal organs four 6 week old mice pasteur institute iran rna concentration measured biophotometer eppendorf hamburg germany 260 nm one microgram total rna reversetranscribed cdna using 200u molony murine leukemia virus rtm mulv reverse transcriptase enzyme fermentas vilnius lithuania 20pmol random hexamer primers cybergene stockholm sweden pcr amplifications mtex101 transcript performed volume 25l using 10 20ng testis cdna forward reverse primers 10pmol specific mtex101 transcript 10x pcr buffer 2.5l dntp mixture 0.2 mm 1 mm mgcl2 1 unit taq dna polymerase roche mannheim germany pcr reactions carried using thermal cycler eppendorf mastercycler gradient indicated preheating cycle 95c 3min 35 cycles denaturation 95c 30sec annealing 60c 30sec extension 72c 60sec finally 7-min cycle 72c the forward reverse mtex101 orf primers used forward 5ccg aat tca tgg gag cct gcc gca tcc ag 3 reverse 5 agg gaa gtg ggt gag ggg gga gca gag cgg ccg c 3. contained ecori noti restriction enzyme sites respectively the pcr products resolved ethidium bromide stained 1.5% agarose gel electrophoresis revealed single distinct band 750bp figure 1 the 750bp band purified using qia quick gel extraction kit qiagen germantown md usa pcr optimization mouse testis cdna mgcl2 gradients 1 4 mgcl2 concentrations 1 4 mm respectively 5 1 kb dna ladder 6 negative control dna the pgem easy vector promega madison wi usa used cloning purified pcr product ligation reac tion set 50ng pgem easy vector promega three units t4 dna ligase 75ng mtex101 purified fragment 6l rapid 2x ligation buffer promega competent cells e. coli jm109 strain used transformation heat shock method 17 the transformed bacteria left 1 hr lb broth 37c recovery later 100l transformation culture plated onto ampicillin 100mg ml sigma louis mo usa iptg sigma 0.5 mm x gal sigma 80g ml containing lb agar plate cultured 16hrs 37c the recombinant plasmids isolated confirmed colonies miniperp kit qiagen digested ecori noti restriction enzymes plasmid dna 800ng used 25l total volume including noti 15units invitrogen carlsbad ca usa ecori 15 units invitrogen 2.5l 10 x reaction buffer 3 invitrogen incubated 1.5 hr 37c mtex101 fragment pgem t easy extracted form agarose gel subcloned pet-28a expression vector merck darmstadt germany digested restriction enzymes ligation reaction performed 125ng digested pet-28a 0.5pmol mtex101 purified fragments 2l rapid 2x ligation buffer pro mega 3 units t4 dna ligase promega 10l total volume incubated overnight 4c ligation products used transformation e. coli jm109 strain heat shock method 17 recovery time 1 hour lb broth transformed bacteria cultured lb agar kanamycin 50g ml sigma usa containing plates 16 hrs 37c the obtained colonies screened colony pcr one confirmed dna sequencing recombinant plasmid purified used transformation bl21 de3 protease deficient strain e. coli a single transformed colony inoculated 50ml lb broth including kanamycin 50g ml sigma usa untransformed bl21 de3 bacteria cultured 50 ml lb medium incubation performed shaking 37c optical density od 600 nm reached 0.6 iptg sigma added remainder final concentration 1 mm incubation continued 2 3 hours cell lysates prepared sonication pellets pbs buffer including 1% protease inhibitor roche protein solutions obtained bacteria boiling sample buffer contained tris hcl ph=6.8 0.5 sds 10% w v glycerol 50% v v bromo phenol blue 0.5% w v 5min samples 50l separated sds page 8% bio rad hercules ca usa non reducing conditions the protein constituents electro phoretically blotted onto polyvinylidene difluoride pvdf membrane millipore billerica usa described towbin et al 13 the membrane blocked 5% skim milk 0.1% tween 20 pbs ph 7.4 reactivity transferred protein(s 1g ml anti mtex101 pab avicenna research institute iran assessed using sheep anti rabbit ig hrp avicenna research institute iran finally membranes visualized using ecl system ge healthcare biotech bucking hamshire uk after cloning mtex101 fragments pgem easy vector several white colonies probable target fragment inclusion screened colony pcr figure 2 a right sized pcr product pet-28a(+ vector cut noti ecori restriction enzymes obtain required fragments next step figures 3 4 coloy pcr transformed jm109 clones pgem easy vector carrying mtex101 gene 1 5 5 selected white colonies 6 negative control blue colony 7 positive control pcr product testis cdna 8 dna ladder viii roche double digestion pgem easy vector containing mtex101 fragment ecori noti restriction enzymes 1 digested vector mtex101 750bp insert cut vector 2 dna ladder viii double digestion pet-28a expression vector restriction enzymes 1 digested pet-28a ecori noti 2 uncut pet-28a 3 1 kb dna ladder e. coli j m109 strains transformed using recombinant pet-28a(+ containing mtex101 fragment undertaken transformation verified colony pcr figure 5 one confirmed colonies clone 2 figure 5 picked detailed analysis dna sequencing alignment dna sequencing results mtex101 orf genbee site 14 confirmed cloned sequence the verified fragment used next round transformation using e coli bl21 de3 strain colony pcr transformed jm109 clones pet-28a vector containing mtex101 fragment 1 2 represent two selected colonies 3 dna ladder viii 4 negative control dna 5 positive control pgem easy vector containing mtex101 fragment western blot analysis using anti mte x 101 peptide polyclonal antibody revealed correct size mtex101 recombinant protein production 27kda bl-21 de3 bacteria figure 6 western blot analysis production recombinant mtex101 bl21 de3 bacteria 1 bl21 de3 containing mtex101 gene induction 2 bl21 de3 containing mtex101 gene induction 3 untransfected bl21 de3 4 protein marker see blue invitrogen after cloning mtex101 fragments pgem easy vector several white colonies probable target fragment inclusion screened colony pcr figure 2 a right sized pcr product pet-28a(+ vector cut noti ecori restriction enzymes obtain required fragments next step figures 3 4 coloy pcr transformed jm109 clones pgem easy vector carrying mtex101 gene 1 5 5 selected white colonies 6 negative control blue colony 7 positive control pcr product testis cdna 8 dna ladder viii roche double digestion pgem easy vector containing mtex101 fragment ecori noti restriction enzymes 1 digested vector mtex101 750bp insert cut vector 2 dna ladder viii double digestion pet-28a expression vector restriction enzymes 1 digested pet-28a ecori noti 2 uncut pet-28a 3 1 kb dna ladder e. coli j m109 strains transformed using recombinant pet-28a(+ containing mtex101 fragment undertaken transformation verified colony pcr figure 5 one confirmed colonies clone 2 figure 5 picked detailed analysis dna sequencing alignment dna sequencing results mtex101 orf genbee site 14 confirmed cloned sequence the verified fragment used next round transformation using e coli bl21 de3 strain colony pcr transformed jm109 clones pet-28a vector containing mtex101 fragment 1 2 represent two selected colonies 3 dna ladder viii 4 negative control dna 5 positive control pgem easy vector containing mtex101 fragment western blot analysis using anti mte x 101 peptide polyclonal antibody revealed correct size mtex101 recombinant protein production 27kda bl-21 de3 bacteria figure 6 western blot analysis production recombinant mtex101 bl21 de3 bacteria 1 bl21 de3 containing mtex101 gene induction 2 bl21 de3 containing mtex101 gene induction 3 untransfected bl21 de3 4 protein marker see blue invitrogen the researchers immunized female mice 8-week old testis lysates obtained 12 monoclonal antibody producing clones tes101 112 immunohisto chemistry analyses revealed tes101 able recognize novel testicular protein determined searching expressed sequence tag est database 3 studies mtex101 protein performed solely tes101 antibody presently commercial antibodies available carry research protein study produced mtex101 recombinant protein useful antibody development investigations mtex101 mrna contains 750 bases encodes 250 amino acids removal putative 25-amino acid signal peptide n terminus reported 38kda band western blot analysis non reducing conditions 24 kda band observed 3 this large difference molecular mass speculated due glycosylation peptide proved true jin et al glycosylation known prime cause post translational modifications ptm proteins 16 the asn x ser thr basic sequence n linked glycosylation however secondary structure protein affect final addition no consensus sequence established linked glycosylation yet 17 jin et al found four putative sites n glyco sylation several possible sites glyco sylation mtex101 amino acid sequence 15 in fact mtex101 highly glycosylated protein clarified oligosaccharide chains peptide n linked carbohydrates 12 de n glycosylation mtex101 created 20kda band close even smaller estimated molecular weight mtex101 amino acid backbone 15 confirming glycosylation cause higher mass native mtex101 the cellular role glycoprotein sugar components investigated via several methods like protein production host lacking oligo saccharide addition system prokaryotes 18 we succeeded produce mtex101 recombinant protein prokaryotic system may useful clarifying role sugar components protein structures however proteins produced method may vary structures functions 19 western blot analysis showed protein molecular mass approximately 27kda non reducing conditions concordant various post translational modification processes prokaryotic systems compared eukaryotes the size recombinant protein 27kda conformity backbone protein 24kda 3kda peptide derived digested vector noti ecori restriction enzymes in study successfully cloned mtex101 tagged expression vector pet-28a(+ followed efficient production relevant recombinant protein this protein used antibody production find role mtex101 spermatogenesis egg fertilization investigation critical role glycosylation function protein

introductionproduction of antibodies against specific proteins of testis germ cells is of great significance for the investigation of processes involved in spermatogenesis , study of infertility problems and determination of the probable role of these proteins as cancer - testis antigens . murine testis specific recombinant protein 101 ( mtex101 ) is a 38kda , gpi - anchored protein which is expressed in testis germ cells of adult mice but it seems to be absent in other tissues . the structure and function of mtex101 is not completely understood yet , but it is speculated that it may transduce biochemical signals into the cytoplasm since mtex101 does not have an intracellular domain but the precise mechanisms are still ambiguous.materials and methodsrna was extracted from three adult mice testis . the rna was used in rt - pcr , employing a pair of specific primers for mtex101 orf region . ta - cloning technique was performed by the insertion of mtex101 into a pgem - t easy vector , followed by its subcloning into a his - tagged expression vector , pet-28a ( + ) . the recombinant mtex101 was then produced by transfection of the expression vector into bl 21 ( de3 ) e. coli strain.resultsa recombinant protein , weighing 27kda , was produced upon iptg - induction of the bacterial host . the presence of mtex101 protein was detected through western blot analysis by anti - mtex101 peptide antibodies.conclusionwe produced mtex101 recombinant protein that could be used for the production of mono and polyclonal antibodies .

malignancies upper aerodigestive tract figure 1 comprising naso- oro- hypo- laryngopharynx squamous cell carcinomas head neck squamous cell carcinomas hnsccs primary tumor type head neck cancer hnc characterized local tumor aggressiveness high rate early recurrences metastasis development second primary tumors major cause morbidity mortality hnscc details 14 90% hnc cases induced chronic exposure carcinogens enclosed forms tobacco synergized heavy alcohol consumptions poor diet see 5 6 it estimated 5%10% suspicious lesions arising mucous membranes mouth pharynx larynx undergo malignant transformation cure rates early disease stage ii range 70% 80% chemoprevention strategies seem promising control potentially malignant oral lesions reviewed 13 however long term survival rates especially advanced hnc improved significantly last decades despite modern therapeutic strategies sophisticated surgical management tumor the estimated five year survival rate advanced disease 30%40% remains poor 13 references therein currently rational therapeutic strategies targeting growth factor receptors specific antibodies kinase inhibitors gained increasing clinical relevance particular treatment locally advanced cancer intent preserving speech swallowing see 13 thus developing new therapeutic strategies defining novel target proteins treatment advanced hnc particular importance respect nuclear receptors nrs transcription factors implicated cancer development recently attracting major interest therapeutic targets see 7 8 as nrs modulate cell proliferation apoptosis invasion migration clearly representing hallmarks cancer cells several highly successful cancer drugs target receptor family 811 since several nrs have shown expressed also head neck cancer cells nrs likely also contributing hnscc development progression 12 13 nrs belong large superfamily transcription factors based sequence comparison currently classified seven subfamilies table 1 these transcription factors able modulate transcription variety target genes several distinct mechanisms including transcriptional activation repression 7 8 14 15 transcriptional regulation either ligand dependent -independent genomic nongenomic allowing nrs mediate gene repression release gene activation gene trans repression details 7 8 16 in particular large group called orphan nuclear receptors natural ligands still unknown exist true orphans recently identified adopted orphans adding additional complexity field table 1 8 17 references within in contrast cell surface growth factor receptors epidermal growth factor receptor egfr activate genetic programs complex intracellular signaling cascades nrs able directly bind specific dna sequences called hormone response elements hres thus nrs composed n terminal regulatory domain activation function 1 af1 followed dna binding domain dbd ligand binding domain lbd another c terminal regulatory domain activation function 2 af2 figure 2 7 8 despite conserved structural organization nevertheless two major modes nr action assigned depending intracellular steady state localization absence ligands figure 3 one group nrs confined cytoplasm within multiprotein complexes absence ligand upon ligand binding actively enter nucleus bind hres homo- heterodimers figure 4 details 7 8 other nrs already reside nucleus complex corepressor proteins ligand binding triggers corepressor dissociation allowing recruitment coactivators 18 19 however order fulfill multiple biological tasks minor major deviations two modes nr action exist 7 8 nrs implicated broad spectrum physiological processes associated many human diseases including metabolic cardiovascular disorders well cancer beside proven clinical relevance hormone regulated malignancies rather limited information pathophysiological role well prognostic therapeutic potential head neck cancer 7 8 12 2022 most studies investigating members two classes nr superfamily thyroid hormone receptor like estrogen receptor like receptors table 1 thus focus relevant members subfamilies summarize potential diagnostic prognostic value discuss therapeutic potential within thyroid hormone receptor like receptor subfamily peroxisome proliferator activated receptors ppars show highest disease relevance hnscc date three isoforms ppar identified able form heterodimers retinoid x receptors rxrs see 23 24 ppars expressed different cell types activate transcription several genes involved variety biological processes including lipid metabolism insulin sensitivity see 23 24 furthermore role limiting inflammation also reported 24 25 as tumor cell metabolism inflammation appear critical tumorigenesis clinical outcome nrs may thus directly indirectly modulate malignancies 26 27 as ppar overexpressed many epithelial malignancies 22 28 29 including oral squamous cell carcinoma absence ligand ppars complexed corepressor proteins thus acting transcriptional repressors ligand binding induces conformational changes facilitating heterodimerization rxr thus leading attraction transcriptional coactivators figures 3 4 see 19 24 natural synthetic ligands ppars include lipophilic molecules fatty acids eicosanoids well thiazolidinedione tzd drugs derivates thereof overview 7 24 31 ppar ligands seem exert effects dosage dependent manner although detailed mechanism currently yet resolved the postulated cancer modulating mechanisms diverse including effects wnt signaling inhibition nfb well modulation cell cycle regulators pro- antiapoptotic proteins linked head neck cancer see 4 23 ) clinical aspects peroxisome proliferator activated receptors hnsccin hnscc overexpression protein level convincingly demonstrated ppar ppar 12 30 33 agonist binding ppar induce cell differentiation growth arrest apoptosis cancer cells additionally activating ppar ligands shown exert antiproliferative human colon breast cancers details 23 24 also suggested potential chemopreventive agents oral carcinogenesis 12 35 36 note since least 1.6 million patients take antidiabetic drugs function ppar ligands epidemiological data long term effects tumor prevention would therefore value rationally design cancer chemoprevention trials paradoxically ppar agonists considered potential therapeutic agents cancer therapy also antagonists studied respect ppar inhibition shown induce apoptosis anoikis inhibit tumor cell invasion squamous cell carcinomas moreover results several studies indicated growth inhibiting activity ppar ligands oscc may ppar independent others showed observed effects strongly dependent ppar-expression 12 38 well type concentration agonist majority oscc cases ppar mrna could detected rt pcr immunohistochemical analysis primary tumors ppar often found low grade tumors especially tumor endothelium favorable impact ppar expression relapse free survival patients could demonstrated the beneficial effects ppar ligands malignancies tested several clinical trials outcomes proved highly diverse trials revealed 40% partial response rates whereas others could show significant beneficial effect 41 42 moreover one may speculate tumor modulating effects ppar ligands mediated indirectly affecting tumor microenvironment cancer associated fibroblasts tumor endothelial cells in fact ppar ligands shown affect endothelial cell proliferation migration hence regulate angiogenesis also hypoxia induced angiogenesis appears affected ppar ligands cancer therapy even precise mechanisms still remain unclear as angiogenesis crucial aspect tumor development therapy resistance metastasis inhibition angiogenesis may hence contributed clinical benefit observed.in sum ppar ligands appear clinical benefit treatment head neck cancer particular oscc nevertheless detailed molecular knowledge ppar biology clearly required increasing knowledge mode action specificity dosage dependence ppar agonistic antagonistic ligands hopefully allow better modeling ppar receptor function thus lead effective design combinatorial application schemes cancer treatment cancer prevention future hnscc overexpression protein level convincingly demonstrated ppar ppar 12 30 33 agonist binding ppar induce cell differentiation growth arrest apoptosis cancer cells additionally activating ppar ligands shown exert antiproliferative human colon breast cancers details 23 24 also suggested potential chemopreventive agents oral carcinogenesis 12 35 36 note since least 1.6 million patients take antidiabetic drugs function ppar ligands epidemiological data long term effects tumor prevention would therefore value rationally design cancer chemoprevention trials paradoxically ppar agonists considered potential therapeutic agents cancer therapy also antagonists studied respect ppar inhibition shown induce apoptosis anoikis inhibit tumor cell invasion squamous cell carcinomas moreover results several studies indicated growth inhibiting activity ppar ligands oscc may ppar independent others showed observed effects strongly dependent ppar-expression 12 38 well type concentration agonist majority oscc cases ppar mrna could detected rt pcr immunohistochemical analysis primary tumors ppar often found low grade tumors especially tumor endothelium favorable impact ppar expression relapse free survival patients could demonstrated the beneficial effects ppar ligands malignancies tested several clinical trials outcomes proved highly diverse trials revealed 40% partial response rates whereas others could show significant beneficial effect 41 42 moreover one may speculate tumor modulating effects ppar ligands mediated indirectly affecting tumor microenvironment cancer associated fibroblasts tumor endothelial cells in fact ppar ligands shown affect endothelial cell proliferation migration hence regulate angiogenesis also hypoxia induced angiogenesis appears affected ppar ligands cancer therapy even precise mechanisms still remain unclear as angiogenesis crucial aspect tumor development therapy resistance metastasis inhibition angiogenesis may hence contributed clinical benefit observed sum ppar ligands appear clinical benefit treatment head neck cancer particular oscc increasing knowledge mode action specificity dosage dependence ppar agonistic antagonistic ligands hopefully allow better modeling ppar receptor function thus lead effective design combinatorial application schemes cancer treatment cancer prevention future another group thyroid hormone receptor like receptors implicated hnscc retinoid acid receptors rars rars characterized activation via vitamin derivatives upon activation rars able heterodimerize retinoid x receptors rxr bind specific hormone response elements hres thereby modulating transcription target genes figures 3 4 8 26 46 date variety coactivator- corepressor proteins identified allowing fine tuning target gene transcription ranging repression full activation however molecular details beginning uncovered 8 26 46 rar activation often leads differentiation cell cycle arrest apoptosis culminating inhibiting tumor growth hence ligand retinoid acid ra derivates thereof currently tested therapeutic agents several cancer types table 2 paradoxically malignancies ra rather promotes cell survival may due ability ra also activate ppars consequence expression prosurvival genes induced could also show channeling ra two nuclear receptor heterodimers mediated cytoplasmic ra transporters crabp2 fabp5 thus strongly depending fabp5/crabp2 ratio thus channeling ra different receptor heterodimers appears crucial regulation cell proliferation positively negatively affecting tumor growth interestingly proteins found differentially expressed metastatic hpv associated hnscc biological clinical effects remain investigated 51 52 an additional way biological regulation epigenetic modulation playing important role cancer development reviewed gene silencing caused aberrant hypermethylation cpg islands detected promoter regions several tumor suppressor genes several studies show hypermethylation rar promoter colon breast lung cancers 54 55 head neck carcinogenesis hypermethylation rar promoter was found indeed associated rar downregulation hence appears biologically relevant clinical aspects retinoid acid receptors hnsccas outlined rationale use retinoids chemoprevention cancer therapy provided experimentally different cellular animal models moreover strategy supported epidemiological data well clinical trial outcomes 26 5961 several clinical chemoprevention trials including patients increased risk developing cancer shown treatment retinoids resulted suppression precancerous lesions see 26 60 also certain retinoids inhibited development second primary tumors patients previously treated early stage cancer remained high risk relapse 26 60 references within however studies using isotretinoin retinoids e.g. retinyl palmitate observe benefit second primary tumor development recurrence mortality hnscc lung cancer 26 62 current trials table 2 therefore aiming resolve controversies recruiting appropriate study populations well use novel drugs improved treatment protocols.reduced rar mrna levels observed several malignant tumors 26 56 references therein also premalignant oral lesions references within thus studies demonstrating rar downregulation based situ hybridization could therefore show decrease amount mrna were first demonstrate decreased expression rxr rar// protein level correlating different stages oscc development progression the molecular mechanism leading downregulation loss rar poorly understood suggested expression rar could depend intracellular level retinoids several studies demonstrated decrease amount rar vitamin deficiency well upregulation ra additionally evidence retinoic acid induces expression rar mrna certain cell lines malignant counterparts cells thus transformed cells may developed aberrant response retinoic acid due deregulated expression coactivator repressor proteins ralhan et al found significant association increase rar mrna levels clinical responses premalignant oral lesions isotretinoin 65 66 hence rar indeed seems contribute suppression premalignant phenotype malignancy may causally linked clinical outcome chemoprevention trials retinoids 26 67 if rar may indeed serve useful diagnostic marker retinoid trials table 2 prevention oral carcinogenesis rar modulation agonist ligand trans retinoic acid atra represents successful example targeting nr contributes impressive clinical benefit liquid tumors references therein lessons learned studies clearly show therapeutic benefit could enhanced combining atra chromatin modulating agents histone deacetylase inhibitors nevertheless design receptor specific drugs well depth understanding molecular regulation rar biology required order fully exploit therapeutic benefit minimize potential side effects area head neck cancer 7 26 as outlined rationale use retinoids chemoprevention cancer therapy provided experimentally different cellular animal models moreover strategy supported epidemiological data well clinical trial outcomes 26 5961 several clinical chemoprevention trials including patients increased risk developing cancer shown treatment retinoids resulted suppression precancerous lesions see 26 60 also certain retinoids inhibited development second primary tumors patients previously treated early stage cancer remained high risk relapse 26 60 references within however studies using isotretinoin retinoids e.g. retinyl palmitate observe benefit second primary tumor development recurrence mortality hnscc lung cancer 26 62 current trials table 2 therefore aiming resolve controversies recruiting appropriate study populations well use novel drugs improved treatment protocols reduced rar mrna levels observed several malignant tumors 26 56 references therein also premalignant oral lesions references within unfortunately recently antibodies convincingly detecting rar available thus studies demonstrating rar downregulation based situ hybridization could therefore show decrease amount mrna were first demonstrate decreased expression rxr rar// protein level correlating different stages oscc development progression the molecular mechanism leading downregulation loss rar poorly understood suggested expression rar could depend intracellular level retinoids several studies demonstrated decrease amount rar vitamin deficiency well upregulation ra additionally evidence retinoic acid induces expression rar mrna certain cell lines malignant counterparts cells thus transformed cells may developed aberrant response retinoic acid due deregulated expression coactivator repressor proteins found significant association increase rar mrna levels clinical responses premalignant oral lesions isotretinoin 65 66 hence rar indeed seems contribute suppression premalignant phenotype malignancy may causally linked clinical outcome chemoprevention trials retinoids 26 67 if rar may indeed serve useful diagnostic marker retinoid trials table 2 prevention oral carcinogenesis rar modulation agonist ligand trans retinoic acid atra represents successful example targeting nr contributes impressive clinical benefit liquid tumors references therein lessons learned studies clearly show therapeutic benefit could enhanced combining atra chromatin modulating agents histone deacetylase inhibitors nevertheless design receptor specific drugs well depth understanding molecular regulation rar biology required order fully exploit therapeutic benefit minimize potential side effects area head neck cancer 7 26 this subfamily composed estrogen receptors er er estrogen related receptor 3-ketosteroid receptors besides estrogen receptors many genes regulated er estrogen axis critical cell proliferation inhibition apoptosis stimulation invasion metastasis well promotion angiogenesis see 10 11 references within since processes clearly state hallmarks cancer cells well accepted ers implicated various cancer types 9 21 sex hormone receptors expressed sexual organs amongst others also vascular epithelium lung epithelium larynx the expression sex hormone receptors could also demonstrated hnscc several studies 12 13 both er isoforms well progesterone receptor pr detectable cancer cells oral cavity salivary gland laryngeal hypopharyngeal cancers whereas tumor stroma mostly negative 12 13 expression er inversely correlated er esophageal carcinoma correlation er levels tumor dedifferentiation staging suggested 73 74 clinical aspects estrogen receptors hnsccconsidering impressive benefit endocrine therapy breast cancer targeting sex steroid hormone receptor potential therapeutic strategy also discussed hnscc 12 75 currently two main strategies pursued endocrine therapy er positive tumors one based steroidal antiestrogens like tamoxifen bind er block function ultimately induce receptor degradation 8 11 the based aromatase inhibitors luteinizing hormone releasing hormone agonists reduce level circulating estrogen thereby inhibiting er activation depriving receptor ligand tamoxifen already shown inhibit proliferation invasion hnscc cell lines resulting apoptosis could enhanced upon combination cisplatin 7678 thus therapeutic role antiestrogens aromatase inhibitors clinical management hnscc currently investigation results completed clinical trials table 2 eagerly awaited.however precise molecular roles impact estrogen receptor like receptors onset and/or progression head neck cancer remain clarified knowledge required order rationally decide whether investigate potential modern endocrine therapy also tumor entity considering impressive benefit endocrine therapy breast cancer targeting sex steroid hormone receptor potential therapeutic strategy also discussed hnscc 12 75 currently two main strategies pursued endocrine therapy er positive tumors one based steroidal antiestrogens like tamoxifen bind er block function ultimately induce receptor degradation 8 11 the based aromatase inhibitors luteinizing hormone releasing hormone agonists reduce level circulating estrogen thereby inhibiting er activation depriving receptor ligand tamoxifen already shown inhibit proliferation invasion hnscc cell lines resulting apoptosis could enhanced upon combination cisplatin 7678 thus therapeutic role antiestrogens aromatase inhibitors clinical management hnscc currently investigation results completed clinical trials table 2 eagerly awaited however precise molecular roles impact estrogen receptor like receptors onset and/or progression head neck cancer remain clarified knowledge required order rationally decide whether investigate potential modern endocrine therapy also tumor entity nrs associated head neck cancer hence seem least partially amenable prevention and/or treatment strategies so far three nr groups mainly linked hnscc retinoic acid peroxisome proliferator activated estrogen receptors also target genes activated nr subfamilies table 3 implicated key elements molecular circuits involved head neck cancer development progression reports members nr superfamiliy rather scarce tumor entity suggesting investigated far taking thyroid hormone receptor example many studies relevance various malignancies conducted whereas role head neck cancer including even thyroid carcinomas analyzed detail likewise data cancer related biological functions orphan nrs still missing tumor entity 7 8 cancer achilles heel may conceivable speculate molecules present diet tobacco beetle nut might deregulate cell metabolism affecting nrs contribute head neck carcinogenesis 27 80 note development novel nr ligands improved specificity activity currently intensively pursued area metabolic diseases see 7 8 81 hence interdisciplinary exploitation existing knowledge nr pharmacobiology may result novel hnscc treatment approaches sum keeping mind enormous success nr targeting therapeutics several malignancies systematic investigation nr biology well clinical relevance highly desirable also head neck cancer together outcomes current clinical trials table 2 improved knowledge hopefully result strategies improved benefit patient

head and neck squamous cell carcinomas are among the most common neoplasms worldwide and characterized by local tumor aggressiveness , high rate of early recurrences , development of metastasis , and second primary cancers . despite modern therapeutic strategies and sophisticated surgical management , overall survival - rates remained largely unchanged over the last decades . thus , the need for novel treatment options for this tumor entity is undeniable . a key event in carcinogenesis is the uncontrolled modulation of genetic programs . nuclear receptors belong to a large superfamily of transcription factors implicated in a broad spectrum of physiological and pathophysiological processes , including cancer . several nuclear receptors have also been associated with head and neck cancer . this review will summarize their mode of action , prognostic / therapeutic relevance , as well as preclinical and clinical studies currently targeting nuclear receptors in this tumor entity .

alcoholic liver disease ald represents spectrum clinical illness morphological changes range fatty liver hepatic inflammation necrosis alcoholic hepatitis progressive fibrosis alcoholic cirrhosis many toxic effects ethanol liver associated metabolism ethanol oxidation generates toxic products acetaldehyde reactive oxygen species result oxidative stress initiates apoptosis cell injury 25 it activated endotoxin cytokines oxidative stress unstimulated cells nf-b heterodimeric complex sequestered cytoplasm interaction ib family inhibitors when cells stimulated ib phosphorylated subsequent release nf-b resulting translocation nf-b cytoplasm nucleus activates expression target genes 7 8 activation nf-b increased expression proinflammatory cytokines chemokines key factors ethanol induced liver injury rats 912 peroxisome proliferators activated receptors gamma ppar family ligand activated nuclear transcriptional factor regulates cell differentiation apoptosis lipid metabolism inflammation recently decreased expression ppar found rats alcoholic liver fibrosis these suggested ppar may play important role development hepatocellular inflammation necrosis fibrosis rats ethanol consumption curcumin diferuloylmethane antiinflammatory antioxidant compound isolated rhizomes plant curcuma longa linn importantly showed curcumin suppressed activation nf-b ethanol induced liver injury rats activation ppar curcumin resulted inhibition nf-b trans activating activity increased expression ppar transcriptional translational levels activated hepatic stellate cells hscs however unclear whether curcumin effect early stage ethanol induced liver injury therefore present study determined effect curcumin early stage ethanol induced liver inflammation improved pathology rats female sprague dawley rats weighing 180220 grams purchased national laboratory animal center mahidol university salaya nakorn pathom used the rats kept controlled temperature room 25 1c standard conditions 12-hour day night rhythm all rats received well care accordance ethical committee faculty medicine chulalongkorn university thailand curcumin powder form cayman chemical company usa dissolved 50% ethanol freshly prepared experiment all rats fed controlled diet contained 35% energy fat 18% protein 47% carbohydrate 4 weeks ad libitum group 1 control n 8) rats fed distilled water 2.0 ml orally via intragastric tube per day 4 weeks group 2 ethanol n 8) rats fed 50% ethanol 7.5 g kg bw day orally via intragastric tube twice day 4 weeks group 3 ethanol curi n 6 rats fed curcumin 200 mg kg bw dissolved 50% ethanol 7.5 g kg bw day via intragastric tube twice day 4 weeks group 4 ethanol curii n 7 rats fed curcumin 600 mg kg bw dissolved 50% ethanol 7.5 g kg bw day using intragastric tube twice day 4 weeks end study three small pieces livers collected frozen liquid nitrogen stored 80c mda analysis sod activity ppar protein expression the remaining liver fixed 10% formalin solution determine histopathology nf-b activation hepatic apoptosis after liver samples fixed 10% formalin solution room temperature processed standard method briefly tissues embedded paraffin sectioned 5 stained hematoxylin eosin picked glass slides light microscopy all fields section examined grading steatosis necroinflammation according colantoni et al steatosis scored percentage parenchymal cells containing fat micro- macrosteatosis 0 parenchymal cells containing fat 1 20% parenchymal cells containing fat 2 2039% parenchymal cells containing fat 3 4050% parenchymal cells containing fat inflammation necrosis scored number foci inflammation necrosis identified low power field light microscope 0 inflammation necrosis 1 1 focus per low power field inflammation necrosis 2 2 foci per low power field inflammation necrosis 3 3 foci per low power field inflammation necrosis mda assayed determining rate production thiobarbituric acid reactive components an aliquot 0.2 ml mixed solution containing 20% acetic acid 0.8% thiobarbituric acid 8.1% sodium dodecyl sulfate heated water bath 95c 60 minutes the solution centrifuged 10 minutes 4 000 rpm absorbance supernatant fraction determined wavelength 546 nm sod determined using method winterbourn light triggered release superoxide radicals riboflavin leads formation blue complex reaction nitroblue tetrazolium one gram liver homogenized 0.1 phosphate buffer ph 7.4 ice cleared centrifugation 3 000 rpm 4c 15 minutes the supernatant fraction incubated solution containing 0.067 phosphate buffer ph 7.8 0.1 edta 1.5 mm nbt 0.12 mm riboflavin 10 minutes illuminated chamber 18 w fluorescent lamp absorbance recorded 560 nm sod activity expressed units mg protein apoptosis measured identification apoptotic nuclei sections liver fragment end labeling dna apoptosis detection kit chemicon usa brief the dna fragments allowed bind antidigoxigenin antibody conjugated peroxidase diaminobenzidine dab applied develop dark brown color slides counterstained hematoxylin the results expressed number positive stained cells per high power field the liver sections deparaffinized xylene ethanol ten minutes water washing sections retrieved antigen nf-b p65 santa cruz usa citrate buffer ph 6.0 microwave thirteen minutes next 3% h2o2 3% normal horse serum performed slides block endogenous peroxidase activity five minutes blocked nonspecific binding twenty minutes respectively then primary antibody used nf-b p65 polyclonal antibody p65 subunit applied dilution 1:150 one hour room temperature incubated secondary antibody thirty minutes when development color dab detected slides counterstained hematoxylin light microscopy positive stained cells presented dark brown nucleus the results expressed number positive stained cells per high power field liver sample 0.1 g ) was homogenized 1 ml lysis buffer 30 minutes ice cleared centrifugation 12 000 rpm 15 minutes 4c a 60 g protein applied 10% sds page gel fractionated proteins transferred polyvinylidene fluoride membrane membrane blocked tbst containing 5% dry nonfat milk 1 hour incubated ppar monoclonal antibodies 1:400 santa cruz usa overnight 4c then washed three times incubated secondary antibody goat antimouse igg horseradish peroxidase 1:4,000 cayman usa 1 hour all data presented means standard deviation sd comparison among groups animals one way analysis variance one way anova and the histologic appearance liver control group normal figure 1(a ethanol treated group histologic features showed mild moderate steatosis mild necroinflammation figure 1(b rats treated ethanol curcumin 400 mg kg bw day improved liver histopathology showed mild steatosis necroinflammation figure 1(c high dose curcumin treatment 1,200 mg kg bw day also improved liver histopathology showed mild steatosis mild necroinflammation figure 1(d summary steatosis necroinflammation score shown table 1 the level hepatic mda marker lipid peroxidation increased significantly ethanol treated group compared control group 3.42 1.36 versus 1.44 0.24 nmol mg protein p .05 curcumin treatment 400 1,200 mg kg bw day decreased elevation hepatic mda level significantly compared ethanol treated group 1.43 0.14 versus 3.42 1.36 1.43 0.29 versus 3.42 1.36 nmol mg protein resp ; our results showed level hepatic sod activity control group 1081.36 145.01 units mg protein ethanol treated group 1135.86 209.48 units mg protein rats treated ethanol curcumin 400 1,200 mg kg bw day levels hepatic sod activity 966.28 139.44 967.84 116.66 units mg protein respectively the number apoptotic nuclei liver control group low 0.38 0.28 cells high power field in contrast numbers apoptotic cells observed frequently centrilobular area ethanol treated group compared control group 2.43 2.68 versus 0.38 0.28 cells high power field p .05 figures 4 5 trend decreased apoptosis low dose curcumin treatment difference reach statistical significance figure 4 the number positive stained cells liver ethanol treated group significantly higher control group 1.08 0.52 versus 0.04 0.04 cells high power field p .05 in contrast curcumin treatment 400 1,200 mg kg bw day decreased number positive stained cells significantly compared ethanol treated group 0.15 0.02 versus 1.08 0.52 0.17 0.09 versus 1.08 0.52 cells high power field resp ; p .05 figures 6 7 order examine change ppar protein expression early stage ethanol induced liver injury the ppar protein expression control group 0.57 0.19 ethanol group 0.68 0.16 rats treated ethanol curcumin 400 1,200 mg kg bw day 0.44 0.03 0.54 0.23 respectively these data show significant change ppar protein expression liver groups figure 8) ethanol oxidation generates toxic metabolites free radicals induces state oxidative stress contributes pathogenesis ald importantly oxidation ethanol cytochrome p450 2e1 cyp 2e1 generates superoxide anion radical hydrogen peroxide 2 21 22 these free radicals capable damaging many cellular components dna protein lipid one characteristic features oxidative stress enhancement lipid peroxidation number studies have demonstrated ethanol intake increased formation lipid peroxidation product mda 2426 we found increase hepatic mda level well pathological changes observed ethanol treated group counteract oxidative stress cells variety antioxidant enzymes including sod catalase glutathione peroxidase the effects chronic ethanol exposure activity sod controversial reports decrease changes 25 28 these studies may reflect variations experimental design diet duration ethanol feeding decreased sod activity ethanol fed rats associated enhancement lipid peroxidation severe pathology liver therefore sod activity liver change early ethanol induced liver injury oxidative stress also initiate amplify inflammation upregulation several genes involved inflammatory response one gene nf-b whose activation results upregulation proinflammatory cytokines activation nf-b upregulation cytokine production occurred ethanol induced liver injury associated lipid peroxidation 9 10 evidence presented curcumin prevented ethanol induced liver injury rats inhibiting expression nf-b dependent genes although high dose curcumin treatment 1,200 mg kg bw better low dose 400 mg kg bw present study showed curcumin improved ethanol induced liver injury reduction oxidative stress inhibition nf-b activation ethanol induced liver injury linked oxidative stress caused production reactive oxygen intermediates cause mitochondrial dysfunction leading release proapoptotic factors cytochrome c activate caspases initiate apoptotic cascade hepatocytes jin coworker observed pathological changes investigated correlation hepatocyte apoptosis cyp2e1 expression oxygen free radical rats ald using tunel assay detected difference apoptosis control ethanol treated group similar human alcoholic hepatitis experimental rat model ald 3335 cells centrilobular area low o2 nutrient supply thus distribution apoptotic cells observed frequently centrilobular area study curcumin treatment did detect difference hepatocyte apoptosis however trend decreased apoptosis low curcumin treatment this stage showed severe liver injury hsc activation normal liver hscs undergo process known activation upregulate cytokines growth factor for instance platelet derived growth factor capable inhibiting ppar expression via mitogen activated protein kinase mediated phosphorylation ppar also tnf- inflammatory cytokine known inhibit ppar expression adipocytes early phase hsc activation liver fibrosis 38 39 thus alcoholic liver fibrosis rats could decrease ppar expression our model showed mild steatosis necroinflammation hsc activation therefore change ppar protein expression found ethanol treated group further studies determined roles ppar different stages ald conclusion study demonstrated curcumin representative phenolic antioxidant antiinflammmation could improve histopathology liver early stage ethanol induced liver injury reduction oxidative stress inhibition nf-b activation for hepatocyte apoptosis curcumin treatment might trend decreased apoptotic cells ethanol fed rats

to study the mechanism of curcumin - attenuated inflammation and liver pathology in early stage of alcoholic liver disease , female sprague - dawley rats were divided into four groups and treated with ethanol or curcumin via an intragastric tube for 4 weeks . a control group treated with distilled water , and an ethanol group was treated with ethanol ( 7.5 g / kg bw ) . treatment groups were fed with ethanol supplemented with curcumin ( 400 or 1 200 mg / kg bw ) . the liver histopathology in ethanol group revealed mild - to - moderate steatosis and mild necroinflammation . hepatic mda , hepatocyte apoptosis , and nf-b activation increased significantly in ethanol - treated group when compared with control . curcumin treatments resulted in improving of liver pathology , decreasing the elevation of hepatic mda , and inhibition of nf-b activation . the 400 mg / kg bw of curcumin treatment revealed only a trend of decreased hepatocyte apoptosis . however , the results of sod activity , ppar protein expression showed no difference among the groups . in conclusion , curcumin improved liver histopathology in early stage of ethanol - induced liver injury by reduction of oxidative stress and inhibition of nf-b activation .

study provides class iii evidence patients seizure free stopped aed treatment long term resective epilepsy surgery nonoperated epilepsy patients in sweden epilepsy surgery procedures reported snesur initiated 1990 an internal control system rejects certain impossible combinations data regular external quality controls performed independent controller since 2005 follow extended 2 years 5 10 15 years postoperatively snesur contains baseline information patient epilepsy history preoperative seizure types syndromes mean monthly seizure frequency year preceding presurgical investigation aeds preoperative investigations psychosocial data surgical data type location surgery histopathologic diagnoses postoperative complications two year follow data cover seizure situation aeds psychosocial data the 5- 10- 15-year follow ups structured telephone interviews regarding seizure situation aeds psychosocial aspects driving study analyzed seizure outcome aed medication 5 10 years resective epilepsy surgery patients 5- 10-year follow ups 2005 2007 hence operated 2000 2002 1995 1997 the cohort comprises 327 patients resective surgery time periods 2005 2007 144/176 patients operated 1995 1997 98/116 adults 46/60 children 18 years 10-year follow 134/151 patients operated 2000 2002 92/103 adults 42/48 children 18 years 5-year follow seventeen patients reoperated long term follow 11 deaths twenty one patients 6.4% lost follow details see figure e-1 neurology web site www.neurology.org control group consecutive patients underwent presurgical investigations time periods operated identified 3 6 operating centers gteborg uppsala lund eighty adults 13 children 94 adults 13 children underwent cross sectional long term follow 2008 mean 9.3 years adults 8.8 years children using structured telephone interview surgical group thirteen adult patients died 4 epilepsy related deaths 1 lost follow 1% reasons surgery nonconclusive workup n 41 multifocality n 27 patient declined surgery n 12 seizure onset within eloquent cortex n 11 neuropsychological reasons n 2 seizure freedom without aura international league epilepsy ilae class ii reported year preceding follow except patients sustained seizure freedom since surgery separately reported patients continuing seizures seizure relapse postoperatively mean monthly seizure frequency last year follow categorized follows 75% reduction seizure frequency 50%74% reduction seizure frequency 0%49% reduction seizure frequency increased seizure frequency comparison 2 groups fisher exact test used dichotomous variables mann whitney u test continuous variables mantel haenszel test ordered categorical variables logistic regression analysis performed independent variable predict seizure free outcome a forward stepwise multiple logistic regression used select independent predictors outcome univariate predictors attaining p value 0.10 this study approved regional board medical ethics university gothenburg consent research obtained controls operated patients board considered long term follow quality control measure necessitating individual consent primary research questions follows patients seizure free without aed long term resective epilepsy surgery compared nonoperated patients ? this longitudinal observational study provides class iii evidence 41% adults 44% children sustained seizure freedom long term surgery compared none nonoperated patients p 0.0005 also 43% seizure free adults 86% seizure free children stopped aeds 10 years compared none nonoperated patients p 0.0005 this study approved regional board medical ethics university gothenburg consent research obtained controls operated patients board considered long term follow quality control measure necessitating individual consent primary research questions follows patients seizure free without aed long term resective epilepsy surgery compared nonoperated patients ? this longitudinal observational study provides class iii evidence 41% adults 44% children sustained seizure freedom long term surgery compared none nonoperated patients p 0.0005 also 43% seizure free adults 86% seizure free children stopped aeds 10 years compared none nonoperated patients p 0.0005 table 1 shows baseline characteristics operated patients controls children 18 years adults the adult underwent hemispherectomy age 20 added pediatric hemispherectomy group none baseline characteristics differed operated nonoperated patients except number previously tried aeds adults p 0.001 iq children p 0.042 baseline data operated patients nonoperated controls significant difference seizure outcome operated patients follow 5 years compared 10 years order enable comparison nonoperated group mean long term follow 9.1 years range 514 results 5- 10-year follow ups operated patients merged figure 1 two year long term mean follow time 7.6 years range 510 seizure situation patients resective epilepsy surgery compared long term follow nonoperated controls mean follow time 9.2 years range 514 seizure free patients include sustained seizure freedom without aura since surgery blue patients seizure free least last year follow green overall 117 62% operated adults seizure free long term follow compared 11 14% controls p 0.001 fifty percent n 93 operated adults sustained seizure freedom 2-year 41% n 78 long term follow none controls seizure free whole time period for children 44 50% operated group seizure free year long term follow compared 5 38% control group significant fifty three percent n 46 operated children sustained seizure freedom since surgery 2-year 44% n 39 long term follow compared none control group adults children proportion sustained seizure freedom long term significantly higher compared nonoperated patients p 0.0005 details seizure outcome operated patients 2 5 10 years epilepsy surgery shown table e-1 eighty seven percent adults well children seizure free 2 years seizure free 5- 10-year follow ups 95% confidence interval ci 7794 8095 respectively seizure outcomes adults children different resection types illustrated table 2 the common resection type tlr 81% adults 43% children followed frontal lobe resection flr adults 12% multilobe resection children 20% adults the best long term seizure outcome tlr 63% seizure free sustained seizure freedom since surgery 44% in children tlr outcome 60% seizure free 55% sustained seizure freedom matched long term hemispherectomy results 60% seizure free sustained seizure freedom if extratemporal procedures summed 31% adults sustained seizure freedom long term follow compared 36% children seizure outcomes long term related resection type main histopathologic diagnoses categorized follows hippocampal sclerosis hs n 45 neurodevelopmental tumors n 34 low grade astrocytomas n 21 cavernous hemangiomas n 21 malformations cortical development n 52 gliosis n 65 n 40 highest seizure freedom rates seen hs 60% 47% sustained since surgery epileptogenic lesions 72% 57% sustained since surgery table e-2 univariate relationship long term seizure freedom following baseline variables was explored operated patients controls epilepsy duration percent life length relative epilepsy duration odds ratio increment units 10% 30 seizures month presence secondarily generalized tonic clonic seizures sgtcs operated patients additional variables positive mri resection types histopathology figure 2 controls the univariate associations nonsignificant although direction operated patients relative epilepsy duration 0.89 95% ci 0.731.09 30 seizures month 0.88 95% ci 0.223.47 sgtcs 0.56 95% ci 0.181.68 surgical group multivariate analysis performed 30 seizures month 0.40 95% ci 0.230.69 relative epilepsy duration 0.91 95% ci 0.831.00 negative predictors positive mri 1.96 95% ci 1.083.55 positive predictor seizure free long term outcome the auc value goodness fit final multiple model 0.66 categorical variables 2 categories resection type histopathology temporal lobe resections tlr epileptogenic lesions epi les chosen reference categories ci confidence interval epi dur per 10% life epilepsy duration percentage life length odds ratio units per 10% life epileptogenic lesions gangliogliomas dysembryoplastic neuroepithelial tumors cavernomas low grade astrocytomas flr frontal lobe resection hemispherectomy hs hippocampal sclerosis mcd malformations cortical development mlr multilobe resection odds ratio vascular malformations cavernomas cysts tuberous sclerosis unknown histopathology p olr parietal occipital lobe resection sgtcs secondarily generalized tonic clonic seizures baseline 183 66% patients had 2 aeds 85 31% 1 aed 8 3% aeds the number aeds used operated seizure free patients decreased time figure 3 overall 45 54% patients seizure free 10-year follow stopped aeds compared none seizure free controls p 0.0005 more children adults stopped aeds 86% children 43% adults p 0.002 there significant association proportion seizure free patients stopped aeds resection type among patients seizures the proportion 2 aeds increased 77% preoperatively 82% 10 years surgery number antiepileptic drugs start preoperative investigations 2 5 10 years patients seizure free 5- 10-year follow table 1 shows baseline characteristics operated patients controls children 18 years adults the adult underwent hemispherectomy age 20 added pediatric hemispherectomy group none baseline characteristics differed operated nonoperated patients except number previously tried aeds adults p 0.001 iq children p 0.042 there significant difference seizure outcome operated patients follow 5 years compared 10 years order enable comparison nonoperated group mean long term follow 9.1 years range 514 results 5- 10-year follow ups operated patients merged figure 1 two year long term mean follow time 7.6 years range 510 seizure situation patients resective epilepsy surgery compared long term follow nonoperated controls mean follow time 9.2 years range 514 seizure free patients include sustained seizure freedom without aura since surgery blue patients seizure free least last year follow green overall 117 62% operated adults seizure free long term follow compared 11 14% controls p 0.001 fifty percent n 93 operated adults sustained seizure freedom 2-year 41% n 78 long term follow none controls seizure free whole time period for children 44 50% operated group seizure free year long term follow compared 5 38% control group significant fifty three percent n 46 operated children sustained seizure freedom since surgery 2-year 44% n 39 long term follow compared none control group adults children proportion sustained seizure freedom long term significantly higher compared nonoperated patients p 0.0005 details seizure outcome operated patients 2 5 10 years epilepsy surgery shown table e-1 eighty seven percent adults well children seizure free 2 years seizure free 5- 10-year follow ups 95% confidence interval ci 7794 8095 respectively seizure outcomes adults children different resection types illustrated table 2 the common resection type tlr 81% adults 43% children followed frontal lobe resection flr adults 12% multilobe resection children 20% adults the best long term seizure outcome tlr 63% seizure free sustained seizure freedom since surgery 44% in children tlr outcome 60% seizure free 55% sustained seizure freedom matched long term hemispherectomy results 60% seizure free sustained seizure freedom if extratemporal procedures summed 31% adults sustained seizure freedom long term follow compared 36% children seizure outcomes long term related resection type main histopathologic diagnoses categorized follows hippocampal sclerosis hs n 45 neurodevelopmental tumors n 34 low grade astrocytomas n 21 cavernous hemangiomas n 21 malformations cortical development n 52 gliosis n 65 n 40 highest seizure freedom rates seen hs 60% 47% sustained since surgery epileptogenic lesions 72% 57% sustained since surgery table e-2 the univariate relationship long term seizure freedom following baseline variables explored operated patients controls epilepsy duration percent life length relative epilepsy duration odds ratio increment units 10% 30 seizures month presence secondarily generalized tonic clonic seizures sgtcs operated patients additional variables positive mri resection types histopathology figure 2 controls the univariate associations nonsignificant although direction operated patients relative epilepsy duration 0.89 95% ci 0.731.09 30 seizures month 0.88 95% ci 0.223.47 sgtcs 0.56 95% ci 0.181.68 surgical group multivariate analysis performed 30 seizures month 0.40 95% ci 0.230.69 relative epilepsy duration 0.91 95% ci 0.831.00 negative predictors positive mri 1.96 95% ci 1.083.55 positive predictor seizure free long term outcome the auc value goodness fit final multiple model 0.66 for categorical variables 2 categories resection type histopathology temporal lobe resections tlr epileptogenic lesions epi les chosen reference categories ci confidence interval epi dur per 10% life epilepsy duration percentage life length odds ratio units per 10% life epileptogenic lesions gangliogliomas dysembryoplastic neuroepithelial tumors cavernomas low grade astrocytomas flr frontal lobe resection hemispherectomy hs hippocampal sclerosis mcd malformations cortical development mlr multilobe resection odds ratio vascular malformations cavernomas cysts tuberous sclerosis unknown histopathology p olr parietal occipital lobe resection sgtcs secondarily generalized tonic clonic seizures at baseline 183 66% patients 2 aeds 85 31% 1 aed 8 3% aeds the number aeds used operated seizure free patients decreased time figure 3 overall 45 54% patients seizure free 10-year follow stopped aeds compared none seizure free controls p 0.0005 more children adults stopped aeds 86% children 43% adults p 0.002 there significant association proportion seizure free patients stopped aeds resection type among patients seizures proportion 2 aeds increased 77% preoperatively 82% 10 years surgery number antiepileptic drugs start preoperative investigations 2 5 10 years patients seizure free 5- 10-year follow since long term results epilepsy surgery obtained rcts observational studies defined quality criteria needed number requirements studies prognosis epilepsy surgery suggested studies based snesur meet many requirements prospective design representative study populations standard protocol outcome measures prolonged longitudinal follow patients lost follow we found 63% adults 60% children seizure free tlr long term follow continuous seizure freedom since surgery adults 41% children 44% expected results good flr 44% adults seizure free sustained 35% children 27% seizure free sustained this still substantially better patients could operated 14% seizure free adults none sustained 38% seizure free children none sustained the adults underwent types resections posterior multilobar 3 sustained long term seizure freedom children undergone posterior resections hemispherectomies long term seizure freedom 55% 60% respectively sustained 46% vs 60% long term outcome resective epilepsy surgery often reported cross sectionally meta analysis 2005 based 78 studies 66% tlr patients 46% parietal occipital lobe resection patients 27% flr patients seizure free follow 5 years postsurgery authors point studies reported sustained seizure freedom surgery a number recent longitudinal long term outcome studies report sustained seizure freedom tlr sustained seizure freedom reported engel 1 engel 1a engel 1a+b studies ilae class ii sustained seizure freedom around 5 years postoperatively varies 46% 55% 60% 80% among studies moderate rates sustained seizure freedom 2 4 prospective prospective study 41% sustained seizure freedom long term follow tlr adults 44% children supports results a number studies report cross sectional long term follow pediatric epilepsy surgery seizure freedom 50% 82% patients 5 12 years tlr only one study longitudinal reports sustained seizure freedom engel 1 54% patients 5 years tlr there retrospective reports long term outcomes patients flr extratemporal resections sustained seizure freedom 5 years surgery varies studies 15% 27% 52% compared 31% adults vs 36% children cohort 86 patients varying extratemporal resections long term reports population based cohorts sparse retrospective cross sectional comprehensive audit ireland national long term seizure outcome data reported forty four percent patients seizure free 10 years resective surgery total number operated patients could accounted recent norwegian retrospective questionnaire study children with a response rate 70% reported 58% seizure free mean 7 years however sustained seizure freedom reported studies recent systematic review 20 studies comparing surgical results nonsurgical control group identified 13 follow least 4 years the controls general patients evaluated surgery various reasons operated overall 44% surgical patients seizure free follow 90% studies seizure freedom reported last follow last year compared 12% medically treated patients this well line findings 58% seizure free last year follow surgical group 17% nonsurgical group children adults together it must remembered patients preoperative investigations considered ineligible epilepsy surgery comparable surgically treated patients may another disease course it difficult though identify reasonable controls long term follow studies clinical point view match operated patients many baseline variables predictors seizure freedom long term 4 years sought several investigators found remaining predictors multivariate analysis commonly identified predictors sgtcs baseline epilepsy duration age surgery we found high baseline seizure frequency relative epilepsy duration negatively positive mri positively related long term seizure freedom epilepsy duration undertaking presurgical investigation repeatedly shown shortened significantly years these results long term outcome studies underline importance earlier identification good candidates resective epilepsy surgery there common swedish protocol discontinuation aeds seizure free patients most adults continue aeds first 2 postoperative years decisions withdrawal taken individually we found 43% seizure free adults many 86% seizure free children discontinued aeds 10 years the reasons difference unknown possibly social consequences seizure relapse greater importance adults e.g. driving occupation therefore may choose continue aeds by contrast concern adverse effects aeds developing brain children may lead earlier decisions withdrawal the proportion seizure free adults children aeds withdrawn successful epilepsy surgery varies widely across studies meta analysis 2007 9 studies identified pooled analysis showed 27% seizure free children 19% seizure free adults discontinued aeds mean follow 7 years however indian study aed withdrawal systematically planned seizure free patients tlr successful 63% 258 patients followed 5 years similar results children canadian study found 82% seizure free children stopped aeds 10 years surgery possible reasons differences patient decisions aed cessation may include socioeconomic cultural differences well doctors inform patients partly depends assessment recurrence risk the timetostop study showed early withdrawal aed children influence long term seizure outcome could unmask incomplete surgical success sooner authors suggest time plan rct aed withdrawal epilepsy surgery children like observational outcome studies epilepsy surgery masking seizure outcome assessment our nonoperated control group recruited 3 largest swedish epilepsy surgery centers hence national sample hand regional referral system reasonable assume sample representative population patients evaluated surgery sweden operated patients need detailed counseling deciding undergo irrevocable brain surgery realistic expectations concerning long term outcomes part information need consider this prospective population based study contributes knowledge supports seizure outcome data prospective single center studies also shows greater proportion seizure free patients studies stopped aed treatment 10 years surgery funded grants swedish research council grant 521 2011 169 sahlgrenska academy gothenburg university lua alf agreement grant alfgbg137431 gothenburg foundation neurological research gothenburg medical society margaretahem foundation unconditional research grant glaxosmithkline anna edelvik k. malmgren served educational advisory board ucb received speaker honoraria ucb

objective : to investigate prospective , population - based long - term outcomes concerning seizures and antiepileptic drug ( aed ) treatment after resective epilepsy surgery in sweden.methods : ten- and 5-year follow - ups were performed in 2005 to 2007 for 278/327 patients after resective epilepsy surgery from 1995 to 1997 and 2000 to 2002 , respectively . all patients had been prospectively followed in the swedish national epilepsy surgery register . ninety - three patients , who were presurgically evaluated but not operated , served as controls.results:in the long term ( mean 7.6 years ) , 62% of operated adults and 50% of operated children were seizure - free , compared to 14% of nonoperated adults ( p < 0.001 ) and 38% of nonoperated children ( not significant ) . forty - one percent of operated adults and 44% of operated children had sustained seizure freedom since surgery , compared to none of the controls ( p < 0.0005 ) . multivariate analysis identified 30 seizures / month at baseline and long epilepsy duration as negative predictors and positive mri to be a positive predictor of long - term seizure - free outcome . ten years after surgery , 86% of seizure - free children and 43% of seizure - free adults had stopped aeds in the surgery groups compared to none of the controls ( p < 0.0005).conclusions : this population - based , prospective study shows good long - term seizure outcomes after resective epilepsy surgery . the majority of the patients who are seizure - free after 5 and 10 years have sustained seizure freedom since surgery . many patients who gain seizure freedom can successfully discontinue aeds , more often children than adults.classification of evidence : this study provides class iii evidence that more patients are seizure - free and have stopped aed treatment in the long term after resective epilepsy surgery than nonoperated epilepsy patients .

prevalence obesity among adolescents united states increased dramatically past 30 years particularly high rates among hispanic african american native american youth 14 currently 33.6% adolescents 1219 years age united states either overweight obese although causes obesity complex widely recognized poor nutrition physical inactivity play important roles for reason public health interventions targeting youths frequently focus health promotion programs schools 69 well calling nutrition exercise counseling health care setting 1012 the potential physicians influence behavioral changes among patients simple nutrition exercise advice opposed time intensive counseling crucial some studies documented value physician counseling either used stand alone strategy part coordinated effort help patients make changes diet physical activity patterns national health organizations also recognized importance clinician counseling called increase provision nutrition exercise counseling given adolescents physician visits 15 16 the surgeon general recent vision healthy fit nation 2010 encourages clinicians recommend healthy eating increased physical activity patients recommends training clinicians health care students effective ways counsel patients lifestyle behavior change california adolescent overweight obesity rates comparable national levels major programmatic policy responses aimed obesity prevention adolescents undertaken schools limit nonnutritious foods beverages sold campus communities increase access nutritious foods safer places exercise 8 9 19 however little known frequency weight related counseling given different racial ethnic groups limited access care course treating preventing obesity health care environment a recent study found race important factor explained prevalence nutrition physical activity counseling among california adolescents african americans compared whites likely receive nutrition counseling hispanics compared whites likely receive nutrition physical activity counseling regards insurance type data suggests california adolescents uninsured qualify low cost free insurance greatest risk overweight obesity yet recent national study found adolescents private insurance generally receive counseling compared low cost insurance changes frequency obesity related counseling overtime race ethnicity insurance type yet examined previous research california suggests physician obesity related counseling declining overall counseling rates 2003 2007 shifting 75% 59% nutrition 74% 60% physical activity insufficient time lack resources inadequate reimbursement patient noncompliance typically cited barriers provision routine advice health care practitioners the objectives current study document trends 2003 2009 either nutrition exercise counseling combination among california adolescents race ethnicity insurance type these findings provide guidance policies programs state high rates adolescent overweight obesity large ethnic populations particular risk further hypothesized physicians would favor dietary counseling exercise counseling providing counseling earlier study stafford et al found physicians offered dietary counseling obese patients 41.5% time exercise counseling offered 32.8% time among healthy weight participants branner colleagues found higher rates nutrition compared exercise counseling among children adolescents 42.1% 26.1% resp data demonstrating trends nutrition exercise counseling race ethnicity insurance type obtained using four biennial california health interview surveys 20032009 largest state surveys united states california health interview survey chis ) is two stage sampling weighted random digital dialing telephone survey representative california noninstitutionalized population within households an adult adolescent randomly selected interviewed trained chis interviewers adolescents directly interviewed the chis program obtained informed consent individuals participating survey current study deemed exempt waived human subjects review university california berkeley institutional review board in study obesity related counseling refers simple advice nutrition and/or exercise practices opposed time intensive counseling adolescents self reported whether discussed nutrition exercise habits physician last routine exam last routine physical exam doctor talk nutrition healthy eating last routine physical exam doctor talk exercise physical activity data analyzed using stata version 10 svy module account weighting raking method variance estimation obesity related counseling proportions presented graphically race ethnicity insurance type period 20032009 better represent obesity related counseling construct categorized variable respondents discussions nutrition exercise physician discussing either nutrition exercise discussing nutrition exercise physician participants self reported weight height used generate centers disease control prevention cdc bmi age gender specific percentiles categorized underweight 5th percentile normal weight 5th<85th percentile overweight 85th<95th percentile obese 95th percentile in addition insurance type variables uninsured medicaid healthy families employer based privately owned insurance public insurance collapsed categories uninsured low cost free employer based private insurance medicaid united states health insurance program certain low income individuals families jointly funded state federal governments healthy families low cost health insurance program children adolescents health insurance qualify medicaid table 1 presents study sample characteristics using chis 2009 participants ranged age 12 17 years 51.0% male 49.0% female the sample consisted primarily hispanics 49.3% non hispanic whites 33.5% most adolescents form health insurance almost 60% covered parents'/guardians employer sponsored health insurance less half adolescents 44.8% 300% federal poverty level based self reported data 28.7% california adolescents either overweight obese 48.2% california adolescents received counseling nutrition exercise subjects table 1 the majority respondents 84.7% reported physical exam within past year table 1 previously published data indicate california adolescent demographics changed 2003 2007 figure 1 table 2 present data obesity related counseling stratified race ethnicity examining nutrition exercise counseling separately period 2003 2009 african americans generally reported higher levels nutrition exercise counseling whites generally reported higher levels exercise nutrition counseling hispanics generally reported higher levels nutrition exercise counseling 20032005 counseling levels remained consistent overall trends show counseling declined 2003 2009 groups except hispanics whites started increase 2007 american indians alaska natives reported sharp decline 2009 2003 2009 proportion adolescents reported counseling nutrition exercise decreased 66.8% 53.7% among hispanics 60.7% 15.1% among american indians alaska natives 61.7% 33.4% among asians 58.8% 42.9% among african americans 60.0% 46.2% among whites figure 1 figure 2 table 3 present data obesity related counseling stratified insurance type those private insurance generally received exercise counseling frequently nutrition counseling study time period there appeared imbalance frequency nutrition exercise counseling uninsured low cost free employer based groups except 2003 adolescents underinsured low cost insurance reported nutrition physical activity counseling counseling appeared decline 20032009 among insurance types although 2007 slight increase observed low cost free insurance group among uninsured counseling declined 70.8% 42.2% among low cost free group counseling declined 64% 53.4% among employer group counseling declined 61.8% 46.6% among private insurance group counseling declined 58.9% 39.8% figure 2 as early 1950s american medical association council food nutrition cited benefits nutrition counseling well inadequacies nutrition education u.s medical schools further counseling shown valuable helping patients change behavior achieve weight loss even beneficial used part coordinated approach health education materials kreuter colleagues reported patients received combination health education materials followed physician counseling 51% likely increase leisure time physical activity 35% likely reduce fat dairy sources follow some groups need obesity prevention counseling may still missing including american indians alaska natives african americans uninsured time trend findings 2003 2009 indicate nutrition exercise counseling decreased racial ethnic groups except hispanics whites started increase 2007 our findings also suggest counseling levels california racial ethnic groups patients different types insurance generally higher compared national levels the higher counseling levels reported study compared national figures may due fewer barriers public health awareness obesity epidemic california stronger health care leadership previously reported barriers counseling include insufficient reimbursement rates lack time lack training medical providers policy advocacy related improved nutrition activity environments need information evidence based obesity related messages referral networks nutrition counseling when examining nutrition exercise counseling separately study period 20032009 interesting differences found race ethnicity hispanic african american chis adolescents generally reported higher levels nutrition exercise counseling whites generally reported higher levels exercise nutrition counseling meanwhile participants private insurance generally received exercise nutrition counseling study period further research needed investigate underlying factors may explain differences findings racial ethnic groups the chis surveys able identify existence discussions conversations adolescents may physicians regarding nutrition exercise messages able ascertain depth discussions given limited time physicians working patients unlikely advice given would depth psychological advice further difficult ascertain whether conversations initiated physician patient these data unable measure specific evidence based obesity related messages limiting sugar sweetened beverages increasing fruit vegetables reducing television viewing increasing moderate vigorous physical activity 7 29 the potential recall bias also exists since adolescents asked self report nutrition and/or exercise data occurred last physical exam however adolescents 84.7% physical exam physician visit within past year this first study examine trends obesity related counseling race ethnicity insurance type among california adolescents additionally one first studies examine trends counseling among american indians alaska natives group also disproportionately affected overweight obesity 3 4 the findings study demonstrated downward trend obesity prevention counseling california among racial ethnic groups health insurance groups changed course begun increase future analysis biennial chis surveys indicate trend continues direction it widely accepted obesity prevention follow socioecological approach combining multiple interventions tailored specific demographic groups while vast amount work already conducted california implement population wide obesity prevention policies schools low income communities momentum must also applied california primary health care settings however physician based counseling continue increase among general adolescent population among vulnerable high risk groups particular require institutional policy changes research effective ways support clinicians use aforementioned evidence based obesity related messages still infancy although preliminary data clinic based obesity interventions begun show promising results at least one us state washington adopted clinic based programs address childhood obesity epidemic establishing partnerships hospitals health care plans community based organizations states may consider adopting program primary care setting order build obesity prevention programs policies previously implemented schools low income communities

purpose . obesity is a serious health threat , particularly among racial / ethnic minorities and those who are uninsured , yet little is known about the implementation of nutrition or exercise counseling or the combination of both among these groups . trends in counseling by race / ethnicity and types of insurance were examined . methods . trend analyses were conducted with the california health interview surveys among those ages 1217 for the period 20032009 . results . race / ethnicity : receipt of both counseling methods declined from 20032009 for all racial / ethnic groups , except hispanics and whites , for whom increases in counseling began after 2007 . hispanics and african americans generally reported higher levels of nutrition than exercise counseling , while whites generally reported higher levels of exercise than nutrition counseling for the study period . insurance type : receipt of both counseling methods appeared to decline from 20032009 among all insurance types , although after 2007 , a slight increase was observed for the low - cost / free insurance group . those with private health insurance generally received more exercise counseling than nutrition counseling over the study period . conclusions . counseling among all racial / ethnic groups and insurance types is warranted , but particularly needed for african americans , american indian / alaska natives , and the uninsured as they are at highest risk for developing obesity . institutional and policy changes in the health care environment will be beneficial in helping to promote obesity - related counseling .

student perception dental school experience essential measure success dental education undergraduates feedback suggestions important improving curriculum learning process this information also helps determine students preferences regarding different elements educational experience endodontics teaching considered complex difficult stressful complex anatomy root canal system responsibility toward patients low self confidence however teaching endodontics recent years improved result development knowledge techniques materials dental students taibah university saudi arabia take preclinical full year endodontic course 3 year 6-year bachelor dental surgery degree the course consists 28 h theoretical lectures 28 3-h laboratory sessions perform technical aspects root canal treatment extracted single- multi rooted teeth there one semester clinical endodontic course 4 year consists 14 theoretical lectures fourteen 3-h clinical sessions students treat single- multi rooted teeth 5 year endodontic treatments performed part comprehensive dentistry care course supervision specialists this study examined endodontic experiences perceptions endodontic practice self rated confidence dental students enrolled taibah university saudi arabia study approval obtained research ethics committee college dentistry taibah university reference number tucdrec/20160107/alrahabi this study enrolled 41 undergraduate dental students registered endodontic courses 2015 academic year college dentistry taibah university saudi arabia participation voluntary students informed could refuse participation questionnaire distributed 19 4-year 25 5-year students final month academic year maximum amount training the questions evaluated self confidence performing nonsurgical root canal treatment experiences discipline the level confidence classified using 5-point scale confident confident neutral confident confident compare results chi square test mann whitney u test used statistical analyses carried using spss version 20.0 spss chicago il usa statistical significance set p 0.05 the overall response rate 93% 18 19 4-year students 23 25 final year students returning questionnaires table 1 shows results first three questions first endodontic case treated level case difficulty number endodontic treatments performed student first endodontic case treated level case difficulty number endodontic treatments performed self confidence 4th- 5th year dental students regarding steps nonsurgical root canal treatment levels confidence different steps root canal treatment confidence levels differed significantly 4- 5-year students following steps root canal treatment determining working length taking interpreting radiographs root canal treatment evaluating quality root canal obturation recalling patients periodically correct manner table 3 summarizes results last question regarding suggestions improve teaching endodontic courses in dentistry evaluating competence important step toward validating quality graduating dentists although relationship self confidence clinical competence medical students fully understood increasing confidence medical students increase competence clinical practice one way standardize education poll students using questionnaires help assessment evaluation improvement education this study obtained information confidence undergraduate dental students taibah university saudi arabia regarding endodontics it revealed upper incisor 78% common tooth first treated students upper incisor root canal treatment relatively easy encourage students another study most students described experience first case okay 78% 7.4% described easy 14.6% described first case difficult possibly first case students involved molar premolar in studies students considered molars difficult tooth treat study maximum number teeth treated 4 year four cases 66.7% students maximum number teeth treated 5 year 11 cases 8.8% students the number teeth treated students 4 5 year meet recommendations european society endodontology 2001 guidelines advised adequate competency student complete root canal treatments 20 teeth although european society endodontology published new undergraduate curriculum guidelines endodontology 2013 focused quality consistency student performance simply quantity clinical exposure however one study reported 81% students 48 dental schools european union achieved minimum number root canal treatments required graduation number treated cases ranged 3 80 canals average 17 canals study observed confidence varied according year student practical steps nonsurgical root canal treatment both groups reported relatively good confidence although significant differences 4 5 year students regarding steps fourth year students confident 5-year students following determining working length dealing x rays root canal treatment evaluating root canal obturation recalling patient correct time this might fewer 4-year students sample fewer requirements 4 year strict supervision supervisors helped 4-year students 5-year students confidence regarding working length determination low 4- 5-year students might result root canal anatomy many dental students find difficult learn variation among individuals the reduction confidence regarding endodontic radiology evaluation root canal obturation determining correct recall period probably results insufficient clinical exposure murray et al wrote lack clinical exposure undergraduate curriculum reduces confidence develops clinical practice students suggestions improving teaching endodontics focused two major issues using rotary nickel titanium niti files treatment increasing credit hours endodontic course introducing advances endodontics undergraduate training niti rotary instruments may improve clinical experience students self confidence help increase numbers cases treated believe introducing niti rotary instruments undergraduate dental curriculum would safe improve endodontics teaching inexperienced operators learn use rotary instruments adequately brief training nevertheless another study found intensive preclinical training prerequisite using niti rotary instruments changing methods teaching endodontics students complete root canal treatment easily quickly minimal procedural accidents improve clinical outcomes low self confidence ameliorated increasing clinical exposure help students obtain necessary skills experience fourth- fifth year dental students taibah university saudi arabia confident regarding root canal treatment although report lower confidence steps root canal treatment process endodontics education improved increasing preclinical clinical sessions using new teaching methods introduce recent advances endodontics undergraduate curriculum

objective : this study examined the endodontic experience , perceptions of endodontic practice , and self - rated confidence of dental students enrolled in taibah university , saudi arabia.materials and methods : a questionnaire was distributed to 41 undergraduate dental students registered in endodontic courses in the 2015 academic year . the questionnaire evaluated their confidence performing nonsurgical root canal treatment . the level of confidence was classified using a 5-point scale as very confident , confident , neutral , not very confident , or not at all confident . the data were analyzed using spss version 20.0 ( spss , chicago , il , usa).results : the participation rate was 93% . the maxillary incisor was the most common first tooth treated . the students were relatively confident , but their confidence levels were lower regarding endodontic radiology , evaluation of root canal obturation , and determining the correct recall period for the patient.conclusion:the confidence of undergraduates in endodontics must be enhanced to increase their clinical competence when performing root canal treatment .

36-year old woman complained insidious onset generalized myoclonus first became apparent age 27 years she perinatal problems development normal childhood juvenile periods adult onset myoclonus worsened progressively right hand four extremities tremulous voice gait disturbance developed 3 years disease onset could continue working nurse she history febrile convulsions seizure infectious disease central nervous system exposure toxic materials intake herbal drugs her younger brother aged 40 years old also progressive generalized myoclonus detected 6 years ago age 34 years figure 1 the patient alert oriented mini mental state examination score 30 she gaze palsy vision hearing normal however voice tremulous generalized positive myoclonus observed four extremities body negative myoclonus dystonia tremor rigidity detected motor sensory functions intact there evidence cerebellar dysfunction ataxic parkinsonian gait although staggered slightly myoclonus examination eyes revealed cherry red spots figure 2 electroencephalogram normal no white matter lesion cerebellar atrophy detected mri brain figure 3 neuraminidase hexosaminidase -galactosidase activities leukocytes cultured fibroblasts patient younger brother normal the cherry red spot pale perifoveal ring develops large deposits lipid sphingolipid oligosaccharide material accumulate ganglionic cells macula.2 characteristic finding storage diseases including sialidoses gm1 gm2 gangliosidoses neuronal ceroid lipofuscinosis niemann pick disease groups farber lipogranulomatosis metachromatic leukodystrophy interestingly niemann pick disease farber lipogranulomatosis metachromatic leukodystrophy associated myoclonus moreover patient report typical findings 3 diseases organomegaly cognitive impairment gaze palsy seen niemann pick disease4 hoarseness arthritis subcutaneous nodules seen farber lipogranulomatosis abnormal brain mri findings metachromatic leukodystrophy in ceroid lipofuscinosis sialidosis gm1 gm2 gangliosidoses myoclonus maculopathy e.g. cherry red spot may coexist although quite similar appearance macular abnormality seen patients neuronal ceroid lipofuscinosis described bulls eye maculopathy distinguished cherry red spot color shape well decreased visual acuity visual field restriction common neuronal ceroid lipofuscinosis.5 moreover adult onset lipofuscinosis autosomal dominant inheritance rather autosomal recessive pattern seen patient.6 gm1 gangliosidosis results deficiency -galatosidase adult form type 3 presents slowly progressive dementia prominent parkinsonian features extra pyramidal dysfunction particularly dystonia.7 gm2 gangliosidosis results deficiency hexosaminidase late form onset adolescence young adulthood may characterized cognitive dysfunction cerebellar dysfunction upper lower motor neuron involvement extrapyramidal dysfunction.8 -galatosidase hexosaminidase activity normal patient normal level intelligence prominent pyramidal extrapyramidal dysfunction detected might diagnose patient gm1 gm2 gangliosidoses sialidosis inherited autosomal recessive disease associated neuraminidase deficiency.9 2 major clinical manifestations type late adult onset type ii early infantile onset type sialidosis typically found patients aged 8 25 years characterized cherry red spot myoclonus seizure neuropathy corneal clouding difficulty walking normal vision intelligence obrien 1978 type ii sialidosis characterized dysmorphism myoclonus mental retardation ocular cherry red spots hepatosplenomegaly the patient report may present clinical evidence type sialidosis laboratory findings support diagnosis activities neuraminidase normal a similar case progressive myoclonic epilepsy reported.10 differences previous report described patient progressive myoclonic epilepsy cherry red spots negative enzyme deficiency theses 1 onset age older previous report 27 versus 13 years adult versus juvenile onset 2 patient sibling disease indicated inherited disease patient previous report familial history 3 patient report history seizure different patient myoclonic epilepsy although cause cherry red spot myoclonus clear knowledge first report adult onset familial cherry red spot myoclonus caused unknown type lysosomal storage disease korea

we report a case of a 36-year - old woman with progressive generalized myoclonus that first became apparent 9 years ago . her younger brother had similar problems . examination of her eyes revealed cherry - red spots . hexosaminidase a , -galactosidase and neuraminidase activity were normal . although the laboratory findings were negative , cherry - red spots , progressive myoclonus and autosomal recessive inheritance pattern suggested that she had an unknown type of lysosomal storage disease .

worldwide spread mycobacterium tuberculosis mtb strains resistant isoniazid rifampicin rif multidrug resistant mdr tuberculosis tb become major public health problem posing formidable challenges due complex diagnostic treatment requirements this highlights need rapid molecular diagnostic techniques could help facilitate early diagnosis appropriate delivery anti tubercular therapy xpert mtb rif assay cepheid real time automated nucleic acid amplification system one technique detects mtb well mutations confer resistance rif 2 h. installed institute guru gobind singh medical college hospital faridkot october 2013 revised national tuberculosis control programme rntcp tb xpert project supported stop tb partnership unitaid rif principle first line anti tb drug rif resistance surrogate marker mdr tb the genetic basis rif resistance approximately 95% cases presence mutations 81 bp rif resistance determining region rrdr rpob gene corresponding codons 507533 escherichia coli numbering system codes beta subunit rna polymerase mtb studies conducted diverse geographical areas shown burden mdr tb mutations responsible drug resistance vary country country region region however enough information important aspect north india data malwa region punjab almost lacking therefore retrospective study conducted determine frequency rif resistance rpob gene mutations among suspected tb mdr cases malwa region punjab districts faridkot fazilka firozpur moga bathinda muktsar area approximately 14,981 km using xpert mtb rif assay knowledge pattern mutations present rif resistant isolates could provide insight epidemiology rif resistant mtb isolates particular area a total 1612 sputum specimens originated patients suspected mdr pulmonary tb malwa region punjab received microbiology laboratory rntcp xpert mtb rif assay october 2013 february 2015 the samples subjected ziehl neelsen zn staining xpert mtb rif assay the xpert mtb rif assay performed directly sputum specimens using xpert mtb rif assay g4 version 5 software version 4.4a per manufacturer instruction cepheid sunnyvale ca usa briefly consisted inactivation sputum specimen naoh isopropanol sample reagent used 1:2 ratio 15 min the mixture introduced xpert mtb rif cartridge loaded xpert mtb rif instrument dna extraction amplification 192 bp segments rpob gene the detection consists hybridization amplicon five overlapping probes complementary rpob core the reports communicated electronically concerned district tb officer drug resistant tb center chi square test proportions used identify significant difference two groups p 0.05 considered statistically significant determine association various epidemiological characteristics patients rif resistant tb odds ratio 95% confidence interval ci calculated using spss statistical software version 20.0.0 spss inc the relationship smear positivity grade relative bacterial burden xpert mtb rif ct value given genexpert operator manual cepheid also analyzed chi square test proportions used identify significant difference two groups p 0.05 considered statistically significant determine association various epidemiological characteristics patients rif resistant tb odds ratio 95% confidence interval ci calculated using spss statistical software version 20.0.0 spss inc the relationship smear positivity grade relative bacterial burden xpert mtb rif ct value given genexpert operator manual cepheid also analyzed out 1612 specimens tested 1308 positive mtb xpert mtb rif assay there 34 errors 18 specimens showed results specimens retested valid results obtained except two one showed error second sample also another could processed due insufficient material second specimen zn staining 1308 specimens positive mtb xpert mtb rif assay showed 1240 positive acid fast bacilli afb 272 21.9% grade 3 positive correlation smear positivity grade relative bacterial burden ct value showed total 272 grade 3 positive specimens 69.4% 22.5% 6.5% 1.6% high ct 16 medium ct 1622 low ct 2028 low ct 28 bacterial load respectively of specimens showing grade 2 grade 1 scanty positivity maximum belonged high medium high medium medium bacterial load groups respectively sputum negative specimens 68/1308 maximum number belonged low bacterial load group of 1308 mtb positive samples xpert tb rif assay 130 9.9% demonstrated rif resistance results obtained 4 specimens retesting 2 came rif sensitive all 4 specimens smear positive ct value 28 the study association epidemiological characteristics patients rif resistant tb showed rif resistance present statistically significant higher number previously treated patients comparison new patients 95% ci 1.1487.135 p 0.006 2.86 patients afb positive sputum smears afb negative smears 95% ci 0.91115.5 p 0.048 3.7 however difference found statistically insignificant different age groups patients p 0.053 male female patients 95% ci 0.7061.57 p 0.798 1.054 patients rural urban background 95% ci 0.691.49 p 0.918 1.02 hiv positive hiv negative patients 95% ci 0.2194.13 p 0.949 0.953 study mutation pattern rif resistance 130 specimens revealed 129 rpob gene mutations 81 bp rrdr mtb detected one 5 different probes b c e one specimen mutation combination i.e. mutations associated one probe b present probe frequencies associated observed rif resistance follow e 73/130 56% b 28/130 21.5% 18/130 13.8% 11/130 8.4% c 1/130 0.7% table 1 accordingly frequencies mutations 5 different rpob gene regions 529533 56% 512518 21.5% 523529 13.8% 507511 8.4% 518523 0.7% district wise pattern mutations seen 130 rifampicin resistant tuberculosis specimens correlation mutations rif resistant sputum specimens obtained different districts table 1 revealed probe e represented mutation region 529533 common six districts study only one specimen revealed rif resistance probe c depicting mutation codon region 518523 out 1612 specimens tested 1308 positive mtb xpert mtb rif assay there 34 errors 18 specimens showed results specimens retested valid results obtained except two one showed error second sample also another could processed due insufficient material second specimen zn staining 1308 specimens positive mtb xpert mtb rif assay showed 1240 positive acid fast bacilli afb 272 21.9% grade 3 positive correlation smear positivity grade relative bacterial burden ct value showed total 272 grade 3 positive specimens 69.4% 22.5% 6.5% 1.6% high ct 16 medium ct 1622 low ct 2028 low ct 28 bacterial load respectively of specimens showing grade 2 grade 1 scanty positivity maximum belonged high medium high medium medium bacterial load groups respectively sputum negative specimens 68/1308 maximum number belonged low bacterial load group of 1308 mtb positive samples xpert tb rif assay 130 9.9% demonstrated rif resistance results obtained 4 specimens retesting 2 came rif sensitive all 4 specimens smear positive ct value 28 the study association epidemiological characteristics patients rif resistant tb showed rif resistance present statistically significant higher number previously treated patients comparison new patients 95% ci 1.1487.135 p 0.006 2.86 patients afb positive sputum smears afb negative smears 95% ci 0.91115.5 p 0.048 3.7 however difference found statistically insignificant different age groups patients p 0.053 male female patients 95% ci 0.7061.57 p 0.798 1.054 patients rural urban background 95% ci 0.691.49 p 0.918 1.02 hiv positive hiv negative patients 95% ci 0.2194.13 p 0.949 0.953 study mutation pattern rif resistance 130 specimens revealed 129 rpob gene mutations 81 bp rrdr mtb detected one 5 different probes b c e one specimen mutation combination i.e. mutations associated one probe b present probe frequencies associated observed rif resistance follow e 73/130 56% b 28/130 21.5% 18/130 13.8% 11/130 8.4% c 1/130 0.7% table 1 accordingly frequencies mutations 5 different rpob gene regions 529533 56% 512518 21.5% 523529 13.8% 507511 8.4% 518523 0.7% district wise pattern mutations seen 130 rifampicin resistant tuberculosis specimens correlation mutations rif resistant sputum specimens obtained different districts table 1 revealed probe e represented mutation region 529533 common six districts study only one specimen revealed rif resistance probe c depicting mutation codon region 518523 although india ranks first 22 countries highest burden tb reliable information magnitude mdr tb country largely unavailable using xpert mtb rif assay observed rif resistance surrogate marker mdr tb 9.9% suspected cases mdr tb malwa region punjab however higher prevalence mdr tb reported indian studies lucknow 27.8% new delhi 17.9% central india 17% globally 3.7% new cases 20% previously treated cases estimated mdr tb india the estimated figure new cases mdr tb 2.1% ci 1.52.7 estimated percentage previously treated cases 15% ci 1317 respectively rntcp carried drug resistant surveys accordance global guidelines indicated low prevalence mdr tb i.e. 3% among new cases 1217% previously treated cases gujarat maharashtra andhra pradesh present study the figure 3.9% 5/126 new 10.6% 125/1182 retreatment cases difference two statistically significant p 0.006 gupta et al also observed mdr tb significantly higher previously treated cases compared new cases concluded previous exposure anti tb agents common cause developing mdr present study another statistically significant association seen smear positive mdr cases comparison smear negative mdr cases p 0.048 gupta et al also observed higher statistically insignificant association mdr tb smear positivity this could mdr tb patients study pulmonary tb patients likely cavitary lesions positive sputum smear results our study population showed slightly higher prevalence rif resistance hiv negative patients hiv positive patients statistically difference insignificant p 0.949 this contrast study gupta et al observed statistically significant difference mdr tb hiv negative comparison hiv positive group patients quy et al reported failure treatment mdr tb associated mdr hiv infection although statistically insignificant differences different age groups showing mdr tb p 0.053 maximum number cases present study age group 2140 years other indian studies also reported predominance younger age group mdr tb there also higher number male patients patients rural background mdr tb study as young adult males economically productive segment society high mdr tb group several socioeconomic implications detecting tb mdr cases xpert mtb rif assay showed 2.1% 34/1612 errors present study mboowa et al reported 12% errors using xpert mtb rif assay g3 version 3 g4 version 5 half contributed former version the lower percentage errors present study could used upgraded g4 version 5 xpert mtb rif assay similar study rufai et al reported 1.8% errors using xpert mtb rif assay g4 nwokoye et al stated low bacterial load limits ability xpert mtb rif assay correctly identify mutated wildtype sequences core region rpob gene the indeterminate results rif resistance detected four samples present study could high ct value 28 corresponding low bacterial burden while using xpert mtb rif assay detection mtb rif resistance mdr suspected cases could collect additional information mutations associated rif resistance it observed pattern mutations 81 bp rrdr mtb isolates present study almost similar reported parts india the common rrdr rpob gene mutations gene region 529533 56% table 1 six districts malwa region recognized probe e. mboowa et al too used xpert mtb rif assay common gene mutations observed codon 531 58% followed 513 25% 526 8% 511 8% designed probes e b a. singhal et al used genotype mtbdr plus assay reported 531 commonly mutated codon 59.0% similarly mani et al reported codons commonly involved mutations 531 53% 526 19% study south india the resistant mutants isolated frequently clinical practice higher mean relative fitness prevalence depend ability survive this might reason higher occurrence mutations codon 531533 study observed rif resistance probe c 518523 one 130 rif resistant sputum samples this similar findings gupta et al used dna sequencing combined ms pcr assay observe mutation rpob region in contrast rif resistance found associated probe c study mboowa et al this could probably lesser susceptibility genetic region mutations selection pressure shaping producing probe c associated rif resistance less malwa region punjab north india mutation combination probe b observed one 1/130 rif resistant specimens present study singhal et al found 6 strains 6/366 one mutations mboowa et al reported specimen one probe failure mutation combination employing xpert mtb rif assay study probably mutations continue arise due ability mtb adapt drug exposure the limitation study gold standard used comparison xpert mtb rif assay results xpert mtb rif better screening tool detection mtb rif resistance shorter period time could help improve early recognization mdr tb prevention transmission malwa region punjab this assay also appears useful technique simultaneous preliminary information regarding mutation pattern rif resistance mtb isolates could helpful understating epidemiology disease identification hot spots implementation tb control program however confirmation detailed study mutations dna sequencing remains indispensable

background : xpert mtb / rif assay has revolutionized the diagnosis of tuberculosis ( tb ) by simultaneously detecting the bacteria and resistance to rifampicin ( rif ) , a surrogate marker for multidrug - resistant tb ( mdr - tb ) in < 2 h. the rif resistance pattern in malwa region of punjab , india , is not documented . here , we report the epidemiology of rif - resistant tb and mutations in rpob gene of mycobacterium tuberculosis ( mtb).materials and methods : a total of 1612 specimens received between october 2013 and february 2015 were tested by xpert mtb / rif assay following manufacturer 's instructions . the results thus obtained were analyzed using spss version 20.0.0 ( spss inc . , chicago , il , usa ) statistical software.result:rif resistance was statistically higher in previously treated patients in comparison to the new patients ( p = 0.006 ) and in patients with acid fast - bacilli ( afb ) positive smears to afb - negative smears ( p = 0.048 ) . rif resistance mutations in 130 specimens revealed frequency of e 73/130 ( 56% ) , b 28/130 ( 21.5% ) , d 18/130 ( 13.8% ) , a 11/130 ( 8.4% ) , and c 1/130 ( 0.7% ) while in one specimen , mutation combination , i.e. , mutations associated with more than one probe ( a and b both ) was present.conclusion:xpert mtb / rif assay is a user - friendly screening tool for detection of mtb and rif resistance from suspected tb / mdr cases in a shorter period of time . it could also serve as a useful technique to have simultaneous preliminary information regarding the mutation pattern of rif resistance in mtb isolates .

hallmark autoimmune diseases pathologic activity immune system organism directed cells tissues the disease direct consequence tissue and/or organ damage mediated autoreactive components immune system autoreactive lymphocytes and/or autoantibodies diagnostic purposes autoantibodies important analytes within systemic autoimmune rheumatic diseases sard anti nuclear antibodies ana directed various cellular components associated autoantibodies antibodies reactive dsdna extractable nuclear antigens ena fundamental diagnosis 13 traditionally ana detected indirect immunofluorescence iif performed human epithelial cells hep-2 this technique requires multistage process consistent visual determination staining pattern serial titrations positive sera followed second test autoantigen specificity determined 2 4 recently american college rheumatology acr stated ana detection iif still considered gold standard this primarily based high sensitivity iif assay inclusion ana detection iif assay diagnostic criteria systemic lupus erythematosus sle autoimmune hepatitis aih 68 in addition ana also considered screening test samples require testing autoantigen specificity dsdna ena 2 9 the specificity ana detection iif however relatively poor especially low titres used screening indeed 1 40 serum dilution 2530% healthy individuals may test positive ana increases even upon ageing 1 10 overall recommended serum dilution gives specificity 95% healthy individuals used cut moreover clinical significance rises increasing titres 11 12 well identification responsible autoantigen 1 9 obviously positive ana test must always interpreted cautiously within clinical context patient clinical setting pretest probability sard generally low primary care added value positive ana test lower compared secondary tertiary care situations pretest probabilities sard often higher current study determined prevalence ana primary general practices secondary regional hospital tertiary care university hospital besides data ana prevalence also ana titres anti ena anti dsdna antibodies included analyses we hypothesize ana prevalence ana titre anti ena dsdna reactivity increase primary tertiary care situations expected also associated increasing pretest probability sard in present study three different patient populations southern part netherlands evaluated compared these three populations consisted patients tested ana november 2011 august 2012 suspicion autoimmune disease all ana requests considered involve diagnostic workup since none patients requests ana and/or anti ena dsdna least 4 years prior study period first patient population ( n 1453 ana requested general practitioners primary care second population n 1621 ana request regional hospital secondary care third population n 1168 ana request university hospital tertiary care testing ana first second cohorts was performed atrium mc heerlen netherlands ana tests third cohort performed maastricht university medical centre mumc maastricht netherlands furthermore regional university hospitals origin hospital department ana requests documented ana detection iif performed hep-2000 cells according instructions provided manufacturer immuno concepts sacramento ca hep-2000 cells transfected gene ssa-60 makes cells sensitive ssa antibody detection 14 15 fitc conjugated goat anti human igg antibody used detection ana five staining patterns considered ana positive homogenous atypical speckled speckled centromere nucleolar case mixed patterns slides evaluated fluorescent microscope axioskop carl zeiss microscopy gmbh jena germany led light source all slides evaluated two independent observers case difference opinion third observer decisive the presence anti ena antibodies screened commercially available line immunoassay ana 3 profile euroline euroimmun lbeck germany after first incubation diluted serum second incubation performed goat anti human igg linked alkaline phosphatase finally third incubation took place bromochloroindolyl phosphate nitro blue tetrazolium chloride bcip nbt substrate detect anti ena antibodies although ana 3 profile euroline kit enables detection 15 different antigens eight evaluated current study ro52 ss ro60 ss b la nrnp sm sm scl-70 topoisomerase 1 jo-1 cenp b reading results automated colour intensities reactions evaluated eurolinescan program euroimmun enable semiquantitative determination equivocal 1 2 3 results considered positive sm scl-70 jo-1 intensity least equivocal ss ro60 ss b la nrnp sm cenp b intensity least 1 required finally cutoff ro52 2 positive lia results defined confirmed commercially available feia elia immunodiagnostics thermo fisher scientific freiburg germany this method uses highly purified smd recombinant ss ro60 ro52 ss b la cenp b scl-70 jo-1 rnp70 u1rnp human antigens coated irradiated polystyrene cups assay performed according manufacturer instructions the sera diluted 1 50 dilution buffer binding anti ena antibodies cups washed subsequently incubated mouse anti human igg heavy chain specific conjugated -galactosidase case antibody association binding detected fluorometrically using 4-methylumbellifery--d galactoside 0.01% substrate for antigens values 10 u ml considered positive primary secondary care anti dsdna antibodies were detected commercially available feia elia immunodiagnostics thermo fisher scientific this method uses circular plasmid dsdna purified escherichia coli antigen the assay performed according manufacturer instructions described anti ena antibodies the sera diluted 1 10 dilution buffer values 15 u ml considered positive tertiary care anti dsdna antibodies detected crithidia luciliae immunofluorescence test clift immuno concepts fitc conjugated goat anti human igg antibody used detection anti dsdna antibodies slides evaluated fluorescent microscope axioskop carl zeiss microscopy gmbh led light source all slides evaluated two independent observers case difference opinion third observer decisive all samples tested first ana iif result negative testing performed unless specifically requested however results additional tests included present study if ana iif positive irrespective staining pattern titration performed 1 320 1 1280 if homogenous ana pattern detected testing anti dsdna antibodies performed feia primary secondary care clift tertiary care additionally case homogenous atypical speckled centromere pattern typing anti ena antibodies performed lia because high correlation atypical speckled ana pattern ss ro60 antibodies antibodies considered positive atypical speckled ana pattern observed combination either positive lia positive feia similarly anti cenp b antibodies considered positive centromere ana pattern observed combination positive anti cenp b result least one anti ena antibody test systems since lia enable specific distinction anti rnp antibodies positivity nrnp sm complex followed testing antibodies rnp70 u rnp feia chicago il graphpad prism version 6 graphpad software inc la jolla ca the kolmogorov smirnov analysis performed determine whether age distributions three study populations normally distributed furthermore chi square test yates correction appropriate performed comparing proportions groups case small samples of three patient populations included 90 6.2% 175 10.8% 187 16.0% patients primary n 1453 secondary n 1621 tertiary care n 1168 respectively tested positive ana therefore eligible current study gender f age median range distribution follows 78/12 57.2 1595 primary care 129/46 57.0 1793 secondary care 130/57 57.3 384 tertiary care the gender distribution differed significantly p 0.009 due strong female preponderance primary care the age distribution differed significantly p 0.005 due fact tertiary care age distribution skewed negatively evaluation origin hospital departments ana requests secondary tertiary care revealed four departments rheumatology dermatology internal medicine neurology requested majority ana screening tests figure 1(a 86% 68% respectively the prevalence ana 3 distinct clinical settings depicted figure 2(a the higher relative ana prevalence tertiary care 16.0% versus secondary care 10.8% apparent 4 clinical disciplines requested majority ana screening test figure 1(a also holds clinical disciplines data shown pooled results ) typically secondary care 39.5% overall ana requests came rheumatology department tertiary care 15.4% within positive ana cohorts patients primary care relatively low titres out 90 positive ana tests 63 sera 70% revealed ana titre 1 80 secondary tertiary care titre 1 consequently higher titres observed frequently secondary tertiary care primary care the distribution titres secondary tertiary care different first glance apparent difference distribution ana patterns three health care levels figure 2(c also comparison distribution ana patterns titre 1 1280 considered highest positive likelihood ratio showed significant differences data shown the prevalence anti ena anti dsdna antibodies defined algorithm described presented figure 3(a primary care 19 21.1% ) patients positive ana n 90 tested positive anti ena and/or anti dsdna antibodies 1.3% total cohort secondary tertiary care 68 175 38.9% 40 187 21.4% ana positive patients revealed anti ena and/or anti dsdna reactivity respectively this 4.2% 3.4% total secondary tertiary care cohorts respectively p 0.367 significantly positive anti ena and/or anti dsdna results found total secondary tertiary care cohorts primary care cohort p 0.0001 p 0.0006 resp secondary care the prevalence anti ena and/or anti dsdna reactivity within positive ana samples highest requests rheumatology figure 1(b in tertiary care however departments rheumatology neurology average reduced prevalence anti ena and/or anti dsdna reactivity compared departments dermatology internal medicine figure 1(b since relevance anti ena anti dsdna antibodies considered increase combined reactivity observed analysed prevalence anti ena and/or anti dsdna antibodies relation combined reactivity figure 3(b primary care setting single positivity appeared abundant secondary tertiary care difference statistically significant no differences observed secondary tertiary care settings either respect antigens recognized specific antibodies no apparent differences observed prevalence antibodies reactive rnp ssa60 ro52 ssb cenp b dsdna figure 3(c anti scl70 antibodies detected samples patients secondary tertiary care however absolute number one cohort low settings in present study analyses ana prevalence ana titre anti ena specificity primary secondary tertiary care results indicate ana prevalence significantly increases primary tertiary care ii low titres 1 80 frequently observed primary care iii anti ena anti dsdna specificities significantly prevalent secondary care primary care interpretation data obtained current study highly dependent viewpoint clinical utility ana test result this result may help clinician identify patient sard especially situations low pretest probabilities diseases risk false interpretation positive ana high this risk false positive interpretation decrease positive ana characterized high titre includes multi)-reactivity ena and/or dsdna since characteristics associated higher positive likelihood ratios 11 12 17 next one realize ana testing performed context multiple diseases varying distinct sard autoimmune liver diseases interpretation positive ana test may different distinct disease patients instance aih systemic sclerosis often positive ana ena reactivity positive ana test part classification criteria sle well aih 68 negative ana test result hand may also useful exclude specific set diseases may drive attention diseases again differs distinct sard negative ana test high negative predictive value sle systemic sclerosis less helpful exclude sjgren syndrome myositis 2 3 obviously definite interpretation dataset hampered lack clinical data patients three cohorts the assumption primary care relatively low pretest probability based previous studies 13 18 19 future studies recommend inclusion clinical data order able thoroughly assess pretest probabilities strengthen assumptions this study however also noteworthy strengths data obtained diagnostic workup patients follow samples included testing algorithm reagents except detection anti dsdna antibodies used three patient cohorts as expected observed gradual increase prevalence ana primary tertiary care present study ana was detected iif screening dilution 1 80 several studies it reported 1015% healthy controls ana positive serum dilution 1 10 20 obviously positive ana test result dependent dilution factor also quality reagents fluorescent conjugate cell substrate fluorescent microscope standardization purposes it therefore recommended screen ana specificity 95% taking account mere presence ana primary care cohort prevalence 6.2% lacks discriminating power identify patients sard hand due high negative predictive value negative ana result furthermore since high titre anti ena and/or anti dsdna multi-)reactivity may increase likelihood identifying patient sard 11 12 17 apparent primary care cohort 30% ana positive sera medium high titre n 27 21% contain anti ena and/or anti dsdna reactivity n 19 37% latter reveal multireactivity n 7 secondary tertiary cohorts ana prevalence also relatively low 11 16% resp clinical settings half ana positive sera high titre 48 49% expected observed anti ena and/or anti dsdna reactivity ana positive sera secondary care 39% higher primary care surprisingly anti ena and/or anti dsdna reactivity tertiary care 21% lower secondary care similar primary care this might related spectrum diseases investigated tertiary versus secondary centres also higher number ana requests tertiary care departments typically involved diagnosis sard might result academic profiling respective departments for instance cardiology department mumc specialized inflammatory cardiomyopathies possible autoimmune aetiology diseases cardiology requested 108 ana tests 9.2% revealing 13% ana positive results 20% anti ena and/or anti dsdna antibody positive a second important difference presence division clinical immunology within department internal medicine tertiary care hospital implying many patients sard evaluated clinical immunologists instead rheumatologists the latter difference might least explain lower relative prevalence anti ena anti dsdna antibodies rheumatology department tertiary care hospital our study shows secondary care majority positive ana results 92.6% well positive anti ena anti dsdna results 95.6% linked departments rheumatology dermatology internal medicine neurology obviously patients highest pretest probabilities sard associated initial clinical presentation likely referred clinical departments in clinical settings lower pretest probabilities ana positive sera likely clinical significance 13 18 19 it might therefore option particular primary care settings move away traditional ana screening test context recent discovery dense fine speckled dfs70 antigen promising could offer possible solution identification exclusion positive sera clinical relevance 21 22 typical ana dense fine speckled pattern dfs known associated dfs70 antigen found commonly prevalent healthy individuals ana positive sera 33.1% whereas sard patients 0.0% sera revealed dfs pattern another study revealed 2 3% sard patients antibodies directed dfs70 antigen obviously sard patients anti ena antibodies might present hamper correct recognition dfs iif pattern indeed identification correct interpretation dfs pattern might prove challenging diagnostic laboratories would require additional training moreover majority patterns recognized seem compatible dfs pattern might consequence interpreting strongest pattern current study since identification dfs pattern might challenging routine diagnostic laboratories inaccurate interpretation significant consequences immunoadsorption protocol diminish anti dfs70 antibody reactivity hep-2000 cells could implemented current iif assay order significantly improve performance characteristics ana iif test 21 25 this approach sustains recognition sard related autoantibodies sera combined reactivities anti dfs70 anti ena antibodies another alternative testing algorithm could instead ana iif include solid phase assays including multiplex screening assays well defined anti ena anti dsdna reactive antibodies 11 12 26 27 approaches enable distinguish reduce number positive ana results lacking clinical relevance in addition multiplex anti ena screening assays considered better recognize particular antigens example ssa jo-1 compared ana iif testing 3 11 12 28 altogether results indicate primary care usage traditional ana screening tests prone false interpretation positive ana results rather alternative testing algorithm detection patients sard might appropriate this might either achieved immunoadsorption anti dfs70 antibodies direct screening anti ena antibodies obviously patient severe clinical manifestations typical sard presenting primary care setting referred directly without laboratory testing rheumatologist clinical immunologist this recommendation may apply general practitioners may also hold clinical departments less likely encounter patients suspected sard

for the diagnosis of systemic autoimmune rheumatic diseases ( sard ) , patients are screened for anti - nuclear antibodies ( ana ) . ana , as assessed by indirect immunofluorescence ( iif ) , have a poor specificity . this hampers interpretation of positive results in clinical settings with low pretest probability of sard . we hypothesized that the utility of positive ana iif results increases from primary to tertiary care . we retrospectively determined ana , anti - ena , and anti - dsdna antibody prevalence in patient cohorts from primary ( n = 1453 ) , secondary ( n = 1621 ) , and tertiary ( n = 1168 ) care settings . results reveal that from primary care to tertiary care , ana prevalence increases ( 6.2 , 10.8 , and 16.0% , resp . ) . moreover , in primary care low titres ( 70% versus 51% and 52% in secondary and tertiary care , resp . ) are more frequent and anti - ena / dsdna reactivities are less prevalent ( 21% versus 39% in secondary care ) . typically , in tertiary care the prevalence of anti - ena / dsdna reactivities ( 21% ) is lower than expected . from this descriptive study we conclude that positive ana iif results are more prone to false interpretation in clinical settings with low pretest probabilities for sard , as in primary care . whether alternative approaches , that is , immunoadsorption of anti - dfs70 antibodies or implementation of anti - ena screen assays , perform better , needs to be determined .

mdct benefits high spatial resolution fast acquisition time making ideal tool stage restage tumours the routine use intravenous oral contrast media unless contraindicated also helps delineate sites disease especially within solid organs the identification nodal involvement ct based nodal size typically using minimum cutoff 1 cm short axis diameter although lead under- staging metastatic nodal involvement the purpose pictorial review discuss imaging appearances ct common cancers arising within abdomen pelvis describe typical sites local nodal haematogenous tumour spread cancers arising stomach pancreas colon kidney ovary prostate reviewed summary tables provided ninety percent tumours adenocarcinomas subdivided two main histological types 1 well differentiated intestinal type associated atrophic gastritis occurs older patients better survival rate 2 undifferentiated diffuse signet ring type common occurs frequently women poorer prognosis gastric adenocarcinoma occurs either proximally cardia distally non cardia former increasing incidence whilst latter declining see table 1 table 1summary table local nodal haematogenous spread gastric cancerlocal spreadlocal spread adjacent structures e.g. pancreas colon spleen)lymph node spreadperigastric pericardial lesser curvature greater curvature suprapyloricextraperigastric left gastric common hepatic coeliac splenic hilum artery hepatic pedicle retropancreatic mesenteric root middle colic para aortichaematogenous spreadmost commonly liver 25% presentation peritoneumnotestranscoelomic spread occur peritoneum e.g. kruckenberg tumours)retropancreatic para aortic mesenteric nodes classified m1 metastatic disease nodal disease gist tumours extremely rare summary table local nodal haematogenous spread gastric cancer ct use oral contrast agents distend stomach essential preferably water rather dilute gastrograffin avoid beam hardening artefacts involvement stomach wall seen thickening irregularity inner middle layer gastric wall t1 tumours transmural thickening abnormal contrast enhancement t2 tumours wall thickness reported greater higher attenuation diffuse histological type compared intestinal type gastric cancer spreads predictable fashion gastric wall presence perigastric fat stranding nodular outline suggestive serosal involvement t3 tumours fig 1 1gastric adenocarcinoma axial contrast enhanced ct cect showing tumour arising lesser curvature stomach asterisk associated enlarged regional gastrohepatic nodes arrows gastric adenocarcinoma axial contrast enhanced ct cect showing tumour arising lesser curvature stomach asterisk associated enlarged regional gastrohepatic nodes arrows spread perigastric less frequently intra abdominal nodes may occur table 1 fig 1 sign describes clinical finding enlarged left supraclavicular lymph node due metastatic involvement abdominal cancers may metastasise site via thoracic duct gastric malignancy classically described commonest primary tumour obstructive jaundice associated bile duct dilatation may occur due enlarged porta hepatis nodes due spread gastric tumour via gastrohepatic ligament directly liver haematogeneous spread via portal vein liver occurs 25% patients presentation liver metastases typically appearing rim enhancing low attenuation lesions portal venous phase peritoneal disease secondary gastric adenocarcinoma may mimic appearance peritoneal disease secondary metastatic ovarian carcinoma omental cake and/or discrete peritoneal deposits noted within abdominal cavity trans coelomic spread also characteristic gastric cancer spread ovary resulting krukenberg tumour typically appears mixed solid cystic adnexal mass involvement peritoneal reflection within pelvis result positive blumer shelf finding tumour found high anterior rectal wall it noted histological tumour types arising stomach different patterns tumour spread gastrointestinal stromal tumours gists common primary mesenchymal neoplasms gastrointestinal tract distinct true smooth muscle neural tumours derived interstitial cells cajal they frequently located within stomach 6070% regarded malignant potential gists typically involve outer muscular layer gi tract thus often demonstrate exophytic growth fig 2 most appear well defined extraluminal combined intraluminal extraluminal masses ct small tend homogeneous attenuation larger heterogeneous unenhanced enhanced scans necrosis haemorrhage central areas necrosis may communicate gastric lumen if arising stomach tumour may extend gastrohepatic ligament gastrosplenic ligament lesser sac nodal spread extremely rare haematogenous spread occur often liver nearly 50% patients gists presenting metastases fig 2 2gastrointestinal stromal tumour gist axial cect showing typical large low attenuation exophytic tumour asterisk arising greater curvature stomach associated liver metastasis arrow note significantly enlarged regional nodes gastrointestinal stromal tumour gist axial cect showing typical large low attenuation exophytic tumour asterisk arising greater curvature stomach associated liver metastasis arrow note significantly enlarged regional nodes pancreatic ductal adenocarcinoma accounts 80% malignant tumours pancreas and ct initial imaging modality used staging suspected pancreatic cancer ct along mri endoscopic sonography used distinguish potentially resectable non resectable patients cancer head pancreas contraindications surgery include distant metastases circumferential involvement superior mesenteric vein portal vein segment 2 cm long thrombus vein occlusion circumferential invasion celiac hepatic superior mesenteric arteries see table 2 table 2summary table local nodal haematogenous spread pancreatic cancerlocal spreadtumour spreads direct perivascular perineural invasion;local invasion involve stomach duodenum retroperitoneum;head uncinate process tumours usually extend along sma mesenteric root;body tail tumours usually infiltrate celiac hepatic splenic arterieslymph node spreadprimary drainage superior inferior anterior posterior splenic lymph nodes;secondary drainage porta hepatis common hepatic coeliac mesenteric root lymph nodes;tertiary drainage peri aortic distal superior mesenteric lymph nodeshaematogenous spreadthese usually involve liver peritoneal surfacesnoteearly lymphatic haematogenous micrometastases presentation common summary table local nodal haematogenous spread pancreatic cancer performing staging ct ideally least two contrast enhanced acquisitions late arterial venous phases advised the pancreas retroperitoneal organ close anatomic relationship abdominal peritoneal reflections the pancreatic head connected liver lesser curvature stomach via hepatoduodenal ligament gastrohepatic ligaments respectively the tail pancreas continuity hilum spleen greater curvature stomach via splenorenal gastrosplenic ligaments pancreatic cancer invade adjacent peritoneal ligaments well transverse mesocolon involve stomach duodenum fig tumour tends spread direct perivascular perineural invasion within subperitoneal space arising pancreatic head uncinate process tumours usually extend along superior mesenteric artery root mesentery biliary pancreatic duct dilatation 3pancreatic adenocarcinoma axial cect showing example tumour arising head pancreas asterisk invasion duodenum there focal thrombus portal vein arrow b axial cect patient associated intra- arrows extrahepatic shown bile duct dilatation c axial cect showing large bulky tumour different patient arising body pancreas asterisk encasing origin celiac axis pancreatic adenocarcinoma axial cect showing example tumour arising head pancreas asterisk invasion duodenum focal thrombus portal vein arrow b axial cect patient associated intra- arrows extrahepatic shown bile duct dilatation c axial cect showing large bulky tumour different patient arising body pancreas asterisk encasing origin celiac axis spread regional nodes occurs involving either peripancreatic nodes nodes celiac axis porta hepatis sometimes nodes afield table 2 most colorectal cancers arise adenomatous polyps polyps greater 2 cm size associated greater 40% risk malignancy local staging rectal cancer mri standard imaging modality increased soft tissue resolution multiplanar capabilities colorectal tumours may appear polypoid infiltrative lesions bowel wall fig early colonic tumours better detected endoluminal distension given colon prepared ct colonography tumour spread serosa appears pericolonic fat stranding may confused associated desmoplastic reaction possibly mimicking diverticulitis within sigmoid colon the presence fluid root sigmoid mesentery engorgement adjacent sigmoid mesenteric vasculature favours diverticulitis whilst presence pericolic lymph nodes suspicious colon cancer tumour spread adjacent organs suggested loss fat planes direct invasion see table 3 table 3summary table local nodal haematogenous spread colorectal cancerlocal spreadinvasion bowel wall peri colonic fat adjacent structureslymph node spreadfollows vascular distribution vessels mesocolon;ascending mesocolon nodes along ileocolic vessels right colic vessel;transverse mesocolon nodes along middle colic vessels;sigmoid descending mesocolon nodes along inferior mesenteric vein;regional lymph nodes rectal cancers include mesorectal sigmoid mesenteric inferior mesenteric lateral sacral presacral internal iliac sacral promontory superior rectal middle rectal inferior rectalhaematogenous spreadliver via portal vein lung adrenal glands bonesnotesin rectal cancers perforated peritoneum transcoelomic spread favours lower right small bowel mesentery pouch douglasfig 4colonic adenocarcinoma axial non contrast enhanced ct showing tumour asterisk ascending colon enlarged ileocolic nodes arrows b axial contrast enhanced ct shows large liver metastasis asterisk summary table local nodal haematogenous spread colorectal cancer colonic adenocarcinoma axial non contrast enhanced ct showing tumour asterisk ascending colon enlarged ileocolic nodes arrows b axial contrast enhanced ct shows large liver metastasis asterisk nodal spread depends site primary tumour follows vascular distribution vessels within mesocolon 11 12 these vessels include ileocolic vessels right colic vessel ascending mesocolon middle colic vessels transverse mesocolon inferior mesenteric vein sigmoid descending mesocolon rectal tumours drainage usually cranial within mesorectum involve regional lymph nodes table 3 5 less common involvement inguinal nodes seen lower rectal tumours proximal lymphatic blockage e.g. extensive adenopathy 5rectal adenocarcinoma coronal reformat cect showing bulky rectal tumour asterisk enlarged right internal iliac nodes double asterisk left paraaortic node arrow rectal adenocarcinoma coronal reformat cect showing bulky rectal tumour asterisk enlarged right internal iliac nodes double asterisk left paraaortic node arrow metastatic disease presentation uncommon 1015% cases haematogeneous spread predominantly seen within liver metastases deriving blood supply hepatic artery compared normal liver parenchyma primarily supplied portal vein result liver metastases imaged portal venous phase seen heterogeneous ring enhancing metastases hypodense surrounding liver parenchyma fig for example venous drainage colon upper rectum via portal vein thus liver common site spread however lower rectum dual drainage superior haemorrhoidal vein draining inferior mesenteric vein portal vein middle inferior haemorrhoidal veins draining pelvic veins directly inferior vena cava this explains distal rectal cancers result isolated pulmonary metastases without hepatic metastases if rectal tumours perforate peritoneal membrane transcoelomic spread may occur favouring lower right small bowel mesentery pouch douglas if colorectal tumours mucinous histology widespread intraperitoneal mucinous metastases may occur characteristic scalloping adjacent viscera pseudomyxoma peritoneii fig 6pseudomyxoma peritoneii axial cect showing mucinous ascites exerting mass effect scalloping solid organs primary gastrointestinal tract origin pseudomyxoma peritoneii axial cect showing mucinous ascites exerting mass effect scalloping solid organs primary gastrointestinal tract origin ct renal tumours appear hypervascular masses larger lesions heterogenous attenuation increasing size spread renal capsule perinephric fat involve gerota fascia early extension renal capsule recognized indistinct tumour margin thickened perirenal fascia perinephric fat stranding extension renal vein occurs 20% patients presentation involvement inferior vena cava ivc 510% patients fig tumour thrombus seen filling defect within vein confused streaming artefact unopacified blood the presence venous distension may misleading rccs hypervascular hence tend increased blood flow venous drainage distinction tumour thrombus bland thrombus within ivc may difficult although former may enhancing tumour vessels within in advanced tumours direct invasion adjacent structures diaphragm posterior abdominal wall muscles may seen see table 4 table 4summary table local nodal haematogenous spread renal cell carcinomalocal spreadperinephric fat ipsilateral adrenal adjacent viscera including muscles);renal vein invasion ivc)lymph node spreadvia lymphatics following renal vessels ipsilateral para aortic nodes direct connections thoracic duct mediastinum also existhaematogenous spreadcommon sites lungs bones cns adrenalsnoteextension renal vein occurs 20% patients presentation ivc involvement 510%fig 7metastatic renal cell carcinoma coronal reformat cect showing inferior vena cava ivc greatly expanded tumour thrombus arrows associated enlarged mediastinal nodes asterisks the primary renal tumour excised b axial cect showing enhancing lesion left gluteus maximus muscle patient increased size interval ct studies keeping metastatic deposit note numerous venous collaterals anterior abdomen short arrows due ivc thrombus c axial cect shows large lytic deposit lumbar spine asterisk patient causing compromise spinal canal cord arrows summary table local nodal haematogenous spread renal cell carcinoma metastatic renal cell carcinoma coronal reformat cect showing inferior vena cava ivc greatly expanded tumour thrombus arrows associated enlarged mediastinal nodes asterisks the primary renal tumour excised b axial cect showing enhancing lesion left gluteus maximus muscle patient increased size interval ct studies keeping metastatic deposit note numerous venous collaterals anterior abdomen short arrows due ivc thrombus c axial cect shows large lytic deposit lumbar spine asterisk patient causing compromise spinal canal cord arrows lymphatic spread rcc tends follow renal veins involve ipsilateral para aortic nodes there also direct connections thoracic duct mediastinum account rare presence mediastinal hilar node involvement fig metastatic involvement renal cell carcinoma seen order decreasing frequency lung 5060% bone 3040% liver 3040% adrenal gland 5% contralateral kidney 5% retoperitoneum 5% brain 5% more unusual sites reported include pancreas peritoneum bowel thyroid muscle fig 7c cross sectional imaging ct mri used preoperative tumour assessment ct imaging modality choice assessing metastatic disease bowel opacification usually achieved positive oral contrast medium e.g. dilute gastrograffin essential detection peritoneal deposits intravenous contrast also routinely administered unless contraindicated imaging performed portal venous phase conversely local pelvic spread better assessed pelvic mri ct see table 5 table 5summary table local nodal haematogenous spread ovarian carcinomalocal spreaduterus broad ligament via fallopian tube);direct invasion rectum colon bladder pelvic side walllymph node spreadvia lymphatics travelling along ovarian vessels terminate common iliac para aortic nodes;via broad ligament terminate internal iliac obturator nodes;via round ligament terminate external iliac inguinal nodestrans coelomic spreadcommon sites undersurface diaphragm liver surface pouch douglas omentum serosal bowel surfaceshaematogenous spreadthis occurs late disease;liver lungs kidney bonenoteascites arise increased production tumour surfaces and/or occlusion retroperitoneal lymph nodes summary table local nodal haematogenous spread ovarian carcinoma primary ovarian cancer variable appearances presenting either solid mass mixed solid cystic lesion fig ovarian cancer spreads locally adnexal structures uterus contralateral ovary although bilateral ovarian cancer may occur 1150% cases invasion pelvic side wall indicated tumour seen encasing iliac vessels within 3 mm pelvic sidewall 8ovarian carcinoma coronal reformat cect showing large solid cystic adnexal mass arising pelvis asterisk large volume para aortic adenopathy double asterisk ascites small peritoneal deposits arrows although para aortic nodal involvement seen metastatic ovarian carcinoma large volume rather unusual b sagittal reformat cect showing subcapsular deposits liver different patient arrows c axial cect patient b showing thick omental cake arrows axial cect patient b showing multiple enlarged short axis diameter 5 mm cardiophrenic nodes arrows ovarian carcinoma coronal reformat cect showing large solid cystic adnexal mass arising pelvis asterisk large volume para aortic adenopathy double asterisk ascites small peritoneal deposits arrows although para aortic nodal involvement seen metastatic ovarian carcinoma large volume rather unusual b sagittal reformat cect showing subcapsular deposits liver different patient arrows c axial cect patient b showing thick omental cake arrows axial cect patient b showing multiple enlarged short axis diameter 5 mm cardiophrenic nodes arrows peritoneal dissemination commonest mode spread found approximately 70% patients presentation common sites include greater omentum paracolic gutters pouch douglas liver capsule fig less commonly implants may seen within mesentery along porta hepatis lesser sac splenic surface gastrosplenic ligament 1618 ascites often present due either increased production tumour surfaces reduced peritoneal resorption invasion lymphatics tumour cells peritoneal deposits ct variety appearances including enhancing nodular soft tissue lesions linear plaque like thickening peritoneal reflections fig 8c tiny calcifications mixed solid cystic purely cystic lesions 19 20 the involvement bowel serosa lead asymmetric bowel wall thickening tethering bowel loops bowel obstruction liver surface implants subcapsular deposits may seen deposits causing characteristic scalloping liver capsule metastatic mucinous tumours ovary lead pseudomyxoma peritoneii although many cases primary mucinous tumour actually arises gastrointestinal tract secondary involvement ovary lymphatic spread occurs via three routes usually seen conjunction peritoneal spread routes include 1 along ovarian vessels common iliac para aortic nodes fig 8a 2 via broad ligament parametria internal iliac obturator nodes 3 rarely via round ligaments external iliac inguinal nodes cardiophrenic nodes defined 5 mm short axis diameter ct characteristically involved main lymphatic drainage route peritoneal cavity fig haematogenous dissemination rare ovarian carcinoma malignant pleural effusion common manifestation presentation other sides spread include spleen kidneys adrenals lungs brain bone mri traditionally used local staging prostate cancer high contrast resolution rectal cancer it able differentiate organ confined disease tumour demonstrates extracapsular spread direct involvement seminal vesicles adjacent organs also well seen mri ct used nodal distant staging prostate cancer see table 6 table 6summary table local nodal haematogenous spread prostate cancerlocal spreaddirect extension prostate capsule seminal vesicles bladder baselymph node spreadorder nodal involvement obturator presacral internal iliac common iliachaematogenous spreadbone lung liver;spinal bone metastases commonest site due direct communication presacral periprostatic veins)notesdenonvillier fascia forms relative natural barrier rectal spread;tumours apex prostate likely demonstrate extracapsular extension relatively little capsule level summary table local nodal haematogenous spread prostate cancer classically two lymph node metastatic patterns reported 9a para aortic lymph nodes pelvic nodal involvement sequential spread obturator nodes presacral nodes internal iliac common iliac nodes pattern 2 involves para aortic nodes second pattern nodal spread felt due haematogenous dissemination 9prostate carcinoma coronal reformat cect showing irregular enlarged prostate tumour white arrow extending bladder enlarged left pelvic side wall node black arrow liver metastases double arrows lesion left pubic ramus large soft tissue component note bones sclerotic keeping diffuse bony metastases b sagittal reformat cect different patient bone windows showing multiple sclerotic metastases thoracolumbar spine prostate carcinoma coronal reformat cect showing irregular enlarged prostate tumour white arrow extending bladder enlarged left pelvic side wall node black arrow liver metastases double arrows lesion left pubic ramus large soft tissue component note bones sclerotic keeping diffuse bony metastases b sagittal reformat cect different patient bone windows showing multiple sclerotic metastases thoracolumbar spine distant spread occurs one third patients involved sites including bone 90% lung 50% liver 25% fig osteoblastic sclerotic metastases rather lytic bone lesions usually seen ct order decreasing frequency skeletal metastases seen within vertebrae fig spinal involvement initially common within lumbar region less likely within cervical spine 97% cf pulmonary metastases occur 527% patients presentation often seen association second pattern nodal involvement pulmonary involvement either appear lymphangitis carcinomatosa due direct invasion pulmonary lymphatics pulmonary nodules due haematogenous spread 22 24 ninety percent tumours adenocarcinomas subdivided two main histological types 1 well differentiated intestinal type associated atrophic gastritis occurs older patients better survival rate 2 undifferentiated diffuse signet ring type common occurs frequently women poorer prognosis gastric adenocarcinoma occurs either proximally cardia distally non cardia former increasing incidence whilst latter declining see table 1 table 1summary table local nodal haematogenous spread gastric cancerlocal spreadlocal spread adjacent structures e.g. pancreas colon spleen)lymph node spreadperigastric pericardial lesser curvature greater curvature suprapyloricextraperigastric left gastric common hepatic coeliac splenic hilum artery hepatic pedicle retropancreatic mesenteric root middle colic para aortichaematogenous spreadmost commonly liver 25% presentation peritoneumnotestranscoelomic spread occur peritoneum e.g. kruckenberg tumours)retropancreatic para aortic mesenteric nodes classified m1 metastatic disease nodal disease gist tumours extremely rare summary table local nodal haematogenous spread gastric cancer ct use oral contrast agents distend stomach essential preferably water rather dilute gastrograffin avoid beam hardening artefacts involvement stomach wall seen thickening irregularity inner middle layer gastric wall t1 tumours transmural thickening abnormal contrast enhancement t2 tumours wall thickness reported greater higher attenuation diffuse histological type compared intestinal type gastric cancer spreads predictable fashion gastric wall presence perigastric fat stranding nodular outline suggestive serosal involvement t3 tumours fig 1 1gastric adenocarcinoma axial contrast enhanced ct cect showing tumour arising lesser curvature stomach asterisk associated enlarged regional gastrohepatic nodes arrows gastric adenocarcinoma axial contrast enhanced ct cect showing tumour arising lesser curvature stomach asterisk associated enlarged regional gastrohepatic nodes arrows spread perigastric less frequently intra abdominal nodes may occur table 1 fig 1 sign describes clinical finding enlarged left supraclavicular lymph node due metastatic involvement abdominal cancers may metastasise site via thoracic duct gastric malignancy classically described commonest primary tumour obstructive jaundice associated bile duct dilatation may occur due enlarged porta hepatis nodes due spread gastric tumour via gastrohepatic ligament directly liver haematogeneous spread via portal vein liver occurs 25% patients presentation liver metastases typically appearing rim enhancing low attenuation lesions portal venous phase peritoneal disease secondary gastric adenocarcinoma may mimic appearance peritoneal disease secondary metastatic ovarian carcinoma omental cake and/or discrete peritoneal deposits noted within abdominal cavity trans coelomic spread also characteristic gastric cancer spread ovary resulting krukenberg tumour typically appears mixed solid cystic adnexal mass involvement peritoneal reflection within pelvis result positive blumer shelf finding tumour found high anterior rectal wall it noted histological tumour types arising stomach different patterns tumour spread gastrointestinal stromal tumours gists common primary mesenchymal neoplasms gastrointestinal tract distinct true smooth muscle neural tumours derived interstitial cells cajal they frequently located within stomach 6070% regarded malignant potential gists typically involve outer muscular layer gi tract thus often demonstrate exophytic growth fig 2 most appear well defined extraluminal combined intraluminal extraluminal masses ct if small tend homogeneous attenuation larger heterogeneous unenhanced enhanced scans necrosis haemorrhage central areas necrosis may communicate gastric lumen if arising stomach tumour may extend gastrohepatic ligament gastrosplenic ligament lesser sac nodal spread extremely rare haematogenous spread occur often liver nearly 50% patients gists presenting metastases fig 2 2gastrointestinal stromal tumour gist axial cect showing typical large low attenuation exophytic tumour asterisk arising greater curvature stomach associated liver metastasis arrow note significantly enlarged regional nodes gastrointestinal stromal tumour gist axial cect showing typical large low attenuation exophytic tumour asterisk arising greater curvature stomach associated liver metastasis arrow pancreatic ductal adenocarcinoma accounts 80% malignant tumours pancreas 70% tumours arise within pancreatic head ct initial imaging modality used staging suspected pancreatic cancer ct along mri endoscopic sonography used distinguish potentially resectable non resectable patients cancer head pancreas contraindications surgery include distant metastases circumferential involvement superior mesenteric vein portal vein segment 2 cm long thrombus vein occlusion circumferential invasion celiac hepatic superior mesenteric arteries see table 2 table 2summary table local nodal haematogenous spread pancreatic cancerlocal spreadtumour spreads direct perivascular perineural invasion;local invasion involve stomach duodenum retroperitoneum;head uncinate process tumours usually extend along sma mesenteric root;body tail tumours usually infiltrate celiac hepatic splenic arterieslymph node spreadprimary drainage superior inferior anterior posterior splenic lymph nodes;secondary drainage porta hepatis common hepatic coeliac mesenteric root lymph nodes;tertiary drainage peri aortic distal superior mesenteric lymph nodeshaematogenous spreadthese usually involve liver peritoneal surfacesnoteearly lymphatic haematogenous micrometastases presentation common summary table local nodal haematogenous spread pancreatic cancer performing staging ct ideally least two contrast enhanced acquisitions late arterial venous phases advised the pancreas retroperitoneal organ close anatomic relationship abdominal peritoneal reflections the pancreatic head connected liver lesser curvature stomach via hepatoduodenal ligament gastrohepatic ligaments respectively the tail pancreas continuity hilum spleen greater curvature stomach via splenorenal gastrosplenic ligaments pancreatic cancer invade adjacent peritoneal ligaments well transverse mesocolon involve stomach duodenum fig tumour tends spread direct perivascular perineural invasion within subperitoneal space arising pancreatic head uncinate process tumours usually extend along superior mesenteric artery root mesentery biliary pancreatic duct dilatation 3pancreatic adenocarcinoma axial cect showing example tumour arising head pancreas asterisk invasion duodenum there focal thrombus portal vein arrow b axial cect patient associated intra- arrows extrahepatic shown bile duct dilatation c axial cect showing large bulky tumour different patient arising body pancreas asterisk encasing origin celiac axis pancreatic adenocarcinoma axial cect showing example tumour arising head pancreas asterisk invasion duodenum there focal thrombus portal vein arrow b axial cect patient associated intra- arrows extrahepatic shown bile duct dilatation c axial cect showing large bulky tumour different patient arising body pancreas asterisk encasing origin celiac axis spread regional nodes occurs involving either peripancreatic nodes nodes celiac axis porta hepatis sometimes nodes afield table 2 most colorectal cancers arise adenomatous polyps polyps greater 2 cm size associated greater 40% risk malignancy local staging rectal cancer mri standard imaging modality increased soft tissue resolution multiplanar capabilities colorectal tumours may appear polypoid infiltrative lesions bowel wall fig early colonic tumours better detected endoluminal distension given colon prepared ct colonography tumour spread serosa appears pericolonic fat stranding may confused associated desmoplastic reaction possibly mimicking diverticulitis within sigmoid colon the presence fluid root sigmoid mesentery engorgement adjacent sigmoid mesenteric vasculature favours diverticulitis whilst presence pericolic lymph nodes suspicious colon cancer tumour spread adjacent organs suggested loss fat planes direct invasion see table 3 table 3summary table local nodal haematogenous spread colorectal cancerlocal spreadinvasion bowel wall peri colonic fat adjacent structureslymph node spreadfollows vascular distribution vessels mesocolon;ascending mesocolon nodes along ileocolic vessels right colic vessel;transverse mesocolon nodes along middle colic vessels;sigmoid descending mesocolon nodes along inferior mesenteric vein;regional lymph nodes rectal cancers include mesorectal sigmoid mesenteric inferior mesenteric lateral sacral presacral internal iliac sacral promontory superior rectal middle rectal inferior rectalhaematogenous spreadliver via portal vein lung adrenal glands bonesnotesin rectal cancers perforated peritoneum transcoelomic spread favours lower right small bowel mesentery pouch douglasfig 4colonic adenocarcinoma axial non contrast enhanced ct showing tumour asterisk ascending colon enlarged ileocolic nodes arrows b axial contrast enhanced ct shows large liver metastasis asterisk summary table local nodal haematogenous spread colorectal cancer colonic adenocarcinoma axial non contrast enhanced ct showing tumour asterisk ascending colon enlarged ileocolic nodes arrows b axial contrast enhanced ct shows large liver metastasis asterisk nodal spread depends site primary tumour follows vascular distribution vessels within mesocolon 11 12 these vessels include ileocolic vessels right colic vessel ascending mesocolon middle colic vessels transverse mesocolon inferior mesenteric vein sigmoid descending mesocolon rectal tumours drainage usually cranial within mesorectum involve regional lymph nodes table 3 5 less common involvement inguinal nodes seen lower rectal tumours proximal lymphatic blockage e.g. extensive adenopathy 5rectal adenocarcinoma coronal reformat cect showing bulky rectal tumour asterisk enlarged right internal iliac nodes double asterisk left paraaortic node arrow rectal adenocarcinoma coronal reformat cect showing bulky rectal tumour asterisk enlarged right internal iliac nodes double asterisk left paraaortic node arrow metastatic disease presentation uncommon 1015% cases haematogeneous spread predominantly seen within liver metastases deriving blood supply hepatic artery compared normal liver parenchyma primarily supplied portal vein result liver metastases imaged portal venous phase seen heterogeneous ring enhancing metastases hypodense surrounding liver parenchyma fig if primary cancer mucinous liver metastases may cystic calcified sites distant metastases determined venous drainage primary site for example venous drainage colon upper rectum via portal vein thus liver common site spread however lower rectum dual drainage superior haemorrhoidal vein draining inferior mesenteric vein portal vein middle inferior haemorrhoidal veins draining pelvic veins directly inferior vena cava this explains distal rectal cancers result isolated pulmonary metastases without hepatic metastases if rectal tumours perforate peritoneal membrane transcoelomic spread may occur favouring lower right small bowel mesentery pouch douglas if colorectal tumours mucinous histology widespread intraperitoneal mucinous metastases may occur characteristic scalloping adjacent viscera pseudomyxoma peritoneii fig 6pseudomyxoma peritoneii axial cect showing mucinous ascites exerting mass effect scalloping solid organs primary gastrointestinal tract origin pseudomyxoma peritoneii axial cect showing mucinous ascites exerting mass effect scalloping solid organs primary gastrointestinal tract origin on ct renal tumours appear hypervascular masses larger lesions heterogenous attenuation increasing size spread renal capsule perinephric fat involve gerota fascia early extension renal capsule recognized indistinct tumour margin thickened perirenal fascia perinephric fat stranding extension renal vein occurs 20% patients presentation involvement inferior vena cava ivc 510% patients fig tumour thrombus seen filling defect within vein confused streaming artefact unopacified blood the presence venous distension may misleading rccs hypervascular hence tend increased blood flow venous drainage distinction tumour thrombus bland thrombus within ivc may difficult although former may enhancing tumour vessels within in advanced tumours direct invasion adjacent structures diaphragm posterior abdominal wall muscles may seen see table 4 table 4summary table local nodal haematogenous spread renal cell carcinomalocal spreadperinephric fat ipsilateral adrenal adjacent viscera including muscles);renal vein invasion ivc)lymph node spreadvia lymphatics following renal vessels ipsilateral para aortic nodes direct connections thoracic duct mediastinum also existhaematogenous spreadcommon sites lungs bones cns adrenalsnoteextension renal vein occurs 20% patients presentation ivc involvement 510%fig 7metastatic renal cell carcinoma coronal reformat cect showing inferior vena cava ivc greatly expanded tumour thrombus arrows associated enlarged mediastinal nodes asterisks the primary renal tumour excised b axial cect showing enhancing lesion left gluteus maximus muscle patient increased size interval ct studies keeping metastatic deposit note numerous venous collaterals anterior abdomen short arrows due ivc thrombus c axial cect shows large lytic deposit lumbar spine asterisk patient causing compromise spinal canal cord arrows summary table local nodal haematogenous spread renal cell carcinoma metastatic renal cell carcinoma coronal reformat cect showing inferior vena cava ivc greatly expanded tumour thrombus arrows associated enlarged mediastinal nodes asterisks the primary renal tumour excised b axial cect showing enhancing lesion left gluteus maximus muscle patient increased size interval ct studies keeping metastatic deposit note numerous venous collaterals anterior abdomen short arrows due ivc thrombus c axial cect shows large lytic deposit lumbar spine asterisk patient causing compromise spinal canal cord arrows lymphatic spread rcc tends follow renal veins involve ipsilateral para aortic nodes there also direct connections thoracic duct mediastinum account rare presence mediastinal hilar node involvement fig metastatic involvement renal cell carcinoma seen order decreasing frequency lung 5060% bone 3040% liver 3040% adrenal gland 5% contralateral kidney 5% retoperitoneum 5% brain 5% more unusual sites reported include pancreas peritoneum bowel thyroid muscle fig cross sectional imaging ct mri used preoperative tumour assessment ct imaging modality choice assessing metastatic disease bowel opacification usually achieved positive oral contrast medium e.g. dilute gastrograffin essential detection peritoneal deposits intravenous contrast also routinely administered unless contraindicated imaging performed portal venous phase conversely local pelvic spread better assessed pelvic mri ct see table 5 table 5summary table local nodal haematogenous spread ovarian carcinomalocal spreaduterus broad ligament via fallopian tube);direct invasion rectum colon bladder pelvic side walllymph node spreadvia lymphatics travelling along ovarian vessels terminate common iliac para aortic nodes;via broad ligament terminate internal iliac obturator nodes;via round ligament terminate external iliac inguinal nodestrans coelomic spreadcommon sites undersurface diaphragm liver surface pouch douglas omentum serosal bowel surfaceshaematogenous spreadthis occurs late disease;liver lungs kidney bonenoteascites arise increased production tumour surfaces and/or occlusion retroperitoneal lymph nodes summary table local nodal haematogenous spread ovarian carcinoma primary ovarian cancer variable appearances presenting either solid mass mixed solid cystic lesion fig ovarian cancer spreads locally adnexal structures uterus contralateral ovary although bilateral ovarian cancer may occur 1150% cases invasion pelvic side wall indicated tumour seen encasing iliac vessels within 3 mm pelvic sidewall 8ovarian carcinoma coronal reformat cect showing large solid cystic adnexal mass arising pelvis asterisk large volume para aortic adenopathy double asterisk ascites small peritoneal deposits arrows although para aortic nodal involvement seen metastatic ovarian carcinoma large volume rather unusual b sagittal reformat cect showing subcapsular deposits liver different patient arrows c axial cect patient b showing thick omental cake arrows axial cect patient b showing multiple enlarged short axis diameter 5 mm cardiophrenic nodes arrows ovarian carcinoma coronal reformat cect showing large solid cystic adnexal mass arising pelvis asterisk large volume para aortic adenopathy double asterisk ascites small peritoneal deposits arrows although para aortic nodal involvement seen metastatic ovarian carcinoma large volume rather unusual b sagittal reformat cect showing subcapsular deposits liver different patient arrows c axial cect patient b showing thick omental cake arrows axial cect patient b showing multiple enlarged short axis diameter 5 mm cardiophrenic nodes arrows peritoneal dissemination commonest mode spread found approximately 70% patients presentation common sites include greater omentum paracolic gutters pouch douglas liver capsule fig less commonly implants may seen within mesentery along porta hepatis lesser sac splenic surface gastrosplenic ligament 1618 ascites often present due either increased production tumour surfaces reduced peritoneal resorption invasion lymphatics tumour cells peritoneal deposits ct variety appearances including enhancing nodular soft tissue lesions linear plaque like thickening peritoneal reflections fig 8c tiny calcifications mixed solid cystic purely cystic lesions 19 20 the involvement bowel serosa lead asymmetric bowel wall thickening tethering bowel loops bowel obstruction liver surface implants subcapsular deposits may seen deposits causing characteristic scalloping liver capsule metastatic mucinous tumours ovary lead pseudomyxoma peritoneii although many cases primary mucinous tumour actually arises gastrointestinal tract secondary involvement ovary lymphatic spread occurs via three routes usually seen conjunction peritoneal spread routes include 1 along ovarian vessels common iliac para aortic nodes fig 8a 2 via broad ligament parametria internal iliac obturator nodes 3 rarely via round ligaments external iliac inguinal nodes cardiophrenic nodes defined 5 mm short axis diameter ct characteristically involved main lymphatic drainage route peritoneal cavity fig haematogenous dissemination rare ovarian carcinoma malignant pleural effusion common manifestation presentation other sides spread include spleen kidneys adrenals lungs brain bone mri traditionally used local staging prostate cancer high contrast resolution rectal cancer it able differentiate organ confined disease tumour demonstrates extracapsular spread direct involvement seminal vesicles adjacent organs also well seen mri ct used nodal distant staging prostate cancer see table 6 table 6summary table local nodal haematogenous spread prostate cancerlocal spreaddirect extension prostate capsule seminal vesicles bladder baselymph node spreadorder nodal involvement obturator presacral internal iliac common iliachaematogenous spreadbone lung liver;spinal bone metastases commonest site due direct communication presacral periprostatic veins)notesdenonvillier fascia forms relative natural barrier rectal spread;tumours apex prostate likely demonstrate extracapsular extension relatively little capsule level summary table local nodal haematogenous spread prostate cancer classically two lymph node metastatic patterns reported 9a para aortic lymph nodes pelvic nodal involvement sequential spread obturator nodes presacral nodes internal iliac common iliac nodes pattern 2 involves para aortic nodes second pattern nodal spread felt due haematogenous dissemination 9prostate carcinoma coronal reformat cect showing irregular enlarged prostate tumour white arrow extending bladder enlarged left pelvic side wall node black arrow liver metastases double arrows lesion left pubic ramus large soft tissue component note bones sclerotic keeping diffuse bony metastases b sagittal reformat cect different patient bone windows showing multiple sclerotic metastases thoracolumbar spine prostate carcinoma coronal reformat cect showing irregular enlarged prostate tumour white arrow extending bladder enlarged left pelvic side wall node black arrow liver metastases double arrows lesion left pubic ramus large soft tissue component note bones sclerotic keeping diffuse bony metastases b sagittal reformat cect different patient bone windows showing multiple sclerotic metastases thoracolumbar spine distant spread occurs one third patients involved sites including bone 90% lung 50% liver 25% fig osteoblastic sclerotic metastases rather lytic bone lesions usually seen ct order decreasing frequency skeletal metastases seen within vertebrae fig spinal involvement initially common within lumbar region less likely within cervical spine 97% cf pulmonary metastases occur 527% patients presentation often seen association second pattern nodal involvement pulmonary involvement either appear lymphangitis carcinomatosa due direct invasion pulmonary lymphatics pulmonary nodules due haematogenous spread 22 24 this review described typical patterns tumour spread common cancers occurring within abdomen pelvis knowledge characteristic sites spread cancers felt essential radiologist reporting staging restaging ct scans it hoped summary tables particular act useful aide mmoir reporting radiologist correct identification metastatic sites disease important impact patient management also bearing patient prognosis

backgroundmultidetector computed tomography ( mdct ) has become the main investigation of choice for staging of many cancers.aimthe purpose of this pictorial review is to discuss the imaging appearances on ct of some of the more common cancers arising within the abdomen and pelvis and to describe their typical sites of local , nodal and haematogenous tumour spread.methodscancers arising from the stomach , pancreas , colon , kidney , ovary and prostate will be reviewed.resultsawareness of the characteristic sites of tumour spread is important to allow accurate identification of all sites of disease.conclusionthis will clearly have an impact on both patient management and prognosis .

long term use immunosuppressive agents prevention allograft rejection increases risk malignancy approximately 100 times high general population the prevalence rate post transplant malignancies total differs geographical areas example europe rate 1.6% australia 24% mean 6% skin cancers mostly squamous cell carcinoma scc common tumors among persons solid organ transplantation but however iranian studies found common malignancy kidney transplantation kaposi sarcoma ks among iranian patients ks skin tumor multicentre origin characterized histologically endothelium lined vascular spaces spindle shaped cells ks presents single multiple lesions mucosal surfaces including skin lungs gastrointestinal tract lymphoid tissues the etiopathogenes ks complex poorly understood almost certainly dependent human herpes virus type 8 hhv -8 infection immunosuppressed immunogenetically susceptible individuals although treatment ks controversial ideally address pathogenic issues the current guideline reduction immunosuppression first line treatment recommendations based anecdotal experience uncontrolled studies perhaps fundamental controversy implications aspects disease surrounds nature ks i.e. whet true malignancy reversible hyperplasia the aim present study investigate frequency ks patients kidney transplantation 21 years period an observational prospective follow study retrospective component carried imam reza hospital kermanshah university medical sciences kums period 19912012 patients pre transplant neoplasm excluded analysis n 46 patients received transplants identified hospital transplant registry patient information includes donor recipient characteristics patient graft survival cancer incidence transplantation data serologic tests hiv received the period follow patient starts day transplantation continues death last reported contact following methodology used similar studies patients removed analysis time graft failure several reasons we usually suspect ks kidney recipient presents multiple hyperpigmented cutaneous nodules may associated gastrointestinal discomfort pulmonary symptoms resistant conventional therapies then battery endoscopic bronchoscopic radiologic pathologic tests used diagnose ks there two main distinct periods immunosuppressive regimen first period 1991- 2002 azathioprine cyclosporine prednisolone the second period 2002 onwards patients received triple immunosuppressive therapy consisting cellcept cyclosporine prednisolone dosages mentioned induction therapy using anti thymocyte globulin atg anti lymphocyte globulin alg preserved high risk patients early phase transplantation treatment acute rejection okt-3 used studied populations the doses immunosuppressive agents reduced changed drugs sirolimus agents withdrawn upon diagnosis ks the method reduction immunosuppression decision agent reduced withdrawn dependent individual patient health condition response treatment physician judgment from march 1991 december 2012 1487 kidney transplantations performed among 67 malignant diseases diagnosed 64 patients overall incidence 4.5% ks diagnosed frequent malignancy 17 25.37% patients table 1 17 ks patients 10 males 7 female median age 47.8 years old the mean time transplantation non ks malignant tumors 34.4 21.8 months range 12140 months ks patients 18.7 25.2 months statistically significantly different p 0.05 after detection ks 12 patients perform serum antibody detection hhv among 8 66.6% seropositive data characteristics transplant patients kaposi sarcoma summarized table 2 type frequency frequent post transplant malignancies n 67 characteristics transplant patients kaposi sarcoma significant increase number ks patients cellcept compared azathioprine interval development ks the sites cutaneous involvement lower extremities 9 52.9% followed upper limb involvement 5 29.41% patients other ks lesions occurred trunk 4 23.5% hard palate 2 11.7% patients immunosuppression reduced 10 58.8% patients 8 80% patients received sirolimus thoroughly withdrawn remainder including three cases visceral involvement 2 11.7% ) patients immunosuppression discontinued 11 91 .6% 12 patients ks skin lesions improved therapy excluded five patients died soon ks diagnosis patients received additional therapy arbitrarily opinion treating clinician lesions improving patients hhv seropositive ganciclovir prescribed renal prognosis patients succumb disseminated disease related management immunosuppression all two patients immunosuppression discontinued functioning grafts ks diagnosed grafts acutely rejected one patient azathioprine one patient cellcept immunosuppressive therapy significant difference two regimens p 0.05 dialysis instituted patients mean 5 weeks discontinuation immunosuppression other patients good response reducing immunosuppression remained grafts period study from march 1991 december 2012 1487 kidney transplantations performed among 67 malignant diseases diagnosed 64 patients overall incidence 4.5% ks diagnosed frequent malignancy 17 25.37% patients table 1 17 ks patients 10 males 7 female median age 47.8 years old the mean time transplantation non ks malignant tumors 34.4 21.8 months range 12140 months ks patients 18.7 25.2 months statistically significantly different p 0.05 after detection ks 12 patients perform serum antibody detection hhv among 8 66.6% seropositive data characteristics transplant patients kaposi sarcoma summarized table 2 type frequency frequent post transplant malignancies n 67 characteristics transplant patients kaposi sarcoma there significant increase number ks patients cellcept compared azathioprine interval development ks the sites cutaneous involvement lower extremities 9 52.9% followed upper limb involvement 5 29.41% patients other ks lesions occurred trunk 4 23.5% hard palate 2 11.7% patients immunosuppression reduced 10 58.8% patients 8 80% patients received sirolimus thoroughly withdrawn remainder including three cases visceral involvement 2 11.7% ) patients immunosuppression discontinued 11 91 .6% 12 patients ks skin lesions improved therapy excluded five patients died soon ks diagnosis patients received additional therapy arbitrarily opinion treating clinician lesions improving patients hhv seropositive ganciclovir prescribed the renal prognosis patients succumb disseminated disease related management immunosuppression all two patients immunosuppression discontinued functioning grafts ks diagnosed grafts acutely rejected one patient azathioprine one patient cellcept immunosuppressive therapy significant difference two regimens p 0.05 dialysis instituted patients mean 5 weeks discontinuation immunosuppression other patients good response reducing immunosuppression remained grafts period study post transplantation ks well known complication renal transplantation possible negative impact patient graft long term survival the ks incidence peaks first year post transplantation study 82.3% ks cases diagnosed first 2 years receiving renal allograft compatible previous studies the results study showed lower incidence ks 1.1% transplant population reported regional countries further ks frequent african renal transplant recipients 13.3% transplanted patients developed ks we investigated ks frequent post transplantation malignancies confirm study saudi arabian turkish studies reported frequent post transplantation malignancies ks 87.5% 80.0% respectively also nafar et al found common malignancy kidney transplantation ks among iranian patients the risk death dissemination malignancy weighed risk graft rejection according results 11 patients 91.6% ks skin lesions improved reduction including 6 patients sirolimus therapy discontinued immunosuppression graft loss rate 11.7% compare study reduction immunosuppression resulted complete remission ks 28% patients saudi arabia 61% italian patients duman et al report complete remission reduction immunosuppressive drugs patients 12/12 graft loss rate 20% turkey reduction immunosuppression allows immune system reduce viral replication producing clinical remission disease new antiviral agents recently introduced promising therapeutic option patients ks however prospective studies determine efficacy approach warranted sirolimus potent immunosuppressive drug recently reported effective agent treatment ks cutaneous ks lesions disappeared patients three months initiation sirolimus therapy sirolimus may become first choice immunosuppressant renal transplant recipients ks pro viding optimal immunosuppression inhibiting progression malignancy hhv-8 described patients hiv infection ks results serologic studies support notion infection hhv-8 nearly universal patients ks since specific antibodies detectable 70% 90% patients ks almost 100% immunocompetent patients disease also clear pre transplantation hhv-8 seropositivity found associated increased risk post transplant ks immunosuppressive treatment may induce reactivation latent virus infection playing important role development combined iatrogenic endemic ks it also possible hhv-8 may transmitted donor induce sarcoma development organ recipient we investigated 67% ks patients seropositive hhv transplantation laboratory studies susceptibility hhv-8 antiviral drugs suggest virus resistant acyclovir penciclovir sensitive ganciclovir foscarnet cidofovir ks common long term complication renal transplant recipients increased incidence compared general population given candidates organ transplantation seropositive hhv-8 -and thus risk ks- identified chemoprevention available high risk population such strategies hhv-8-seropositive candidates organ transplantation directed virus immunosuppressive regimen carefully monitored avoid possibility rejection

introductionthe long - term use of immunosuppressive agents for prevention of allograft rejection increases the risk of malignancy approximately 100 times as high as that in the general population and kaposi 's sarcoma ( ks ) is a relatively common malignancy after kidney transplantation . the aim of present study was to investigate the frequency of ks in patients with kidney transplantation in 20 years period.material and methodsin this study charts and pathology reports of 1487 recipients for kidney allografts treated at imam reza hospital between 1991 and 2012 were reviewed . the spss software package version 16 ( spss inc . , chicago , illinois , usa ) was used for the statistical analysis.resultsthere were 17 of 1487 incident cases of ks kidney transplant population at our hospital in period of study . there is no significant difference between age and gender of patients . the mean time between transplantation and non - ks malignant tumors was 34.4 21.8 months ( range 12140 months ) , while in ks patients it was 18.7 25.2 months , which was statistically significantly different ( p < 0.05 ) . after detection of ks in 12 patients , we perform serum antibody detection against hhv . among them , 8 ( 66.6% ) were seropositive.conclusionks is a common long - term complication in renal transplant recipients , with an increased incidence compared with the general population . given that candidates for organ transplantation who are seropositive for hhv-8 -and thus at risk for ks- can now be identified , chemoprevention should be available in this high - risk population .

breast cancer common cancer among american women except skin cancers the chance developing invasive breast cancer time woman life little less 12% it second leading cause cancer death women exceeded lung cancer the chance breast cancer responsible woman death 3% although clinical signs disseminated disease occur fewer 10% women time diagnosis disease relapses form metastasis within 5 years surgery half apparently localized tumors it difficult predict occurrence distant metastases since breast cancer heterogeneous disease encompassing complex pathologic entities a dynamic interaction tumors immune system essential tumor survival growth metastasis tumors infiltrated large number immune cells constitute major cell population tumor microenvironment tumor cells depend microenvironment provide signals growth anti apoptosis angiogenesis metastasis however tumor cells also surveillance due recognition immune cells foreign analysis interactions tumor cells host immune system led realization tumor cells devised multiple strategies evade immune attack development invasive cancer however result genetic changes tumor cell also result genetic epigenetic changes within host host cells including inflammatory cells endothelial cells fibroblasts recruited activated microenvironment transformed cells the acute inflammatory response might succeed eliminating malignant cells chronic inflammatory process develops conjunction dying tumor cells the subsequent reciprocal interactions responding normal host cells genetically altered cells result development invasive cancer there constant interplay innate adaptive immune systems leads protective immune response pathogens transformed cells contributes effectively discrimination self nonself persistent protumor immune responses inflammation generally accepted initiating primary tumor development also recognized mediators cancer metastasis thus novel anticancer therapeutic strategies targeting molecular and/or cellular mechanisms regulating collaborative interactions may provide efficacious relief metastatic disease this paradox first resolved matzinger 1994 proposed immune system designed combat danger rather mediate recognition nonself self pathogen associated molecular patterns pamps endogenous molecules created upon tissue injury since called damage associated molecular patterns damps signal threat either infection injury organism independently nonself- self identity 710 damage associated molecular patterns damps include endogenous intracellular molecules released activated necrotic cells extracellular matrix ecm molecules upregulated upon injury degraded following tissue damage among cellular receptors sense danger signals toll like receptors tlrs represent key molecular link tissue injury infection inflammation tlrs critical bridging innate adaptive immune responses play significant role cancer immunosurveillance innate immune cells including natural killer nk natural killer nkt cells play critical role protecting host cancer macrophages dendritic cells dcs particular function major sensors invading pathogens transformed cells via tlrs adaptive immunity crucial elimination pathogens tumor cells late phase host defense responses generates specific tumor immunity immunological memory tlrs known regulate cancer immunity tolerance controlling suppressive function regulatory treg cell innate immune responses mediated immune cells 1113 tlr signaling critical innate adaptive immune responses thought restricted immune cells however many studies suggest tumor cells bear tlrs tlr signaling promotes tumor growth immune evasion 1517 tlr activation damps may initiate positive feedback loops increasing tissue damage enhances proinflammatory responses leading chronic inflammation as tlrs widely expressed tumor cells immune cells play important roles initiation progression cancer may thus serve important target effective perspective breast cancer treatment tlrs 1 2 4 5 6 expressed cell surface tlrs 3 7 8 9 found almost exclusively within endosomes different tlrs exhibit specificity pathogen derived ligands tlrs 2 3 4 5 7 9 recognize bacterial lipoproteins double stranded rna poly c lipopolysaccharides lps flagellin single stranded rna cpg containing dna respectively 1823 tlr10 expressed humans mice tlr8 functional mice tlrs 11 12 13 expressed mice humans there several studies suggest damp mediated inflammation plays vital role necrotic cells found induce proinflammatory tissue repair gene synthesis cause dc maturation tlr2-dependent manner result release intracellular contents other intracellular molecules heat shock proteins including hsp70 gp96 hsp22 hsp72 high mobility group box-1 protein hmgb1 well ecm molecules biglycan tenascin c versican fragments ecm molecules including oligosaccharides hyaluronic acid ha heparan sulfate hs shown activate tlrs tlr1 along tlr2 found important activation professional antigen presenting cells -defensin-3 host derived antimicrobial peptide self nucleic acids also described endogenous danger signals namely mrna recognized tlr3 single stranded rna ssrna sensed tlr7 8 igg chromatin complexes recognized tlr9 tlr2 4 7 8 shown activated antiphospholipid antibodies apl isolated patients apl syndrome the signaling pathways utilized various tlrs differ results varied cellular responses for example tlr3 receptor double stranded rna couples adaptor protein trif in contrast tlrs couple adapter myeloid differentiation primary response gene 88 myd88 25 26 the traf6 turn activates tak1 phosphorylates activates ikk complex resulting release translocation nf-b nucleus tak1 also activates stress activated protein kinase sapk pathways activates c jun nh2-kinases jnk p38 the myd88-coupled tlrs induce synthesis cytokines tnf- il-6 il-1 key mediators inflammatory response 27 28 tlr4 receptor lps unique activates myd88-dependent trif dependent pathways the link inflammation cancer well documented 29 30 several inflammatory diseases including inflammatory bowel disease increase risk cancer conversely tumors epidemiologically unrelated overt inflammatory conditions breast cancer activation oncogenes trigger production inflammatory molecules recruitment inflammatory cells tumor microenvironment inflammatory cells molecules influence almost every aspect cancer progress including metastatic ability tumor cells there biological heterogeneity among tumors regard cellular infiltrates identifying subsets mononuclear inflammatory cells tumor centre invasive front seem associated occurrence distant metastasis intratumour leucocytes peripheral blood penetrate tumor architecture phenotypic modification invasive front tumor centre this seems dynamic process inflammatory cells immunomodulatory mediators present tumor microenvironment polarize host immune response towards specific phenotypes impacting tumor progression previously six recognized hallmarks cancer namely unlimited replicative potential self sufficiency growth signals insensitivity growth inhibitors evasion programmed cell death ability develop blood vessels tissue invasion metastasis a group cytokine proteins including il-1 il-6 tnf- rankl activate inflammation known augment tumor cells ability metastasize affecting several steps cells dissemination implantation secondary sites 29 32 33 inflammatory cytokines lie downstream master gene transcription factor nf-b promoting inflammation activated there strong evidence tumor microenvironment inflammatory activation innate immune system plays role progression cancer 34 35 major source inflammatory cytokines tumor microenvironment specialized white blood cells called macrophages tumor associated macrophages assist malignant behaviour tumor cells producing cytokines also secreting growth factors matrix degrading enzymes 3638 it long suggested may common pathways inflammation shared responses infection malignancy recent evidence indicates tlrs macrophages may critical elements common pathways myd88 reported activate ap-1 nf-b subunit p65 p50 also c rel c ebp c ebp. case lps signaling tlr4 nf-b ap-1 activities relatively preserved myd88-deficient macrophages specific defect c rel profound defect c ebp/ activation likely accounts reduction il-12 p40 il-6 tnf. absence c ebp/ specifically tlr signaling impairs key proinflammatory cytokines without affecting nf-b dependent genes ib toll like receptors expressed cells immune system growing evidence tlrs also expressed tumor cells may influence tumor growth host immune responses activation tlrs expressed tumor cells may profound consequences tumor growth factors released tlr activation tumor immune evasion may facilitated inhibitory cytokines inflammatory factors proteinases small molecules nitric oxide recent evidence suggests tlrs also contribute tumor cell resistance apoptosis increased invasiveness the human breast cancer cell line mda mb-231 found express tlr1-tlr10 mrna protein levels knockdown tlr4 gene mda mb-231 resulted dramatic reduction breast cancer cell viability inhibition il-6 il-8 cytokines compared vector control another study highlights role tlr9 highly invasive mda mb-231 breast cancer cell line activated promotes mda mb-231 cell invasion increasing activity matrix metalloproteinase 13 mmp13 mmp8 samples mammary carcinomas recurrence also exhibited significant increase mrna levels tlr3 tlr4 tlr9 a significant percentage tumors also showed tlr4 expression mononuclear inflammatory cells 21.6% tlr9 expression fibroblast like cells 57.5% tumors high tlr3 expression tumor cell high tlr4 expression mononuclear inflammatory cells mics tlr9 high fibroblast like cells significantly associated higher probability metastasis this study highlights importance tumor stromal cells tumor behavior tlr induced inflammation inflammatory cells drives metastatic cascade synthetic tlr9-ligands cpg sequence containing oligonucleotides stimulated tlr9 expressed cancer cells well various normal cells including mesenchymal stem cells stimulated invasion vitro this invasion mediated via downregulation tissue inhibitor matrix metalloproteinase-3 timp-3 matrix metalloproteinase-13 mmp-13 activation expression tlr9 isoforms b detected clinical breast cancer specimens expression tlr9 invasive effects breast cancer cells found regulated estrogen receptor- er sex steroid hormones tlr9 expression also found affected commonly used hormonal cancer therapy bicalutamide activation tlr signaling tumor cells ligands also trigger apoptosis may therapeutic effects for example randomized clinical trial efficacy poly u dsrna therapeutic effect mediated tlr3 expressed tumor cells could therefore represent effective targeted treatment patients tlr3-positive cancers the predictive value tlr3 expression tumor cells efficacy poly u dsrna determined 194 breast cancer patients enrolled randomized clinical trial however conventional chemotherapy vivo injection poly u alone combination failed reduce tumor growth unless immune chemotherapeutic regimen vaccination tumor antigens included recently tlr5 found highly expressed breast carcinomas activation tlr5-signaling pathway found overly responsive breast cancer cells inhibiting cell proliferation anchorage independent growth in addition secretion soluble factors induced flagellin found growth inhibition breast cancer cells autocrine fashion this inhibitory activity confirmed vivo using mouse xenografts models human breast cancer cells sites chronic inflammation often associated establishment growth various malignancies including breast cancer enhanced neutrophilic granulocytic infiltration lungs bone proarthritic arthritic mice subsequent increase circulating levels proinflammatory cytokines macrophage colony stimulating factor csf interleukin-17 il-17 interleukin-6 il-6 vascular endothelial growth factor vegf tumor necrosis factor alpha tnf alpha found contribute increased metastasis breast cancer associated secondary metastasis found significantly increased pro arthritic arthritic conditions breast cancer metastasis found significantly reduced blocking il-17 cox-2 pathway inflammatory tlr signaling also shown promote attraction generation th17 cells induced tumor cells tumor derived fibroblasts enhanced migration th17 cells tumor sites reported due expression chemokines tumor derived fibroblasts there currently approximately twenty drugs preclinical development dozen clinical trials there clearly many options targeting tlrs key function tlrs induce cytokines well validated diseases successfully targeted clinic tlrs occur early pathways inhibiting might potent inhibiting downstream cytokine targets are feasible option cell surface tlr2 tlr4 tlr5 small molecule antagonists e.g. eritoran tlr4 odn based inhibitors tlr7 might better prospect hard predict target effects efficacy kinases signaling pathways might also sensitive inhibition one major concern however inhibitors might block multiple tlrs therefore give rise unwanted immunosuppression studies knockout mouse indicate less redundancy tlrs relation inflammation imiquimod already approved antiviral effects whereas mpl approved vaccine adjuvant terms antagonism effects tlr inhibitor eritoran found significant somewhat marginal develop effective tlr therapeutic targeting strategy tasks identifying determining pathogenesis challenging medical conditions like cancer analysis genetic sequence molecular structure epigenetic observations functional activities animal model human clinical studies design clinical study based study indication dosing regimens drug delivery route format consideration pharmacokinetics timely objective assessment adverse events details targeting tlrs therefore likelihood prevent induction many immune inflammatory proteins the wide tissue distribution tlrs however may make difficult determine whether agonist antagonist effective therapeutically metastasis regulated intrinsic genetic changes malignant cells also microenvironment several studies demonstrated sites chronic inflammation often associated establishment growth various malignancies toll like receptors tlrs emerged sensors detect variety invading pathogens malignant cells since discovery decade ago tlrs shown critical efficient innate adaptive immunity framework tlr mediated signaling pathway explained however tlr activation may two edged sword antitumor pro tumor consequences the general expression functionally active tlrs tumor cells inflammatory cells stroma putative endogenous ligands suggests tlr signaling may continually activated may contribute tumor progression metastasis understanding tlr function tumor biology may lead discovery new therapeutic targets cancer therapy

breast cancer remains a major cause of death in women in the developed world . as toll - like receptors ( tlrs ) are widely expressed on tumor cells and play important roles in the initiation and progression of cancer , they may thus serve as important targets and have an effective perspective on breast cancer treatment . expression of tlrs on breast cancer cells and mononuclear inflammatory cells can promote inflammation and cell survival in the tumor microenvironment . inflammation and cancer are related . it is well known that persistent inflammatory conditions can induce cancer formation , due to production of cytokines and chemokines , which play a crucial role in promoting angiogenesis , metastasis , and subversion of adaptive immunity . tlr signaling in tumor cells can mediate tumor cell immune escape and tumor progression , and it is regarded as one of the mechanisms for chronic inflammation in tumorigenesis and progression . this paper delineates the expression of various tlrs in promotion of inflammation and development of mammary tumors . understanding the mechanisms through which tlrs on breast cancer cells and inflammatory cells regulate growth , survival , and metastatic progression can make them potential targets for breast cancer therapy .

forensic odontology established important often indispensible science medicolegal matters identification dead the forensic importance dental tissue well recognized tooth hardest human tissues they well preserved long period even death hence dental remains stable biological evidence encountered crime cases yield useful information blood grouping one major factors identification biological materials forensic investigations widely used technique forensic laboratories the presence abo blood group rhesus factor applied inherited antigens detected red cell surface specific antibodies once blood group rhesus factor established remains unchanged throughout life kind 1960 discovered presence abo blood group saliva absorption elution ae method blood grouping dried stain elution procedure described 50 years ago employed widely forensic serology 1960 kind refined technique ae technique procedure originally devised siracusa employed forensic laboratories proven sensitive reliable reproducible pulp tissue one protected tissues surrounded sides dental hard tissues pulp contains numerous blood vessels blood group antigens certainly present tooth pulp the distribution abo substances pulp cavity wall dentin edge enamel gradually reduces fewer possibilities diffusion antigens blood saliva the existence blood group antigens tooth dentin enamel nature substantiated infusion sedimentation phenomena combined inherently present antigens this theory describes infusion water soluble antigens saliva tooth tissue the presence abo blood group rhesus factor antigen soft hard dental tissues makes possible contribution human identification even decomposed bodies therefore blood group rhesus factor determination biological evidence tooth material great importance forensic odontology the aim study determine abo blood grouping rhesus factor dentin pulp extracted teeth using ae technique 0 3 6 9 12 months extraction a brief case history relevant medical history recorded patients selected study consent taken the blood groups determined study participants using capillary blood slide agglutination method carious teeth grossly decayed teeth excluded teeth extracted periodontal orthodontic purposes included study the extraction procedure carried local anesthesia following aseptic protocol department oral maxillofacial surgery the extracted teeth dried stored labeled bottles span 3 6 9 12 months the pulp scooped spoon excavator dentin powdered using straight fissure bur figure 1 the blood grouping teeth performed ae technique using powdered dentin dental pulp the pulverized dentin powder pulp divided three equal parts taken six sterile test tubes containing 2 ml saline labeled respectively test tubes three drops antiserum b d added respectively test samples sufficiently soaked antiserum 2 h left standing room temperature each sample washed five times cold saline solution centrifuging 3000 rpm 5 min supernatant removed pipette then two drops fresh saline added sample test tubes heated water bath temperature 5055c 10 min elude antibodies ( dissected teeth samples b pulverized dentine c dried pulp tissue drop 0.5% red cell suspension known blood group b freshly prepared immediately put respective test tubes the samples incubated 37c 30 min enhance agglutination centrifuged 15002000 rpm 1 min gentle shaking test tube presence absence red cell agglutination ascertained macroscopically microscopically magnification 4 figures 2 3 macroscopic observation agglutination dentin l pulp r samples microscopic observation agglutination dentin l unstained x100 pulp r unstained x400 samples 4 data analyzed proportion for comparison chi square test fisher exact test used small sample two tailed p 0.05 considered statistically significant 0.01 considered highly statistically significant data analyzed proportion comparison chi square test fisher exact test used small sample two tailed p 0.05 considered statistically significant 0.01 considered highly statistically significant abo blood grouping dentin pulp showed gradual decrease sensitivity time period increased dentine the sensitivity ranged 100% 73% pulp sensitivity ranged 100% 80% there significant difference sensitivities dentin pulp table 1 abo blood grouping pulp dentine rh factor grouping dentin pulp showed gradual decrease sensitivity time period increased 9 months in dentine sensitivity ranged 100% 40% pulp sensitivity ranged 100% 23% overall pulp showed better sensitivity dentin except 12 months time period dentin showed better sensitivity pulp moreover comparison sensitivities dentin pulp p values obtained significant table 2 rh factor blood grouping pulp dentine compared sensitivity abo rh factor blood grouping dentin pulp accordance time period dentin pulp showed almost similar results 0 9 months 12 months both dentin pulp showed vast difference sensitivities abo rh blood grouping significant p value table 3 comparison abo rh factor blood grouping dentin pulp overall mean sensitivity dentin abo blood grouping 88% rh factor blood grouping 79% significant p 0.03 the overall mean sensitivity pulp abo blood grouping 90% rh factor blood grouping 82% significant p 0.04 dentin pulp showed p 0.58 abo blood grouping 0.46 rh factor blood grouping table 4 figure 4 overall comparison blood group systems teeth components graph comparisons overall sensitivity abo rh factor blood grouping dentin pulp lattes rightly said fact belonging definite blood group fixed character every human altered neither lapse time intercurrent disease human identification mainstay civilization identification unknown individuals always paramount importance society the use blood group substances medico legal examination grounded fact blood group established individual remains unchanged lifetime several decades the technique ae sensitive widely employed according kind nickolls periera outtridge ae proved markedly sensitive absorption inhibition test ae shown success rate mixed agglutination certain antigens rh blood group considered complex genetically blood type systems since involves 45 different antigens surface red cell teeth used blood grouping considered hallmark identification biological materials forensic investigations considering fact present study attempt made detect abo rh factor antigen dentin pulp time period 0 3 6 9 12 months for abo blood grouping dentin pulp showed 100% sensitivity samples tested immediately extraction sensitivity gradually reduced time period prolonged pulp showed better sensitivity dentin difference statistically insignificant suggesting dentin pulp almost equal antigenic potential although pulp better sensitivity weakened time period increased till date various studies conducted smeets et al shetty premlata ballal david ramnarayan et al different time period showed pulp better tool dentin decrease sensitivity dentin pulp time periods increased the overall decrease sensitivity could due dehydration loss pulp antigens insufficient quantity pulp calcification canals cell lysis contamination tooth time lapse procedure rh factor blood grouping dentin pulp showed 100% sensitivity samples tested immediately extraction sensitivity gradually reduced time period prolonged pulp showed better results dentine difference statistically insignificant suggesting dentin pulp almost equal antigenic potential weakened time period increased similar abo antigens this may attributed autolysis dehydration loss pulp antigens similar abo antigens is study available english language literature conducted determination rh factor antigens along abo blood group antigens freshly obtained pulp samples study both pulp dentin samples used tested 0 month extensive time period 12 months abo rh factor blood grouping dentin pulp showed gradual decrease sensitivity time period increased 12 months both dentin pulp showed drastic decrease sensitivity rh factor blood grouping abo blood grouping statistically significant difference the sensitivity pulp better dentin blood grouping systems insignificant p value abo blood grouping better rh factor grouping teeth components p values obtained significant this indicates antigenicity pulp better dentin abo rh blood groups abo antigens better expressed rh factor blood group antigens the outcome study showed abo rh blood group antigens could detected 12 months studies english literature compare study this shows pulp contains amounts antigen dentin antigenicity decreases time blood grouping teeth straight forward technique concentrations blood group antigens low teeth compared tissues body fluids study it assumed origin blood group antigen dental hard tissue based infusion sedimentation phenomenon combined inherently present antigens considering factors support presence blood group antigens dentin pulp also pitfalls false positive result mistyping blood group period study came close consequence results obtained pulp better dentine another aspect highlighted abo rh factor antigens detected dentin pulp even 12 months extraction teeth blood grouping one bases identification biological materials forensic investigations abo blood grouping widely used technique forensic laboratories the presence abo blood group antigens along rh factor antigens pulp hard dental tissues makes potential substance identification highly decomposed bodies body part teeth bones significant tissue remains blood group substances hard dental tissues thus remain unaffected even adverse environmental conditions teeth used mode identification blood group study teeth one indestructible parts body exhibit least turnover natural structure the presence abo blood group rh factor antigen soft hard tissue makes possible identification deceased ae test identify blood groups teeth may immense value identification accused also investigation mass disaster fire victims basis results obtained study dentin pulp reliable sources blood group determination upto 12 months abo rh factor blood grouping especially teeth ensues remnants existing individual identity although expression abo blood groups rh factor seen dentin pulp intensity abo blood groups rh factor higher pulp dentin abo blood group antigens better expressed rh factor antigens dentin pulp blood group determination teeth warrants advance exploration establishment identification person skeletal remains paramount importance forensic odontologist till date english language literature studies conducted detect abo rh factor blood group antigens tooth material 12 months this study detected blood groups antigens abo rh systems tooth material extensive time period 12 months this study thus quantum known learned much needs understood challenging branch forensic odontology

objective : the aim of the study was to determine blood groups and rhesus factor from dentin and pulp using absorption - elution ( ae ) technique in different time periods at 0 , 3 , 6 , 9 and 12 months , respectively.materials and methods : a total of 150 cases , 30 patients each at 0 , 3 , 6 , 9 and 12 months were included in the study . the samples consisted of males and females with age ranging 1360 years . patient 's blood group was checked and was considered as control . the dentin and pulp of extracted teeth were tested for the presence of abo / rh antigen , at respective time periods by ae technique.statistical analysis : data were analyzed in proportion . for comparison , chi - square test or fisher 's exact test was used for the small sample.results:blood group antigens of abo and rh factor were detected in dentin and pulp up to 12 months . for both abo and rh factor , dentin and pulp showed 100% sensitivity for the samples tested at 0 month and showed a gradual decrease in the sensitivity as time period increased . the sensitivity of pulp was better than dentin for both the blood grouping systems and abo blood group antigens were better detected than rh antigens.conclusion:in dentin and pulp , the antigens of abo and rh factor were detected up to 12 months but showed a progressive decrease in the antigenicity as the time period increased . when compared the results obtained of dentin and pulp in abo and rh factor grouping showed similar results with no statistical significance . the sensitivity of abo blood grouping was better than rh factor blood grouping and showed a statistically significant result .

cystic echinococcosis ce severe zoonosis caused cyclophyllidean cestode echinococcus granulosus the disease worldwide distribution endemic regions many countries mediterranean basin north east africa western central asia china south america australia 1 2 although distribution echinococcus granulosus considered worldwide higher developing countries tropics subtropics especially rural communities close contact dogs various domestic animals western countries ce considered reemerging zoonosis due resurging prevalence 4 5 the worldwide distribution disease partly due easy adaptability parasite several domestic wild intermediate hosts clinically three broad morphological forms echinococcosis recognized cystic echinococcosis caused e. granulosus alveolar echinococcosis caused e. multilocularis polycystic echinococcosis caused e. vogeli e. oligathrus 79 the sheep strain defined g l mitochondrial genotypic grounds generally considered widespread strain e. granulosus world one mainly involved ce humans at least five ten strains e. granulosus strains g 1 g 10 found infective humans sub saharan africa disease consequences may include poor quality life disability adjusted life years dalys costs medical treatment lost opportunity income generation mortality cases animals reduced productivity monetary losses due abattoir condemnations organs 14 15 the dalys human cystic echinococcosis recently estimated onchocerciasis almost africa trypanosomiasis the annual ce associated economic losses global basis recently estimated least us$2 billion zambia like sub saharan africa echinococcosis reported many parts country although much information currently available making one neglected tropical diseases western province zambia hydatid cysts are reported diagnosed cattle carcasses meat inspection although reports inconclusive however comprehensive study carried thus far describe echinococcosis infections intermediate final hosts also determine economic public health significance based circumstantial evidence assumed disease serious public health socioeconomic implications given interactions exist cattle dogs humans also uncontrolled disposal abattoir waste remains animal slaughters however assertion needed supported well structured studies the aim study therefore determine prevalence hydatidosis cattle presented slaughter abattoirs western province zambia assess economic losses due organ condemnation using cross sectional epidemiological survey view identifying intervention measures aimed reducing transmission disease humans different animals hosts the study conducted western province zambia october 2007 november 2008 western province lies longitudes 22 degrees 25 degrees east latitude 13 degrees 30 mins 17 degrees 45 mins south the province covers area 126,386 km represents 17% total land surface zambia covers 752,000 km figure 1 about 10% 12,950 km total land area consists vast sandy upland the province dry cold winters april july hot dry season august october hot wet summers november march the annual flooding zambezi plains controls pattern life people livestock western province people practice transhumant subsistence livelihood thus flooding largest population cattle people concentrated along edges plains western province cattle population approximately 452,400 making one largest cattle producing areas zambia dog population estimated 65,315 mongu highest number dogs 16,210 followed kalabo 13,496 shangombo 11,732 sesheke 8,638 kaoma 6,254 senanga 4,750 lukulu 4,236 dogs generally belong specific households feeding supplemented often freedom roam scavenge neighbourhood all cattle slaughtered within province mostly mongu senanga abattoirs due movement ban imposed 1998 result outbreak contagious bovine pleural pneumonia cbpp therefore data obtained cattle slaughtered mongu good representation true provincial picture the study conducted two tier study involving prospective abattoir survey retrospective review meat inspection reports zambeef starbeef abattoirs mongu a retrospective study carried based review postmortem reports findings meat inspection abattoirs last eleven years 19942007 data obtained district veterinary offices abattoir reports meat inspection movement livestock carried previous 11 years western province information collected included number cattle slaughtered breed type organs condemned number weight condemned organs the aim provide baseline information retrospective understanding prevalence dynamics spatial distribution disease western province also estimate annual economic loss due organ condemnation this study conducted october 2007 october 2008 zambeef starbeef abattoirs mongu district cattle slaughtered two abattoirs sourced seven districts western province except sesheke district all 4061 cattle slaughtered study period included survey the slaughtered cattle subjected thorough postmortem inspection lesioned organs identified samples collected prior commencement prospective study meat inspectors two slaughterhouses underwent house refresher training recognition hydatid cysts various organs carcasses according procedures recommended fao unep 1994 each animal slaughtered uniquely identified using stock movement permits included veterinary camp origin district information obtained interviewing owner the age animals obtained interviewing owners cases ultimate owner brought cattle otherwise age estimated using dentition described jenkins visceral organs including lungs liver heart spleen kidneys examined visual observation palpation systematic incision carcass according procedures recommended fao unep 1994 hydatid cysts identified visual inspection palpation organs meat inspection enumerated a sample hydatid cysts inspection removed whole collected polythene bags a separate polythene bag used hydatid cysts obtained one animal uniquely labelled stored ice transportation within one hour mongu regional laboratory viability determination cattle classified positive hydatidosis found one hydatid cysts internal organs mongu regional laboratory the collected cysts individually grossly examined degeneration calcification described oostburg et al the cyst wall carefully incised scalpel blade contents poured petri dish the contents examined microscope 40x magnification presence protoscoleces germinal layer also put glycerine placed two microscopic glass slides examined presence protoscoleces cysts contain protoscoleces contained pus calcified considered sterile viable further viability protoscolices checked microscope using dye exclusion principle staining 0.1% eosin stain 15 minutes the protoscolices took stain classified dead considered alive viable 18 19 the loss attributed condemnations offal due echinococcus determined using modification formula described yamene 1990 cited getaw et al this basis average price wholesome intact visceral organs obtained zambeef starbeef abattoirs mongu data stored microsoft excel spread transferred stata statistical packages version 10 stata corp infections cattle prospective retrospective data determined proportion test positive subjects total number tested apparent prevalence estimates converted true prevalence values taking account sensitivity specificity test methods described dohoo 2003 the annual economic loss result condemned organ estimated taking account average number cattle slaughtered per annum zambeef starbeef abattoir percentage condemned organs using following formula described yemane 1990 cited getaw et al ( 1)annual loss=(npsiluclu)+(npsilicli)+(npsiheche)+(npsikicki nps total number positive animal slaughter ilu prevalence lung hydatidosis ili prevalence liver hydatidosis ihe prevalence heart hydatidosis iki prevalence kidney hydatidosis clu cost lung cli cost liver che cost heart cki cost kidney a retrospective study carried based review postmortem report findings meat inspection abattoirs period eleven years 1994 2007 exemption 1997 1998 2002 data missing period 158 456 bovines slaughtered inspected 4689 cases bovine hydatidosis recorded table 2 the overall combined prevalence bovine echinococcosis period review estimated 3.0% table 1 close prevalence observed prospective study annual prevalence ranged lowest 1.56% n 12641 2006 highest 4.7% n 2633 2001 a review postmortem records eleven year period revealed distribution hydatid cysts bovine highest lung 93.47% 95% ci 92.7594.14 followed liver 6.55% 95% ci 5.887.29 spleen lowest 0.02% 95% ci 0.000.12 prevalence a total 4061 cattle mongu n 2441 senanga n 577 kalabo n 653 lukulu n 335 shangombo n 47 kaoma n 8) slaughtered zambeef starbeef abattoirs october 2007 november 2008 84 2.1% carcasses table 3 diagnosed positive hydatidosis postmortem inspections variation prevalence hydatidosis according district origin cattle coming mongu highest prevalence cyst positive cases 2.5% compared senanga 2.1% kalabo 1.4% lukulu 0.6% table 3 sex found positively associated hydatidosis p 0.035 female cattle likely test positive males odds ratio 1.62 hand hydatidosis independent age p 0.31 mean age among positives 7.8 years range 7.47.6 among negatives 7.5 years range 7.38.3 terms distribution hydatid cysts organ 51.2% were found lungs 47.6% livers 1.2% kidneys mukukutu camp senanga district accounted highest prevalence 4.0% 95% ci 3.811.8% lukulu central camp lukulu district lowest prevalence 0.3% 95% ci 0.20.9% comparison camps different districts observed mongu highest prevalence bovine hydatidosis limulunga veterinary camp 2.9% 95% ci 1.44.4% lowest prevalence luandui camp 1.5% 95% ci 0.53.7% senanga district the highest prevalence mukukutu camp 4.0% 95% ci 3.811.8% lowest mouyo camp 1.6% 95% ci 0.043.2% kalabo district the highest prevalence observed sikongo camp 3.3% 95% ci 1.28.0% lukulu district the highest prevalence mbanga camp 1.8% 95% ci 1.75.3% lowest lukulu central camp 0.3% 95% ci 0.20.9% the overall median number cysts organ 6 range 221 lungs median 6 range 221 liver median 4 range 35 the number hydatid cysts examined lung 108 liver 16 the lung highest density cysts per organ compared liver table 4 there significant difference viability rate hydatid cysts recovered lung 43.5% liver 43.8% the prices used estimation annual economic loss condemned organs 2011 average prices wholesome intact visceral organs obtained zambeef butchery mongu average weights various organs calculated data obtained abattoir prospective study the average weight lung estimated 2.92 kg liver spleen 3.34 kg 2.00 kg respectively the average cost lung zmk zambian kwacha 12,000 per kg liver zmk 18,000 per kg spleen zmk 12,000 the cost one lung average weight cost kg 2.92 12000 zmk 35,040 cost liver average weight cost kg 3.34 18000 zmk 60,120 cost spleen= average weight cost kg 2 12000 zmk24 000 average annual slaughter= 14,405 in study investigated prevalence hydatidosis based pm findings two abattoirs western province zambia it therefore noted prevalence estimates provided may bias abattoir sample populations always representative reference populations animals drawn this often animals brought slaughters old production considering reduced sensitivity pm inspection based diagnosis there always possibility positive cases missed resulting underreporting actual disease burden despite short comings abattoir survey data routinely used estimate disease burden easy feasibility conducting abattoir surveys compared field surveys based random study designs besides abattoir data provides opportunity developing intervention strategies timely diagnosis condemning carcasses infected zoonoses likely enter food chain the observed prevalence hydatid cysts cattle sampled two abattoirs mongu found low 2.1% comparable observed retrospective survey 3.0% furthermore findings study agreement observed study done sudan reported prevalence 3% cattle arusha tanzania study nonga karimuribo reported prevalence 4.2% cattle similarly for instance rkia azlaf allal dakkak reported prevalence 23.0% bovine hydatidosis morocco kebede ethiopia reported prevalence 22.1% in study distribution hydatidosis varied according district mongu reporting highest prevalence compared districts the reason high prevalence mongu could attributed high numbers cattle dog populations coupled high number home slaughters ceremonies cases inspected veterinary department staff there increased dog cattle interaction due high populations free range rearing cattle often herded boys dogs increases contact cattle dog faeces further dog access slaughterhouse waste mongu abattoirs likely increase exposure cattle dogs district sex found positively associated hydatidosis p 0.035 female cattle likely test positive males iran observed prevalence higher females males there significant difference prevalence hydatid cysts carcasses slaughtered 2007 2008 p 0.024 prevalence bovine hydatidosis 2007 1.3% 95% ci 0.691.93 2008 2.4% 95% ci 1.82.9 this could result animals coming areas higher prevalence bovine hydatidosis mongu senanga 2008 2007 however could fully ascertained due absence trace back information period review the lung found affected organ 51.2% compared liver 47.6% kidney 1.2% this agreement reported getaw et al observed lung higher prevalence 55.2% liver 37.1% kidney least affacted organ the results also agreement findings cadmus adesokan 2009 nigeria kebede et al study ethiopia however results odds findings study conducted libya researchers reported higher prevalence liver lung al khalid 1998 cited dakkak showed libya 75% positive bovine hydatidosis cases liver 37.5% lung 12.5% spleen the reason lung liver mostly affected could due fact lungs livers first capillary beds encountered migrating echinococcus oncospheres via portal vein route peripheral organs the lungs however larger capillary bed organs could account observed higher prevalence seen organs humans however liver commonly affected the explanation differences predirection sites cattle human beyond scope study cysts viability study revealed overall percentage viable cyst study 43.5% comparable findings researchers like ibrahim found cyst viability 47.8% sheep 24% goats observe viable cyst survey berhe found lower viability rate 10.7% cattle tigray region ethiopia possible reason viable cysts observed rinaldi et al could due differences immunological responses different individual hosts deworming animals use antihelmintics total 19 hydatid cyst infested organs investigated 15 lungs 4 livers cyst fertility viability density found lung higher average density cysts infestation 7 cysts per lung table 4 liver low hydatid cyst density 4 cysts per liver this however different findings ibrahim saudi arabia observed liver higher cyst density the difference cyst density could mainly attributed higher vascularisation lung tissue compared liver the reason difference cyst density could result soft texture lung tissue comparison liver harder texture thus restricting hydatid cyst development the number hydatid cysts examined lung 108 liver 16 most dead cysts liver found calcified compared lung kebede et al berhe reported higher fertility rate pulmonary lower fertility rate hepatic cysts this could probably due various metabolic reactions take place liver compared lungs however ibrahim found higher fertility rate liver 38.8% lung 25.1% dalimi et al reported higher fertility rate liver lung the high percentage viable cysts indicates high risk dog exposure situations offal carelessly disposed dogs access infected offal like situation western province zambia this points possible intervention area dogs prevented ingesting infected cysts lungs liver study the annual economic loss result condemnation organs due bovine hydatidosis low k 15 894,039.00.(3,311 us$ per annum the loss found low due low prevalence hydatidosis cattle western province zambia the total annual loss could greater estimated amount bearing mind took account direct losses indirect losses result weight loss due ce losses reduced milk production reduction reproduction cattle the main thrust study describe hydatidosis situation western province increase public health awareness describe socioeconomic impact recommend possible mitigation measures it noted however echinococcosis disease multiple hosts objective study could addressed application conventional observational studies study demonstrated hydatidosis important disease endemic western province the disease also causes considerable economic losses result offal condemnations despite low infection rate demonstrated current study certain socioeconomic conditions favourable existence ce therefore ce still remains one important helminth zoonotic disease hence need increased attention control prevention disease livestock dog echinococcosis prevalence studies surveillance help map ce risk landscape profiles determine communities greatest risk human ce molecular analysis human animal hydatidosis would desirable order effectively map epidemiology disease determine spread disease a specific study disease dogs could also help knowing prevalence definitive host wildlife species shown harbour e. granulosus zambia view extensive livestock wildlife interface areas province furthermore study small ruminants sheep goats may improve epidemiological understanding disease zambia current study done cattle it also suggested areas presence large numbers wildlife definitive hosts observed parts kalabo lukulu kaoma districts increased effort made sample possible wildlife definitive host echinococcus spp effort made ascertain host specificity local strains parasite respect cattle domestic animals effectively come control program possible wildlife reservoirs survival eggs local climatic soil conditions investigated

a cross - sectional study was conducted from october 2007 to november 2008 to estimate the prevalence of hydatidosis in slaughtered cattle from two abattoirs in mongu , western province , zambia , using prospective and retrospective data . out of the 4061 cattle examined during postmortem inspection , 84 ( 2.1% ) were positive for hydatidosis . no cases were detected from kaoma and shangombo districts ; however , prevalence ranged from 0.6% to 2.5% in districts where it was present . sex was found to be positively associated with hydatidosis ( p = 0.035 ) with female cattle being more likely to have hydatidosis ( or = 1.62 ) . in the retrospective study ( 1994 to 2007 ) , annual prevalence of hydatidosis ranged from 1.56% ( n = 12,641 ) in 2006 to 4.7% ( n = 2633 ) in 2001 with an overall prevalence of 3% ( 4689/158,456 ) . this value is comparable to that observed in cattle slaughtered between october 2007 and november 2008 ( 2.1% ) . hydatidosis was observed in the lungs ( 51.2% ) , liver ( 47.6% ) , and kidneys ( 1.2% ) . the percentage of viable cysts was 43.7% . this study confirms the presence of hydatidosis in cattle in western province of zambia and estimates economic losses due to organ condemnations . data presented herein provides a useful baseline for developing policy and intervention measures .

septic internal jugular vein sigmoid sinus thrombosis rare condition complicates local regional infectious inflammatory processes occurring head neck these include deep neck infections lemierre syndrome central venous catheterization cvc cannulation17 this life threatening condition prompt management essential decrease potential thrombosis related morbidity mortality we report case internal jugular vein sigmoid sinus thrombosis due misplaced central venous catheter a 52-year old woman presented severe bursting headache vomiting drowsy mentality brain computed tomography ct scan revealed subarachnoid hemorrhage basal cistern small amount hematoma left sylvian fissure fig we identified aneurysmal rupture middle cerebral artery left side cerebral catheter angiography fig postoperative chest x ray normal except malposition central venous catheter right internal jugular vein fig ten days later patient developed fever elevated white blood cell count 227000 elevated c reactive protein 33.6 the central venous catheter removed antibiotics administrated different intravenous route despite managements patient stupor next day brain ct scan revealed cerebral infarction hemorrhagic transformation right temporal lobe ct angiography identify vasospasm fig retrospective analysis contrast enhanced ct scan ct angiography showed empty delta sign absence venous flow within right internal jugular vein sigmoid sinus sufficient diagnosis sinus thrombosis fig results central venous catheter tip blood culture reported staphylococcus epidermidis methicillin resistant staphylococcus aureus respectively we could start systemic heparinization due hemorrhagic transformation cerebral infarction right temporal lobe we administrated mannitol steroids manage increased intracranial pressure however patient died severe pneumonia due septic emboli one week fig 2c indications cvc intravenous administration drugs parenteral nutrition hemodialysis hemodynamic monitoring13 many institutions cvc is routinely inserted undergoing major surgery treating patients critical illnesses cancer the frequently available anatomical sites cvc subclavian internal jugular veins these procedures carry substantial risk mechanical lesions arterial puncture pneumothorax cardiac tamponade nerve lesions thrombotic septic complications13 malpositioning catheter tip may happen often subclavian vein internal jugular vein the reported incidence primary misplacement catheter tip infraclavicular subclavian vein catheterization varies 5% 24% even inserted experienced clinicians7 inadvertent catheterization ipsilateral internal jugular vein one common misplacements reported incidence around 7%15 the positioning catheter tips within cardiac silhouette associated increased risk cardiac tamponade6 also positioning catheter tip subclavian vein associated high risk thrombus formation vessel occlusion2 the risk thrombosis may increase hyperosmolar parenteral nutrition fluid administered misplaced central venous catheter internal jugular vein3,15 moreover malpositioned catheter tips damage endothelium precipitate formation thrombi17 when cvc causes thrombosis risk catheter related sepsis may increase patients cvc risk catheter related infection reported range 1% 10%1 contamination thrombus skin puncture site may result septic endophlebitis occasional blood borne infections may also contaminate thrombus embolic septic thrombi may involve lungs less frequently joints viscera brain17 subclavian internal jugular vein thrombosis associated indwelling catheters propagate vessels extension intracranial sinuses veins rare three reports describe association cerebral venous sinus thrombosis central venous hyperalimentation due placement catheter tip internal jugular vein3,15,16 the authors warn potential thrombosis due retrograde infusion valveless internal jugular dural sinus system also suggest small caliber vein may predispose thrombosis case we found malpositioned catheter tip internal jugular vein follow chest x ray ignored all intravenous fluids e.g. total parenteral nutrition mannitol antibiotics administered misplaced catheter the patient condition worsened leading thrombosis internal jugular vein secondary sigmoid sinus thrombosis since advent antibiotics fever chills otalgia tenderness percussion mastoid emissary vein headache vomiting common pathognomonic features8,18 occasionally neurologic symptoms related increased intracranial pressure infarct present deteriorating mental status lethargy seizures hemiplegia coma may lead death rarely remote septic conditions pneumonia presenting symptoms9 nonspecific signs symptoms disease masking effects antibiotics diagnosis difficult the diagnosis sigmoid sinus thrombosis confirmed ct magnetic resonance imaging angiography contrast enhanced ct scans demonstrate multiple intraluminal filling defects nonvisualization sinus18 in addition low density lumen sharply defined dense vessel wall distension thrombosed vein empty delta sign positive signs sinus thrombosis19 vascular imaging cerebral angiography highly specific recognition sinus thrombosis detect lack blood flow thrombosed cerebral veins dural sinuses chest x rays may also demonstrate septic embolic pleura pulmonary complications often bilateral revealing nodular infiltrates pleural effusion17 retrospectively confirmed contrast enhanced brain ct scans revealed low density lumen surrounding sharply enhanced dense vessel wall sigmoid sinus right side also right internal jugular vein sigmoid sinus visualized ct angiography treatment consists aggressive antimicrobial therapy heparinization anticoagulation decreasing intracranial pressure antibiotic selections directed toward causative pathogen cultured initial site infection recent studies shown heparinization safe beneficial despite possibility increased risk hemorrhage4,10,16 currently heparin recommended initial drug choice cerebral venous sinus thrombosis followed long term anticoagulation warfarin5,10,12 although procedures allow rapid clot removal reduction venous hypertension hemorrhagic complications occur leading high morbidity mortality14 occlusion cerebral veins due thrombosis may induce localized brain edema venous infarction resulting elevated intracranial pressure finally death frequently results increased intracranial pressure caused obstruction venous cerebrospinal outflow11 case culture results subclavian catheter tip blood confirmed staphylococcus epidermidis methicillin resistant staphylococcus aureus respectively switched broad spectrum antibiotics vancomycin unfortunately could start heparinization due concurrent cerebral hemorrhage transformed cerebral infarction severe pneumonia due septic emboli eventually developed lung fields patient died diagnosis internal jugular vein sigmoid sinus thrombosis challenging due vague clinical features therefore if patients malpositioned cvcs present symptoms fever chills headache vomiting increased intracranial pressure mental deterioration focal neurologic deficits intracranial sinus thrombosis considered even vague symptoms may need investigated radiologically discover thrombosis early treated

septic internal jugular vein - sigmoid sinus thrombosis ( ijv - sst ) associated with a malpositioned central venous catheter is a rare condition . it is potentially life - threatening and necessitates early diagnosis and rapid administration of appropriate medications . unfortunately , it is difficult to diagnose due to vague clinical presentations . several studies such as ct , mri , and cerebral angiography should be performed and carefully examined to help make the diagnosis . we report a case of septic ijv - sst due to a malpositioned central venous catheter .

also used treat multiple myeloma bone metastases calcium disorders 2 these patients reportedly often develop bisphosphonaterelated osteonecrosis jaw bronj caused subsequent dental surgery 3 4 general thought nitrogencontaining bisphosphonates much high risk osteonecrosis nitrogen notcontaining bisphosphonates thus medications cancer zoledronate zometa thought much high risk osteonecrosis medications osteoporosis alendronate bonalon 5 besides bisphosphonates antiresorptive agents denosumab antiangiogenic medications also cause osteonecrosis 6 thus american association oral maxillofacial surgeons position paper published 2014 committee recommended changing nomenclature bronj term medicationrelated osteonecrosis jaw mronj accommodate growing number jaw osteonecrosis cases associated antiresorptive antiangiogenic therapies 7 according position paper three categories risk factors mronj 1 medicationrelated risk factors e.g. bisphosphonate use 2 local factors e.g. dental surgery 3 demographic systemic factors medication factors case report patient developed mronj died sepsis although received shortterm oral bisphosphonate therapy received dental surgical treatment completely edentulous however many systemic factors diabetes cirrhosis steroid use interstitial pneumonia the presence multiple systemic factors high risk mronj even though medicationrelated factors local factors 8 9 10 the patient 59yearold man history smoking drinking insulin use diabetes cirrhosis associated chronic hepatitis c steroid use interstitial pneumonia sepsis spinal disk herniation this study conducted according guidelines hiroshima city hiroshima citizens hospital written informed consent obtained patient white blood cell count wbc 7800/l creactive protein crp level 15.523 he treated intravenous steroids i.e. methylprednisolone sodium succinate 1000 mg day 3 days prednisolone sodium succinate 20 mg twice daily 4 days methylprednisolone sodium succinate 1000 mg day 3 days regimen followed oral steroids i.e. prednisolone 60 mg day 2 months prevent steroidinduced osteoporosis treated oral bisphosphonate i.e. alendronate 35 mg week 7 weeks however administration drugs stopped right buccal space infection the patient severe swelling right buccal area infraorbital region hypesthesia tenderness spontaneous pain fig there ulcerations exposed bone alveolar part right incisor molar fig computer tomography ct scanning radiocontrast agent showed swelling right buccal area showed mandibular bone resorption fig 2b magnetic resonance imaging mri demonstrated abnormal signal e.g. low signal t1weighted t1w1 mri high signal t2weighted t2w1 mri bone marrow right mandibular angle fig based results patient diagnosed right mandibular cellulitis sepsis disseminated intravascular coagulation dic we administered intravenous antibiotic treatment irrigated part exposed bone povidone iodine every weekday 3 days first visit sequestrectomy drainage therefore changed antibiotics meropenem hydrate meropen sumitomo dainippon pharma co. ltd osaka japan alone meropenem hydrate ampicillin sulbactam unasyn pfizer inc one month first visit swelling right buccal area nearly disappeared fig 4b exposed bone remained alveolar portion right mandibular molar pus discharge present fig antibioticresistant bacteria grampositive bacilli detected time table 1 therefore changed antibiotics sitafloxacin gracevit daiichi sankyo tokyo japan fig 3 seven weeks first visit condition taken turn worse died multiorgan failure finally diagnosed patient mronj his multiple systematic factors mronj caused lethal sepsis fulfilled diagnostic criteria previous treatment bisphosphonate exposed bone maxillofacial region persisted 8 weeks history radiation therapy jaws ( b bisphosphonaterelated exposed necrotic bone right posterior mandibular drainage ( bone resorption present right part mandibula orthopantomogram analysis ( b c right buccal swelling apparent bone resorption mandibula based computer tomography ct analysis ( e abnormal signal i.e. low signal t1weighted imaging tiwi high signal t2weighted imaging t2w1 bone marrow right angle part mandibula bacterial identification microbial sensitivity test transition laboratory test values white blood cell count wbc creactive protein crp level use several antibiotics cellulitis medicationrelated osteonecrosis jaws mronj ( disappearance swelling right buccal area infraorbital region ( c discharge pus exposed bone alveolar part right mandibular molar in recently years many reports osteonecrosis jaw onj caused bisphosphonates antiresorptive antiangiogenic therapies 6 11 12 bisphosphonaterelated osteonecrosis jaw medicationrelated osteonecrosis jaw 7 denosumab rank ligand inhibitor antiresorptive agent used treat osteoporosis multiple myeloma giant cell tumor 13 the manufacturer reports frequency onj denosumab nearly frequency zoledronic acid treatment 14 thus may development onj associated inhibition bone resorption rather use certain type drug however considered careful attention required use bisphosphonates present case due frequent use treatment osteoporosis osteopenia diseases many reports indicate incidence onj significantly higher use intravenous iv bisphosphonates zoledronic acid zometa novartis basel switzerland use oral bisphosphonate 3 15 the incidence onj use oral bisphosphonates higher japan europe america 16 the period drug use also important longterm use considered high risk development onj patient the period oral bisphosphonates use 7 weeks caused severe symptoms it may symptoms multiple systemic factors case thus thought another option use bisphosphonate highrisk patient least administration perform risk assessment mronj enough in addition presence comorbid condition obesity alcohol use smoking risk factor mronj 9 poor oral hygiene oral infection periodontal disease also risk factors 18 19 the dentures possibly contaminated oral bacteria case know whether dentures illfitting denturerelated traumatic ulcers already ulcerations exposed bone first saw however think denturerelated traumatic ulcers might promoted mronj osteonecrosis jaw also reported patients history surgery edentulous regions jaw 20 physicians careful use bisphosphonates bone resorption inhibitors patients regardless presence absence teeth surgical history important thing prevent mronj it required cooperation among physicians nurses dentists dental hygienists pharmacists medical staff 7 physicians prescribe bisphosphonates bone resorption inhibitors provide detailed explanation patients risk mronj consult dentists patient even small risk factor prevent mronj dentists dental hygienists explain sufficiently patients importance oral hygiene perform oral care dental treatments patients use drugs there tendency believe mronj caused longterm bisphosphonate use especially intravenous bisphosphonate dental surgery we found multiple systemic factors worse risk factor mronj may cause lethal disease sepsis physicians careful administering bisphosphonate antiresorptive agents antiangiogenic medications patients multiple systemic factors even patients seem problems oral cavity ky involved study conception design drafting manuscript involved study conception design chief doctor patient fo one main doctors patient performed data acquisition mn supervisor main doctor patient ks ey performed analysis interpretation data yh one main doctors patient performed data acquisition si made critical revision report st made critical revision corresponding author

key clinical messagemedicationrelated osteonecrosis of the jaw ( mronj ) is developed even in the patients who are edentulous and treated with shortterm bisphosphonate therapy and oral administration . it sometimes causes lethal sepsis in patients who have multiple health problems such as diabetes , cirrhosis , steroid use for interstitial pneumonia , sepsis , and spinal disk herniation .

supported nci 2p50 ca09825806 nci u01 ca168394 stand cancer aacr dream team translational cancer research grant su2c aacr dt0209 tcga gdac grant nih nci u24 ca143883 gbm mdacc uterine spore career development award nci p50ca098258 lwt

pik3r1 ( encoding the p85 subunit of phosphatidylinositol 3-kinase ) is the 11th most frequently mutated gene across tumors . we recently reported neomorphic p85 mutants that induce signaling cascades not predicted by the canonical functions of p85 , suggesting the need to functionally annotate specific mutations in cancer genes for effective genome - informed personalized therapy .

review current knowledge nonpharmacologic approaches prevention early treatment type 2 diabetes this study reviewed research reports dealing nonpharmacologic interventions aimed preventing type 2 diabetes early lifestyle interventions the results randomized controlled trials show people impaired glucose tolerance received enhanced lifestyle advice significantly lower average 50% reduced incidence type 2 diabetes compared allocated receive usual care individuals able correct lifestyle habits recommended usual healthy life patterns mostly protected type 2 diabetes thus compelling evidence exists cases type 2 diabetes prevented least onset disease significantly delayed randomized controlled trials unequivocally demonstrated lifestyle management highly efficient prevention also early management type 2 diabetes this evidence lifestyle modification diabetes prevention stronger multifactorial diseases in early randomized intervention study malmhus sweden 19 lower rates type 2 diabetes found igt men randomized dietary intervention compared received therapy more recently several trials tested efficacy lifestyle intervention prevention type 2 diabetes the feasibility diet exercise intervention men igt assessed another study malm sweden 20 reference group comprised men want join intervention groups randomly assigned the lifestyle intervention aimed reducing intake refined sugar simple carbohydrates fat saturated fat energy alcohol increase intake complex carbohydrates vegetables physical activity training consisted two weekly 60-min sessions various dynamic activities end 5-year study period 11 29% men intervention group reference group developed type 2 diabetes respectively overall progression diabetes swedish men relatively low even reference group compared data observational studies 1 the intervention resulted significant changes lifestyle physiological parameters another study 577 subjects igt assigned either control exercise alone diet alone exercise plus diet group da qing china 14 using cluster randomized trial design participants assigned clinics dietary intervention encouraged reduce weight bmi 25 kg 61% participants aiming 23 kg otherwise high carbohydrate 5565% energy moderate fat 2530% energy diet recommended the participants encouraged increase level leisure time physical activity least 12 units per day clinics assigned exercise intervention one unit would correspond instance 30 min slow walking 10 min slow running 5 min swimming the cumulative 6-year incidence type 2 diabetes lower three intervention groups 4146% compared 68% control group the results finnish diabetes prevention study dps provided first convincing evidence proper randomized controlled trial type 2 diabetes prevented lifestyle modification 21 a total 522 individuals igt randomized either intensive lifestyle control intervention average 3.2 years follow type 2 diabetes incidence reduced 58% lifestyle group the lifestyle intervention goals 1 reduction weight 5% 2 total fat intake 30% energy 3 saturated fat intake 10% energy 4 fiber intake 15 g/1,000 kcal 5 moderate exercise 30 min day first year study body weight decreased average 4.5 kg intervention group 1.0 kg control group subjects p 0.0001 indicators central adiposity fasting glucose insulin 2-h postchallenge glucose insulin a1c reduced significantly intervention group compared control group 1-year examination fig changes clinical metabolic characteristics among intervention control group participants dps 2h p gluc 2-h plasma glucose diast diastolic blood pressure f p gluc fasting plasma glucose serum syst systolic blood pressure diabetes prevention program dpp 22 recruited 3,234 individuals igt fasting plasma glucose 95 mg dl randomized receive intensive dietary exercise counseling metformin placebo the main aims intervention 7% weight reduction 150 min week moderate physical activity the relative risk reduction 2.8 years 58% lifestyle intervention group compared placebo group the effect lifestyle higher effect metformin showed 35% relative risk reduction first year intervention weight reduction 5.6 kg 6% slight gradual regain end study year 4 23 the indian diabetes prevention program 14 recruited 531 people igt randomized four groups control lifestyle modification metformin combined lifestyle modification metformin lifestyle modification included advice physical activity 30 min brisk walking per day reduction total calories refined carbohydrates fats avoidance sugar increase fiber rich foods after median follow 30 months relative risk reduction type 2 diabetes incidence lifestyle modification 26.4% metformin 28.2% lifestyle modification metformin compared control group thus added benefit combining pharmacologic lifestyle interventions japanese trial 24 ) included 458 igt men randomized receive either intensive lifestyle intervention n 102 standard intervention n 356 the aims intensive intervention body weight reduction bmi 22 kg otherwise maintain present weight consume large amounts vegetables reducing amount foods 10% reduction fat 50 g day alcohol intake 50 g day physical activity 3040 min day the cumulative 4-year incidence type 2 diabetes intervention group 67% lower control group body weight decreased 2.2 0.4 kg intervention control groups respectively the trials listed demonstrated benefits healthy lifestyle delaying deterioration glucose tolerance manifest type 2 diabetes least long intervention continued data possible long term effects active lifestyle counseling scarce 12-year follow malm study 25 revealed mortality among men former igt intervention group lower control group 6.5 vs. 14.0/1,000 person years p 0.009 median 7-year follow dps marked reduction type 2 diabetes incidence sustained 13 more importantly median postintervention follow 3 years type 2 diabetes incidence 4.6 7.2 per 100 person years intervention control groups respectively log rank test p 0.0401 i.e. 36% additional risk reduction the absolute risk difference groups increased postintervention period intensive lifestyle intervention limited time yield long term benefits type 2 diabetes risk individuals igt the 20-year follow original da qing cohort showed lower type 2 diabetes incidence persisted lifestyle intervention groups combined compared control participants the risk reduction remained essentially also postintervention period 26 ( 26 observed statistically significant differences cvd events cvd total mortality control group combined intervention groups cvd mortality tended lower 17% among individuals received lifestyle intervention in published prevention trials main aim see comprehensive lifestyle intervention reduces type 2 diabetes risk chinese prevention study 14 attempt determine whether diet exercise intervention effective randomizing participating clinics diet physical activity diet plus physical activity intervention revealed difference outcome two interventions dps risk diagnosed diabetes strongly associated number lifestyle goals achieved 21 success achieving intervention goals dps estimated food records exercise questionnaires success score 0 5 ) there strong inverse correlation success score incidence diabetes total follow this especially apparent success achieving goals assessed year 3 probably reflects importance sustained lifestyle changes 13 the hazard ratios 1.00 0.87 0.67 0.70 0.23 success scores 0 45 respectively p trend 0.001 the effects various components intervention interesting therefore post hoc analyses related issue completed the independent effects achieving success score components 3-year examination assessed including five lifestyle goal variables individually cox model table 1 univariate hazard ratios diabetes incidence 95% ci 0.45 0.310.64 weight reduction baseline 0.65 0.450.95 intake fat 0.59 0.311.13 intake saturated fat 0.69 0.490.96 intake fiber 0.62 0.460.84 physical activity comparing achieve respective goal when five success score components simultaneously included cox model multivariate adjusted hazard ratios diabetes 95% ci 0.43 0.300.61 weight reduction 0.80 0.481.34 intake fat 0.55 0.261.16 intake saturated fat 0.97 0.631.51 intake fiber 0.80 0.571.12 physical activity furthermore weight change significantly associated achievement four lifestyle goals consequently success score strongly inversely correlated weight reduction 27 multivariate logistic regression model predict diabetes 10-year follow correspondingly reduction body weight reported main determinant risk reduction u.s after adjustment components intervention 16% reduction diabetes risk per 1 kg weight lost first year intervention furthermore lower percent calories fat increased physical activity predicted weight loss increased physical activity important help sustain weight loss achieving physical activity goal 150 min week reduced diabetes risk especially among participants achieve weight reduction goal 7% risk reduction 44% compared achieved neither weight reduction physical activity goal these findings suggest dietary composition physical activity important diabetes prevention effect diabetes risk primarily mediated resulting weight reduction nevertheless multicolinearity it also noted indian diabetes prevention program 15 chinese prevention study 14 participants relatively lean large change body weight despite remarkable reduction diabetes risk apparent thus studies components intervention weight control responsible beneficial effects diabetes risk with compelling evidence type 2 diabetes prevented delayed strategies implement primary prevention type 2 diabetes high risk subjects well population level urgently needed while type 2 diabetes prevention trials rigorously defined populations explicitly characterizing glycemic status studies include groups risk developing type 2 diabetes methods also define groups high risk developing type 2 diabetes recently developed increasingly used several countries 28 the recent analysis dps also shown people significantly benefit lifestyle interventions 27 prospective study based data u.k estimated association achievement five lifestyle goals used dps type 2 diabetes risk developing diabetes 4.6-year follow 29 the incidence type 2 diabetes inversely related number goals achieved p 0.001 none participants met five goals 0.8% total population developed diabetes whereas risk diabetes highest meet goals if entire population able meet one goal total incidence diabetes predicted decrease 20% this finding suggests health promotion interventions result increase healthy lifestyle general population might significantly reduce growing burden type 2 diabetes groups targets prevention efforts identified several reasonably effective strategies however universal well tested method identify high risk developing type 2 diabetes may variation optimal strategies different populations regions around world it also important realize identification people high risk type 2 diabetes asymptomatic type 2 diabetes identical diagnosis type 2 diabetes practice identify people high risk simple cost efficient tools the main question however implement efficient preventive strategy individuals identified high risk i.e. translate results recent successful type 2 diabetes prevention trials real life setting 30 much attention put biochemical methods assessment glycemia early diagnosis type 2 diabetes much less coverage detection asymptomatic type 2 diabetes the evidence compelling without applying oral glucose tolerance test assessment postprandial glucose large proportion early cases type 2 diabetes remain unrecognized 31 the international diabetes federation consensus group recently prepared document prevention type 2 diabetes 32 this shows international diabetes community ready accept principle primary prevention type 2 diabetes must considered essential part public health policy diabetes the american diabetes association consensus development conference 2006 outlined principles regarding impaired fasting glucose ifg igt interventions applied among individuals 26 the american diabetes association consensus group also recommended lifestyle intervention initially people ifg igt weight control physical activity mention diet ifg igt present well additional risk factors people additional risk factors combination lifestyle intervention metformin recommended however evidence show combination lifestyle metformin effective contrary results indian diabetes prevention program suggest additional benefit metformin lifestyle intervention 15 it clear much antidiabetic drugs help preventing progression ifg igt overt diabetes overall costs risk benefit ratio long term evident long term effects lifestyle interventions highly beneficial long term costs low 13,26 ( 33 analysis stress real answer reductions incidence prevalence diabetes social policy medical care

objectiveto review the current knowledge about nonpharmacologic approaches in the prevention and early treatment of type 2 diabetes.research design and methodsthis study reviewed the research reports dealing with nonpharmacologic interventions aimed at preventing type 2 diabetes with early lifestyle interventions.resultsthe results from the randomized controlled trials all show that people with impaired glucose tolerance who received enhanced lifestyle advice had significantly lower ( on average 50% reduced ) incidence of type 2 diabetes compared with those allocated to receive usual care . individuals who were able to correct their lifestyle habits as recommended for usual healthy life patterns were mostly protected against type 2 diabetes . thus , compelling evidence exists that most of the cases of type 2 diabetes can be prevented or at least the onset of the disease can be significantly delayed.conclusionsrandomized controlled trials have unequivocally demonstrated that lifestyle management is highly efficient in the prevention and also in the early management of type 2 diabetes . this evidence of lifestyle modification in diabetes prevention is stronger than for most other multifactorial diseases .

function sensory receptors nrec movement control muscle coordination perception space position temporo mandibular joint tmj fundamental although presence nrec tmj still debated authors reported lack nervous fibers articular disk 1,2 florid innervation tmj reported several studies animal models human 3 6 suggested 6 concentration sensory receptors within tmj higher areas supporting higher strong tensions articular movements chewing biting speaking discordance other authors disclosed presence mechanical nrec articular disk human tmj 7,8 also distinguishing receptors capsulated uncapsulated bases morphological features the aim study ascertain presence distribution nrec human tmj using immunohistochemical investigations healthy pathological tmj arthritis arthrosis the study approved bioethics committee department odontology surgery university bari 10 samples capsular pericapsular soft tissues disk obtained healthy patients six men four women mean age 39 years suffered surgery tmj accidental trauma temporo mandibular region remaining 7 cases four men three women mean age 57 years patients surgically treated severe degenerative lesions tmj chronic arthritis arthrosis all specimens immediately fixed neutral buffered formalin embedded paraffin 5 micron thick sections cut stained haematoxylin eosin pas gomori reticulin azan mallory trichrome consecutive sections used immunohistochemical detection antigens listed table 1 all antibodies used commercially avalaible dako italia spa milan italy glial fibrillary acidic protein gfap myelin basic protein mbp neurofilaments nf neuron specific enolase nse synaptophysin s-100 protein s-100 becton dickinson burlingame usa leu-7 cases immunohistochemical alkaline phosphatase anti alkaline phosphatase apaap method performed 9 sections anti neurofilaments antibodies treated 10 minutes 1% saponin phosphate buffered saline pbs ph 7.2 application primary antibodies with histochemical techniques h&e stain nrec easily detectable figures 1 8 however used identify corresponding tissue immunostained slides specimens such types nrec detected immmunohistochemistry table 2 globular receptors thin capsule closely resembling ruffini ones exhibited strong immunoreactivity core s-100 nse leu-7 abundant superficial peri articular muscles peri articular fibrous capsule b elongated onion like receptors thick capsule mimicking pacini receptors positive mbp s-100 nse leu-7 particularly abundant deep muscle fibres peri articular dense fibrous tissues c fusiform capsulated receptors morphologically similar golgi receptors located within peri articular fibrous tissues ligament fibromuscolar resections strongly positive s-100 mbp leu-7 weaker gfap reactivity types nrec a+b+c especially core punctate reactivity synaptophysin neurofilaments also evident free thin nervous endings high density within subsynovial connective tissues intra- periarticular fibrous tissues along perimisial endomisial sarcolemma striated muscle fibres detected showing immunoreactive neurofilaments nse synaptophysin s-100 antibodies articular fibrous cartilage articular disk ) any previously described nrec identified s-100 protein seemed react chondrocytes normal diseased tissues furthermore chondrocytes healthy individuals appeared round shaped distinct cell borders central nuclei evident s-100 reactivity nucleus cytoplasm diseased tmj instead chondrocytes showed different morphoology especially s-100 immunostaining elongated cytoplasm one thick dendritiform processes variable length strong reactivity s-100 protein the number dendritiform chondrocytes higher specimens diseased patients healthy patients seems undergo reactive reparative proliferation discal peridiscal tissues few studies reported literature precise identification distribution nrec articular peri articular tissues tmj past authors 3 6 identified ruffini's like pacini like golgi like receptors articular periarticular tissues using conventional histochemical methods usually performed identify nerve fibres receptors 7,8 using immunofluorescent techniques authors 3 demonstrated presence nervous fibers periarticular fibrous tissues seemed run along blood vessels reaching fibrous cartilage tmj ending inside our study confirmed results preceding reports presence several different types nrec periarticular soft tissues tmj allowing additionally precise immunohistochemical identification ruffini's like pacini's- like golgi's like receptors skeletal muscles tendons periartcular dense fibrous connective tissues subsynovial tissues in fact nrec appeared nse s-100 mbp immunoreactive showing gfap leu-7 immunoreactivity lower degrees free nervous endings immunohistochemically positive neurofilaments nse s100 protein detected periarticular soft tissues higher density muscles vascular venous plexus posterior part discal ligaments trilaminar zone cartilagineous disk the latter besides appeared constituted s100 immunoreactive chondrocytes healthy individuals patients chronic degenerative tmj lesions pathological patients severe disk damage number morphology chondrocytes severely different comparison normal tissues 11 chondrocytes fact numerous rough thick elongated cytoplasmic processes conferring dendritic like appearance instances dendritic processes extremely long consequently cytoplasm origin could detected single section consecutive sections specimen instances this cellular component prolongments cartilagineous disks showed neurofilaments nse synaptophysin immunoreactivity morphological changes chondrocytes patients chronic arthritic disease tmj observed conferring appearance neural cells axons previously described literature 10 this misleading feature emphasized occurence s-100 immunoreactivity dendritic chondrocytes well normal chondrocytes nevertheless s-100 positive cells articular cartilage tmj bear rare thick coarse cytoplasmic processes one antigens commonly found peripheral nerve fibres e.g. leu-7 mbp neurofilaments nse synaptophysin except s-100 could detected in contrast peripheral nerve fibres usually exhibit long thin varicose cytoplamic prolongments variable combination mentioned antigens usually detectable conjunction s-100 reactivity the results study indicate free nervous endings described authors 3 8 definitely proven nrec appears likely stress especially pathological conditions chondrocytes prolongments might morphologically resemble nrec articular disk although immunophenotype rather different lack expression typical neural antigens although immunochemistry easily used study distribution location nrec articular tissues also suggest ultrastuctural immuno ultrastructural studies performed order definitely assess chondrocytes exclusive cell type articular cartilage also nrec could present tmj

aim : a study was performed on the articular disk and periarticular tissues of the temporo - mandibular joint ( tmj ) with immunohistochemical techniques to give evidence to the presence of neuroreceptors ( nrec ) in these sites . methods : the study was carried out on tissue samples obtained from 10 subjects without tmj disease and from 7 patients with severe tmj arthritis and arthrosis . we use antibodies directed against following antigens : gliofibrillary acidic protein ( gfap ) , leu-7 , myelin basic protein ( mbp ) , neurofilaments 68 kd ( nf ) , neuron specific enolase ( nse ) , s-100 protein ( s-100 ) and synaptophysin ( syn ) . results : this study revealed that ruffini's - like , pacini's - like and golgi's - like receptors can be demonstrated in tmj periarticular tissues and that free nervous endings are present in the subsynovial tissues but not within the articular disk . we observed elongated cytoplamic processes of chondrocytes that demonstrated strong s-100 immunoreactivity but they were unreactive with all other antibodies . these cytoplamic processes were more abundant and thicker in the samples obtained from patients with disease tmj . conclusion : the results of this study confirm that different nrec are detectable in tmj periarticular tissues but they are absent within the articular disk . in the latter site , only condrocytic processes are evident , especially in diseased tmj , and they might have been confused with nervous endings in previous morphological studies . nevertheless the absence of immunoreactivity for nf , nse and syn proves that they are not of neural origin .

areview history mental disorders shows wide prevalence among human beings always a glance statistics reveals mental disorders abnormalities affecting humans increasing pace world health organization report revealed incidence mental disorders 10% among young adults noorbala et al study mental health among individuals 15 years age n 19,370 randomly selected reported 34.2% subjects different types mental disorders hand university students as major social group human resource future investment society mental health great importance the mentioned statistics show high prevalence disorders among university students one hand university entrance process influences students mental health educational stressors immigration major cities far family facing financial problems etc hand if students face additional stress due stressful nature major mental health considered among stressful educational courses nursing midwifery based study association mental health educational stressors nursing students kerman nursing school 2011 an increase number students referrals counseling centers shows social cultural growth one hand asking help believed sign mental growth hand reveals disturbing factors decreasing students academic performance study conducted private universities malaysia therefore experts education psychologists sociologists educational policy makers seek appropriate pattern facilitate students overall growth mental health improvement regard realizing need humans scientists tried explore reconstruct humanistic methods consistent human beings psychological characteristics reach mental health therefore recent past psychologists turned new educational treatment methods namely neurolinguistic programming nlp in addition wide spectrum human behaviors mediated regulated human language the importance nlp lies fact programming collection skills based psychological characteristics human beings individuals obtain ability use personal capabilities much possible in article titled neurolinguistic methodology controlling examination anxiety reported anxiety one destructive factors students mental health every level reduce educational function they introduced nlp one efficient methods control pre exam anxiety as mentioned earlier students medical group including nursing midwifery tolerate high stress due stressful nature course education also working environment need decision making critical situations with regard various employment opportunities working conditions hospitals affect mental health researcher conducted study aim define compare efficacy nlp training mental health nursing midwifery students islamic azad university tehran medical branch 2011 2012 the sample size calculated 30 subjects group alpha 0.05 z 1.96 delta 0.80 due subjects dropping study midwifery group finally 52 subjects entered study groups both groups homogenous concerning age range sex education level faculty university group comparison conducted regard adequacy sample size(based sample size formula the first section personal characteristics including age sex course study year entering university marital status place birth residence head household parents education family monthly income history psychotropic drug stimulants narcotics consumption history disastrous experience past 6 months the second section consisted 28-item goldberg general health questionnaire four subscales physical signs anxiety social dysfunction depression the total score general health obtained subjects adding scores four sub scales questions 1 7 connected physical signs 814 anxiety 15 21 social function 2128 connected depression each question four options scores ranging 0 3 never 0 normal 1 almost normal 2 actually normal 3 the total scores ranged 0 84 scores 23 showed low general health reported general validity test 88% subscales 50% 81% they also reported reliability subscales physical signs 0.78 anxiety 0.86 social dysfunction 0.77 depression 0.88 then educational program form 1-month program containing five 120-min educational sessions held the sessions lecture form questions answers accompanied slide show short films an education booklet cd prepared valid references prior educational session distributed among attendants sessions skills nlp taught 1 defining goal 2 time management 3 self assertion then 1 month last educational session subjects mental health measured questionnaire data analyzed descriptive absolute relative distribution table mean sd inferential paired test statistical tests ethical considerations present study included obtaining consent subjects giving explanations goal study they also assured confidentiality data mere use data analysis some limitations researchers control personal differences different levels motivation comprehension interest subject iq social cultural differences could affected subjects level learning subjects honesty responses relevancy answers control researchers lack control group due less number volunteers educational classes interference students classes limitations study about 57.7% subjects nursing students 42.35% midwifery students 80.8% single 19.2% married 78.8% born tehran 21.2% cities 19.2% consumed psychotropic medications 13.5% history referring psychiatrist 30.8% smoked leisure time mean scores nursing students mental health dimensions 56.23 14.7 nlp education 17.36 9.44 nlp education score mental health showed significant reduction 39 scores education compared education in words nlp education significant effect reduction mental health scores p 0.001 18.42 table 1 with regard subscales mean score physical signs dimension 14.30 4.78 education 4.76 3.63 education p 0.001 the mean score anxiety 15.10 4.22 education 4.76 3.63 education p 0.001 the mean score depression 10.73 5.38 education 1.01 2.27 education p 0.001 the mean score social function 16.10 2.52 8.53 3.63 intervention p 0.001 the mean score depression 10.37 5.38 1.01 2.27 intervention p 0.001 a reduction mean score observed dimensions education shows positive effect nlp education the mean score mental health among midwifery students 53.72 15.97 education 23.63 12.06 education significantly less pre test values showing nlp effective subjects mental health p 0.001 table 2 with regard mental health dimensions mean score physical signs 11.36 5.10 education 5.54 4.30 education p 0.001 the mean score anxiety 14.54 6.32 education 5.54 4.35 education p 0.001 the mean score social function 16.36 3.23 education 10.01 3.54 education p 0.001 the mean score depression 11.45 5.56 education 2.54 3.71 education p 0.001 determination comparison nursing students health status education determination comparison midwifery students health status education nursing group mean score mental health 56.23 14.7 education 17.36 9.44 education midwifery group 53.72 15.97 23.63 12.06 education there significant difference mean scores general health education concerning course study p 0.561 difference significant education nursing midwifery subjects nursing students mental health influenced nlp education compared midwifery students p 0.041 nursing group mean score physical signs 14.30 4.78 education 4.76 3.63 education midwifery group 11.36 5.10 education 5.54 4.30 education significant difference mean scores physical signs concerning course study nlp education p 0.584 nursing group mean score anxiety 15.10 4.22 education 3.06 3.01 education midwifery group 14.54 6.32 5.54 4.35 education showing significant difference concerning course study p 0.019 anxiety nursing group significantly higher midwifery group education after nlp education anxiety nursing group less midwifery group revealing effect nlp education nursing group in nursing group mean score social function 16.10 2.52 education 8.53 3.63 education midwifery group 16.36 3.23 education 10.01 3.54 education revealing significant difference mean scores social function regard course study education p 0.153 nursing group the mean score depression 10.73 5.38 education 1.01 2.27 education midwifery group 11.45 5.56 education 2.54 3.17 education showing significant difference p 0.153 the mean scores mental health pre test significantly different groups respect variables place birth interest selected course interest present course mental disease consumption psychotropic medications referring psychiatrist existence disastrous event 6 months prior study smoking alcohol consumption p 0.05 mental health lower among students tehran compared students cities it also lower among students interested course study compared the students history mental disease referral psychiatrist lower mental health compared history mental health among students experiencing disastrous event past 6 months consuming psychotropic medication cigarettes alcohol lower others mean scores students mental health showed significant difference regard smoking water pipe p 0.005 mental health lower among students always smoked cigarette water pipe compared comparison pre test post test mean scores students mental health showed significant difference variables associated family p 0.05 in nursing group mean score mental health 56.23 14.7 education 17.36 9.44 education midwifery group 53.72 15.97 23.63 12.06 education there significant difference mean scores general health education concerning course study p 0.561 difference significant education nursing midwifery subjects nursing students mental health influenced nlp education compared midwifery students p 0.041 nursing group mean score physical signs 14.30 4.78 education 4.76 3.63 education midwifery group 11.36 5.10 education 5.54 4.30 education significant difference mean scores physical signs concerning course study nlp education p 0.584 nursing group the mean score anxiety 15.10 4.22 education 3.06 3.01 education midwifery group 14.54 6.32 5.54 4.35 education showing significant difference concerning course study p 0.019 anxiety nursing group significantly higher midwifery group education after nlp education anxiety nursing group less midwifery group revealing effect nlp education nursing group nursing group mean score social function 16.10 2.52 education 8.53 3.63 education midwifery group 16.36 3.23 education 10.01 3.54 education revealing significant difference mean scores social function regard course study education p 0.153 nursing group mean score depression 10.73 5.38 education 1.01 2.27 education midwifery group 11.45 5.56 education 2.54 3.17 education showing significant difference p 0.153 the mean scores mental health pre test significantly different groups respect variables place birth interest selected course interest present course mental disease consumption psychotropic medications referring psychiatrist existence disastrous event 6 months prior study smoking alcohol consumption p 0.05 mental health lower among students tehran compared students cities it also lower among students interested course study compared the students history mental disease referral psychiatrist lower mental health compared history mental health among students experiencing disastrous event past 6 months consuming psychotropic medication cigarettes alcohol lower others mean scores students mental health showed significant difference regard smoking water pipe p 0.005 mental health lower among students always smoked cigarette water pipe compared comparison pre test post test mean scores students mental health showed significant difference variables associated family p 0.05 the results obtained showed nlp education effective mental health nursing midwifery students p 0.001 results consistent results sahebalzamani et al conducted study effect life skills training general health students showed life skills training effective nursing midwifery students mental health p 0.01 11.2 results consistent result zamini et al studied effect nlp education self efficiency problem solving among students our results showed nlp education notably effective students mental health indicating students general health promoted nlp education the results showed mean scores mental health 56.23 14.7 53.72 15.97 nursing midwifery groups respectively education showing significant difference regard course study p 0.561 but 17.36 9.44 23.63 12.06 nursing midwifery groups respectively education showing significant difference regard course study p 0.041 it concluded mental health higher nursing group given nlp education compared midwifery group in words nlp education notable effect nursing students mental health promotion results study concerning mental health dimensions showed anxiety influenced education nursing students needs studies investigating dimensions regard the obtained results consistent result sahebalzamani et al reporting effect expression skill education self esteem decisiveness high school girls p 0.000 with regard increasing changes sophistication society development social communications preparation individuals especially young generation facing difficult situations essential issue since iran young population unfortunately corruption social assaults increased recent years policy makers education training system related authorities essentially plans lower corruption assault increase job opportunities society create jobs students our results showed nlp education promote individuals mental health level providing nlp education skills including setting goal time management skill self expression form nlp nlp education public education increase level knowledge positive effect various dimensions human life as students future investment society mental health great importance a family first place children experience common life ciability therefore based findings suggested consider nlp education along educational courses promote individuals general health also lower depression anxiety social function reduction physical problems prevent mental physical disorders

background : neurolinguistic programming ( nlp ) refers to the science and art of reaching success and perfection . it is a collection of the skills based on human beings psychological characteristics through which the individuals obtain the ability to use their personal capabilities as much as possible . this study aimed to investigate the efficacy of nlp training on mental health in nursing and midwifery students in islamic azad university tehran medical sciences branch.materials and methods : in this quasi - experimental study , the study population comprised all nursing and midwifery students in islamic azad university , tehran medical branch , of whom 52 were selected and assigned to two groups through random sampling . data collection tool was goldberg general health questionnaire ( 28-item version ) . after primary evaluation , nlp training was given in five 120-min sessions and the groups were re - evaluated . the obtained data were analyzed.results:in the nursing group , paired t - test showed a significant difference in the scores of mental health ( with 39 points decrease ) , physical signs ( with 7.96 scores decrease ) , anxiety ( with 10.75 scores decrease ) , social function ( with 7.05 scores decrease ) and depression ( with 9.38 scores decrease ) . in the midwifery group , it showed a significant difference in mental health ( with 22.63 scores decrease ) , physical signs ( with 6.54 scores decrease ) , anxiety ( with nine scores decrease ) , and depression ( with 8.38 scores decrease).conclusions : this study showed that nlp strategies are effective in the improvement of general health and its various dimensions . therefore , it is essential to conduct structured and executive programs concerning nlp among the students .

polycystic ovary syndrome pcos first reported 1935 known one common endocrine hormones disorders women reproductive age afflicting many 10 the name syndrome derived appearance ovaries afflicted women ovary enlarged size full cysts these cysts form follicles filled liquid sacs full developed ovum due lack set standard unified diagnostic criteria rate prevalence syndrome reported different studies varied some studies used sonography diagnostic criteria found prevalence pcos ranged 21% 22% respectively contrary studies using oligomenerrhea hyperandrogenemia manifestations pcos diagnostic criteria this syndrome accounts 30 40% common causes infertility resulting ovary dysfunctions in addition pcos considered leading cause ovary disorders recent studies indicate person may pcos without showing one mentioned symptoms symptoms signs enumerated pcos follows increased androgenic hormones metabolic syndrome insulin resistance fat related disorders type 2 diabetes cardiovascular disease endometrial cancer blood pressure the patients pcos also suffer anxiety depression symptoms believed mostly result disorders occurred reproduction cycle naturally completed releasing ovum every month the exact cause pcos yet completely known however factors insulin resistance hyperinsulinaemeia obesity heredity genetics factors environmental factors exposure high levels masculinizing hormones embryonic life cycle related factors hyperandrogenemia gonadotropins secreting functioning hyperprolactinemia hypothyroidism thyroid related dysfunctions diet may play part developing pcos according previous studies eating habits different patients pcos healthy persons foods seem affect hormone parameters year 2008 one case control study carried al zahra hospital city tabriz iran 60 women studied results showed intake amounts ca mg vitamin dairy fruits nuts seeds remarkably low among women pcos the frequency milk dairy intakes products also lower compared healthy women p 0.05 another study billaudel et al revealed vitamin calcium play critical role insulin secretion insulin resistance human animal models another research 103 women pcos 103 healthy women provided evidence decreased amount adiponectine calcium vitamin patients suffering pcos higher thyroglobulin there also significant correlation adioponectrine calcium concentrations oh 25 in one prospective study 3157 young women aged 18 30 pereira et al reported 2002 amount dairy intake insulin resistance indirectly related study pereira et al found inverse relationship consuming 4 units dairy products per day metabolic syndrome females as indicated previous research diet dairy intake source calcium trigger pcos condition also may directly affect obesity insulin resistance two factors act causes pcos numerous studies demonstrated association diet components risk factors developing various diseases however previous studies address relationship nutrition choices type diet chosen patients the adverse health effects pcos infertility diabetes cardiovascular diseases growth prevalence impose huge financial health costs society affect affecting many families therefore however number studies addressed relationship dairy intake pcos limited hence present study intends explore relationship amount dairy intake pcos as descriptive cross sectional study present research tried find relationship amount dairy consumption pcos condition 400 women referred shahid beheshti hospital clinic 2013 far exclusion inclusion criteria study is concerned noteworthy criteria inclusion study willingness participation lack precocious puberty uterus cancer pregnant contrary subjects excluded study unwilling participation respond 30 food items included food frequency questionnaire ffq diagnosed typical chronic diseases follow specific diet start study the data related food intakes checked researcher using ffq ffqs person asked often consumed certain foods given l foods validity reliability previously confirmed the data history developing ovary dysfunctions endocrine disorders related reproductive system genetics background first related family members ovarian disease age first menstruation history thyroid diseases patients medication history kind medicine used surgery period developing pcos physical activity collected nutritious expert using self developed questionnaire to weight kg participants measured clothes without shoes the height participants measured normal condition without wearing shoes using strip tape body mass index bmi ) was calculated dividing weight kg value square root height value the pcos condition identified sonography diagnostic assessment checking patients clinical manifestations performed trained authority data analysis performed descriptive analysis logistic regression tests using spss software version 15 age age menarch bmi test applied mann whitney test applied kcal variables chi square test applied table 1 shown table 2 variables mann whitney test used the study confidence coefficient considered 95% level strength study 80% furthermore ratio pcos afflicted patients sampling error assumed 50% 0.07% respectively frequency central tendency spread health condition characteristics participants frequency central tendency spread food intake characteristics sample population study as descriptive cross sectional study present research tried find relationship amount dairy consumption pcos condition 400 women referred shahid beheshti hospital clinic 2013 far exclusion inclusion criteria study is concerned noteworthy criteria inclusion study willingness participation lack precocious puberty uterus cancer pregnant contrary subjects excluded study unwilling participation respond 30 food items included food frequency questionnaire ffq diagnosed typical chronic diseases follow specific diet at start study written information consent form signed participants the data related food intakes checked researcher using ffq ffqs person asked often consumed certain foods given l foods validity reliability previously confirmed the data history developing ovary dysfunctions endocrine disorders related reproductive system genetics background first related family members ovarian disease age first menstruation history thyroid diseases patients medication history kind medicine used surgery period developing pcos physical activity collected nutritious expert using self developed questionnaire weight height participants also measured to weight kg participants measured clothes without shoes the height participants measured normal condition without wearing shoes using strip tape body mass index bmi ) was calculated dividing weight kg value square root height value the pcos condition identified sonography diagnostic assessment checking patients clinical manifestations performed trained authority data analysis performed descriptive analysis logistic regression tests using spss software version 15 age age menarch bmi test applied mann whitney test applied kcal variables chi square test applied table 1 shown table 2 variables mann whitney test used the study confidence coefficient considered 95% level strength study 80% furthermore ratio pcos afflicted patients sampling error assumed 50% 0.07% respectively frequency central tendency spread health condition characteristics participants frequency central tendency spread food intake characteristics sample population study this study carried 400 women mean standard deviation sd age 29.5 4.8 years old mean sd bmi 24.1 4.8 admitted shahid beheshti hospital the prevalence pcos persons study found 9.9% based primary analyses data descriptive analysis relationship history ovarian diseases genetics use medications pcos no relationship observed pcos variables table 1 history ovarian diseases statistically significant difference patients pcos healthy people p 0.001 as family history similar result obtained 22.6% patients pcos revealed family history pcos on contrary significant relationship physical activity pcos p 0.86 a significant relationship also observed use medications pcos p 0.001 the pcos afflicted patients healthy persons show difference terms weight bmi the average age patients pcos 26.7 compared 29.8 average age healthy persons the two groups also differed terms amount calorie intake 4247 kcal subjects pcos 6410 kcal healthy subjects the average age first menstrual period found 13.35 years among healthy individuals 13.02 years among individuals afflicted pcos table 1 the average sum dairy intake 581.5 611 g healthy persons patients pcos respectively table 2 the results using logistic regression revealed association genetics pcos p 0.13 table 3 contrary ( p 0.001 odds ratio 0.2 confidence interval ci 95% 0.082 0.490 age p 0.001 0.85 ci 95% 0.787 0.934 use medication three confounding variables p 0.001 0.17 ci 95% 0.064 0.477 pcos table 3 based results bmi pcos significantly related relationship may remarkable p 0.068 every one unit increase bmi accompanied increase risk affliction pcos although like bmi relationship significant remarkable p 0.088 after modifying effects confounding variables direct significant relationship found intake milk pcos p 0.028 every 1-unit increase milk intake led 1-increase risk factors table 3 in present study evaluated effects dairy product pcos according results study significant relationship observed component dairy foods group variables pcos however modifying effects confounding variables found milk intake pcos directly related very studies conducted exploring direct effect dairy foods may pcos the results empirical research effect dairy foods weight believed one effective factors infliction pcos inconsistent without producing rigid strong outcome the results available clinical evaluations especially address effects diet rich dairy foods weight yield fixed outcome the results previous studies line results according adebamowo et al relationship slim low fat free fat milk increased frequency acne component pcos two intervention studies thompson et al harvey berino et al provided evidence additional weight loss choosing diet rich dairy foods compared low dairy diet the results studies similar one earlier research zemel et al ( 2004 study period 12 weeks however periods two recent studies association observed variables question 48 weeks 52 weeks respectively the findings 3-year prospective study large number children young adults revealed subjects higher intake milk higher bmi although reported increase trivial per year adjusting number body weight factors statistically significant chavarro et al prospective cohort study found high intake low fat dairy products may lead increase women risk ovulation related infertility incorporating high fat dairy foods may decrease risk ( 1994 reported positive association intakes milk age related decreased fertility rates 31 nations put differently consuming milk gunther et al study divided 155 women normal weight three sub categories per amount dairy foods intake within 1 year diets intervention terms caloric value although results study support hypothesis related dairy foods intake weight loss following 51 healthy women participating study 6-month period study revealed compared low intake dairy foods diet high dairy intake lower fat accumulation results previous studies line findings two studies zemel a considerable decrease reported bmi waist circumference notable decrease plasma insulin one case control study dixon et al argued intricate association obesity dairy products intake concluding children higher age inverse association intake dairy foods obesity analyzing number databases a group cross sectional studies adults children almost demonstrated inverse relationship intake dairy foods initial obesity the samples used studies mostly selected among post menopausal middle aged women carruth skinner research group preschool children concluded number servings estimated per day obviously inversely related fat accumulation positively related individuals slimness in particular serving resulted additional weight loss 0.9 1.1 kg as consuming dairy foods insulin resistance relationship cross sectional study conducted 496 samples participants aged 20 68 aged 2009 enumerated this study tried assess amounts consumed dairy foods using food history questionnaire validity checked based results compared groups samples situated top quarter intake dairy products lowest mean scores insulin resistance markers although observed differences statistically significant eating whole fat dairy products inversely associated homa ir contrast relationship low fat dairy products insulin resistance markers a case control study keshavarzi demonstrated risk infertility among women ate 3 glasses milk per day lower intake milk much 70% most studies done obese subjects children adolescents whole findings study indicated statistically significant relationship consuming milk yogurt sherbet frozen yogurt cheese cream pcos conversely became evident pcos history ovarian diseases p 0.001 age p 0.001 use medication p 0.001 three confounding variables inversely related furthermore although statistically significant relationship obtained bmi pcos threshold significant p 0.068 every one unit increase bmi associated 10% increase risk pcos course relationship significant similar bmi relationship insignificant threshold significance p 0.0880 after modifying effects confounding variables statistically significant relationship observed milk intake risk pcos p 0.028 hence every 1-unit increase amount milk consumed caused 1%-increase risk pcos study addressing relationship history ovarian diseases pcos relationship use medication pcos the research suggest since medications used majority participants metformin anti fertility well thyroid medications helped prevent developing pcos due effect androgen secretion luteinizing hormone follicle stimulating hormone ratio based past research higher age makes lower possibility pcos affecting ovulation however noteworthy yielding inconsistent results studies addressed issue women pcos suspicious make changes diets instance choosing low fat dairy foods instead high fat ones positive relationship changes anovulatory infertility would expected foods factors relevant augmentation phenotype attributes pcos may increase infertility risk due disturbed ovulation the current study revealed average intake milk pcos significant relationship explain average total intake low- free fat milk estimated 52 61 gr 55 132 gr healthy patient individuals respectively the average amount low- free fat milk consumption found 12.4 39.35 gr healthy persons 76.55 gr pcos patients furthermore individuals pcos condition revealed higher consumption low- free fat milk per results past studies positive relationship low fat milk pcos low fat dairy products may increase level insulin like growth factor igf researchers controversies the igf existing human ovarian cells may stimulate cell activity related changes observed pcos it yet known whether change level igf caused diet may contribute pcos clinical manifestations research suggest fatty acids dairy products may potential positive effects ovary function details the substance soluble fat available dairy products plays essential role creating effects compared low fat dairy products whole milk fat rich dairy products since estrogen decrease level igf existence high fat dairy foods may explain observed association the frequent increased insulin sensitivity high fat dairy consumers may improve ovulation performance eating low fat dairy foods has also accompanied excess androgens secretion known one components pcos one weak points study cross sectional design fails identify cause effect relationships in addition hormone tests thyroid prolactine homa ir tests taken subjects in contrast strength points mentioned study include large number samples lack similar study iran directly addressing relationship dairy products intake pcos evaluating foods intakes using validated ffq using sonography test known reliable method pcos diagnose based findings study milk intake prevalence pcos may related way due adverse health effects condition high prevalence society well shortage research effectiveness diets preventing treating need research felt future research better address laboratory practices thyroid prolactine sexual hormones well

background : polycystic ovary syndrome ( pcos ) is the most common endocrine disorder in reproductive women . nearly 10% of young women in this period involved . although factors such as insulin resistance , hyper insulinemia , obesity and dietary are suggested to be associated with pcos , cause of pcos is not completely understood . dairy products ( a key component of the usual diet ) of participants can also affect the factors of this disease and may have beneficial effects on treatment of pcos . however , research in this area is scarce . the purpose of this study was to evaluate the relationship between dairy products consumption and pcos.methods:this descriptive cross - sectional study of 400 women was conducted in shahid beheshti hospital of isfahan university of medical science , iran . dietary intake was evaluated by validated food frequency questionnaire . other variables such as ovarian disease , inherited predisposition , age at menarche , physical activity and history of other diseases were evaluated using questionnaire . data analysis was performed by a logistic regression test using spss software version 15 predictive analytics software and solutions.results:there were a significant association between pcos and ovarian disease ( p < 0.001 ) , age ( p < 0.001 ) and using medication ( p = 0.001 ) . body mass index ( bmi ) was inversely associated with pcos , but it was not significant ( p = 0.068 ) . there was a significant direct relationship between milk consumption and risk of pcos after adjusting for confounding factors ( p = 0.028).conclusions : the findings of this study indicated that ovarian disease and medication use is directly linked to pcos . dairy consumption was not significantly correlated with pcos . however , after adjustment for confounders , there was an direct relationship between milk consumption and risk of pcos .

milrinone phosphodiesterase iii inhibitor currently used treat pediatric patients cardiac diseases increases level cyclic adenosine monophosphate myocardium vascular smooth muscle high levels cyclic adenosine monophosphate enhance contractility myocardium increasing calcium influx relaxing vascular smooth muscles,1 therefore increasing cardiac output decreasing afterload milrinone also lusitropic property improves myocardial relaxation.2 unlike inotropes dopamine dobutamine epinephrine milrinone associated increase myocardial oxygen consumption.3 milrinone widely used due inotropic vasodilatory lusitropic properties it frequently prescribed cardiac surgery due efficacy preventing low cardiac output syndrome.4 milrinone also commonly administered pediatric patients myocarditis bridge therapy patients heart failure waiting cardiac transplantation.5)6 milrinone shown improve heart contractility patients septic shock.7 milrinone currently one commonly used label cardiovascular medications children.8 although reports showed efficacy safety short term milrinone treatment 35 hours children heart disease,9)10 safety efficacy long term use milrinone children limited due lack sufficient evidence based studies pediatric populations currently milrinone widely used 3 days usually based extrapolation studies adults clinical experience therefore objective study evaluate safety efficacy current pattern milrinone administration 3 days pediatric patients a retrospective analysis conducted using data collected patients received milrinone treatment 3 days seoul national university children hospital january 2005 december 2012 patients divided two groups based indication milrinone treatment group consisted patients received milrinone prevent low cardiac output syndrome cardiac surgeries whereas group b consisted patients received milrinone treatment due acute heart failures causes cardiac surgeries patients following conditions underwent following treatments excluded study 1 severe left ventricular outflow obstructive diseases aortic stenosis 2 hypertrophic restrictive cardiomyopathies 3 milrinone administration immediately cardiopulmonary resuscitation 4 multi organ failures 5 simultaneous administration 3 inotropes milrinone increase blood pressure 6 renal replacement therapies including peritoneal dialysis 7 myocardial infarctions 8) univentricular heart surgeries however patients receiving 3 inotropes included inotropes added interval 2 hours consecutively patients characteristics including age sex height weight body surface area recorded the following parameters analyzed identify clinical application milrinone 1 initial infusion rate 2 maintenance continuous infusion rate 3 total duration milrinone therapy 4 concomitantly infused inotropes the operation anesthesiology records patients undergone cardiac surgeries also studied identify data related anatomic diagnosis type surgery time cardiopulmonary bypass time aortic cross clamping systolic blood pressure heart rate echocardiographic data left ventricular internal dimension end diastole ejection fraction fractional shortening obtained immediately starting milrinone treatment compared values prior treatment cessation cases where appropriate echocardiographic data could obtained day milrinone treatment discontinued echocardiographic data obtained within week treatment endpoint used the safety milrinone determined based occurrence adverse events hypotension arrhythmia chest pain headache hypokalemia thrombocytopenia hypotension defined sudden decrease blood pressure within two hours starting milrinone necessitated addition inotropes cessation milrinone arrhythmia classified supraventricular tachycardia ectopic atrial tachycardia atrial fibrillation flutter accelerated junctional rhythm junctional ectopic tachycardia ventricular tachycardia ventricular fibrillation evidence chest pains headache milrinone use collected patient chart potassium levels platelet counts 24 48 hours starting milrinone infusion estimated changes hemodynamic parameters echocardiographic data analyzed using pairwise comparison test wilcoxon signed rank test the frequency hypokalemia thrombocytopenia milrinone infusion analyzed using mcnemar test univariate multivariate logistic regression analysis used evaluate relationships diverse variables including practical use milrinone development arrhythmia statistical analyses descriptive data presented means standard deviation whereas categorical variables presented proportions data manipulation statistical analyses performed statistical package social sciences spss 19.0 windows spss inc somers ny usa excel 2010 microsoft the study protocol approved institutional review board seoul national university hospital patient consent waived due study retrospective design a retrospective analysis conducted using data collected patients received milrinone treatment 3 days seoul national university children hospital january 2005 december 2012 patients divided two groups based indication milrinone treatment group consisted patients received milrinone prevent low cardiac output syndrome cardiac surgeries whereas group b consisted patients received milrinone treatment due acute heart failures causes cardiac surgeries patients following conditions underwent following treatments excluded study 1 severe left ventricular outflow obstructive diseases aortic stenosis 2 hypertrophic restrictive cardiomyopathies 3 milrinone administration immediately cardiopulmonary resuscitation 4 multi organ failures 5 simultaneous administration 3 inotropes milrinone increase blood pressure 6 renal replacement therapies including peritoneal dialysis 7 myocardial infarctions 8) univentricular heart surgeries however patients receiving 3 inotropes included inotropes added interval 2 hours consecutively patients characteristics including age sex height weight body surface area recorded the following parameters analyzed identify clinical application milrinone 1 initial infusion rate 2 maintenance continuous infusion rate 3 total duration milrinone therapy 4 concomitantly infused inotropes the operation anesthesiology records patients undergone cardiac surgeries also studied identify data related anatomic diagnosis type surgery time cardiopulmonary bypass time aortic cross clamping systolic blood pressure heart rate echocardiographic data left ventricular internal dimension end diastole ejection fraction fractional shortening obtained immediately starting milrinone treatment compared values prior treatment cessation cases where appropriate echocardiographic data could obtained day milrinone treatment discontinued echocardiographic data obtained within week treatment endpoint used the safety milrinone determined based occurrence adverse events hypotension arrhythmia chest pain headache hypokalemia thrombocytopenia hypotension defined sudden decrease blood pressure within two hours starting milrinone necessitated addition inotropes cessation milrinone arrhythmia classified supraventricular tachycardia ectopic atrial tachycardia atrial fibrillation flutter accelerated junctional rhythm junctional ectopic tachycardia ventricular tachycardia ventricular fibrillation evidence chest pains headache milrinone use collected patient chart potassium levels platelet counts 24 48 hours starting milrinone infusion estimated changes hemodynamic parameters echocardiographic data analyzed using pairwise comparison test wilcoxon signed rank test the frequency hypokalemia thrombocytopenia milrinone infusion analyzed using mcnemar test univariate multivariate logistic regression analysis used evaluate relationships diverse variables including practical use milrinone development arrhythmia statistical analyses descriptive data presented means standard deviation whereas categorical variables presented proportions data manipulation statistical analyses performed statistical package social sciences spss 19.0 windows spss inc the study protocol approved institutional review board seoul national university hospital patient consent waived due study retrospective design in total 2299 eligible admissions identified study period admissions a total 730 admissions 684 patients met inclusion criteria selected present study twenty seven patients received milrinone twice one patient received milrinone thrice serial cardiac surgeries most patients 715 97.9% received milrinone prevent low cardiac output cardiac surgeries there 715 admissions group 15 admissions group b. male female ratio 5.6:1 the mean age patients time milrinone infusion 0.82 years table 1 total 429 admissions 60% group underwent cardiac surgeries less 3 months age the common cardiac defect ventricular septal defect group 42.4% followed tetralogy fallot 11% coarctation aorta ventricular septal defect 6.4% table 2 accordingly common type surgery closure ventricular septal defect followed repair tetralogy fallot coarctoplasty group b the duration milrinone treatment ranged 3 64.4 days 149 20.4% ) two inotropes milrinone used 425 59.4% admissions the commonly infused inotrope group dopamine 83.4% whereas patients group b received dobutamine table 3 systolic blood pressure fractional shortening ejection fraction milrinone treatment significantly p<0.05 increased group compared values obtained immediately cardiac surgeries however significant difference systolic blood pressure fractional shortening ejection fraction milrinone treatment group b. groups heart rate significantly p<0.05 reduced milrinone use table 4 there reports adverse events majority admissions 78.7% table 5 although diverse arrhythmias occurred 75 10.3% admissions 3 0.4% required reduction discontinuation milrinone infusion alleviate arrhythmia two developed junctional ectopic tachycardia one developed ectopic atrial tachycardia one third patients group b well approximately 10% patients group developed arrhythmia total 41 58.6% 70 arrhythmias group classified junctional ectopic tachycardia the development arrhythmia influenced initial infusion rate maintenance continuous infusion rate duration milrinone treatment based univariate logistic regression analysis group data following parameters associated development arrhythmia male gender age 3 months cardiopulmonary bypass time 180 minutes multivariate analysis group data dicated male gender cardiopulmonary bypass time 180 minutes influenced development arrhythmia however incidence rate increase significantly p=0.390 108/730 14.4% initial point 118/730 16.2% 24 48 hours starting milrinone treatment thrombocytopenia increase slightly significantly p=0.039 occurred 4/729 0.5% initial point 12/729 1.6% 24 48 hours starting milrinone treatment most patients group thrombocytopenia required platelet transfusions cardiac surgeries platelet count increased maintained 50000/dl spontaneously 2 admissions 1 platelet transfusion 6 admissions 2 platelet transfusion 2 admissions cardiopulmonary bypass time 249.272.8 minutes vs. 153.170.4 minutes ; p=0.004 significantly longer group patients thrombocytopenia patients without thrombocytopenia the initial infusion rate maintenance continuous infusion rate duration milrinone treatment associated thrombocytopenia two patients group b low platelet count due additional medical illnesses hemophagocytic lymphohistiocytosis fungal infection in total 2299 eligible admissions identified study period admissions a total 730 admissions 684 patients met inclusion criteria selected present study twenty seven patients received milrinone twice one patient received milrinone thrice serial cardiac surgeries most patients 715 97.9% received milrinone prevent low cardiac output cardiac surgeries there 715 admissions group 15 admissions group b. male female ratio 5.6:1 the mean age patients time milrinone infusion 0.82 years table 1 total 429 admissions 60% group underwent cardiac surgeries less 3 months age the common cardiac defect ventricular septal defect group 42.4% followed tetralogy fallot 11% coarctation aorta ventricular septal defect 6.4% table 2 accordingly common type surgery closure ventricular septal defect followed repair tetralogy fallot coarctoplasty group b the duration milrinone treatment ranged 3 64.4 days 149 20.4% ) two inotropes milrinone used 425 59.4% admissions the commonly infused inotrope group dopamine 83.4% whereas patients group b received dobutamine table 3 systolic blood pressure fractional shortening ejection fraction milrinone treatment significantly p<0.05 increased group compared values obtained immediately cardiac surgeries however significant difference systolic blood pressure fractional shortening ejection fraction milrinone treatment group b. groups heart rate significantly p<0.05 reduced milrinone use table 4 there reports adverse events majority admissions 78.7% table 5 although diverse arrhythmias occurred 75 10.3% admissions 3 0.4% required reduction discontinuation milrinone infusion alleviate arrhythmia two developed junctional ectopic tachycardia one developed ectopic atrial tachycardia one third patients group b well approximately 10% patients group developed arrhythmia total 41 58.6% 70 arrhythmias group a classified junctional ectopic tachycardia whereas common arrhythmia identified group b ventricular tachycardia the development arrhythmia influenced initial infusion rate maintenance continuous infusion rate duration milrinone treatment based univariate logistic regression analysis group data following parameters associated development arrhythmia male gender age 3 months cardiopulmonary bypass time 180 minutes multivariate analysis group data dicated male gender cardiopulmonary bypass time 180 minutes influenced development arrhythmia however incidence rate increase significantly p=0.390 108/730 14.4% initial point 118/730 16.2% 24 48 hours starting milrinone treatment thrombocytopenia increase slightly significantly p=0.039 occurred 4/729 0.5% initial point 12/729 1.6% 24 48 hours starting milrinone treatment most patients group thrombocytopenia required platelet transfusions cardiac surgeries platelet count increased maintained 50000/dl spontaneously 2 admissions 1 platelet transfusion 6 admissions 2 platelet transfusion 2 admissions cardiopulmonary bypass time 249.272.8 minutes vs. 153.170.4 minutes ; p=0.004 significantly longer group patients thrombocytopenia patients without thrombocytopenia the initial infusion rate maintenance continuous infusion rate duration milrinone treatment associated thrombocytopenia two patients group b low platelet count due additional medical illnesses hemophagocytic lymphohistiocytosis fungal infection in present study reviewed current patterns milrinone use continued 3 days of total 2299 eligible admissions milrinone used 730 31.8% admissions involved use milrinone 3 days although korean national insurance covers 35 hours milrinone use found milrinone frequently prescribed longer duration actual settings suggesting significant label use the frequent use milrinone pediatric patients undergoing heart surgery supported findings prophylactic intravenous use milrinone cardiac operation pediatrics primacorp trial demonstrated low cardiac output syndromes could prevented high dose milrinone infusion pediatric cardiac surgeries.10 although initial maintenance milrinone infusion rates determined present study lower previously reported primacorp study values similar reported european practices.4)10 terms efficacy issue fractional shortening ejection fraction improved milrinone infusion group patients consistent previous findings.9)11 chang et al.9 reported milrinone treatment neonates low cardiac output congenital heart surgery improved cardiac index without changing myocardial oxygen consumption duggal et al.11 documented milrinone therapy improved left right myocardial performance index reliable index reflects myocardial contractility our findings revealed significant changes fractional shortening ejection fraction milrinone infusion group b contrary previously reported data adults.12 severity disease group b likely influence results seven 46.7% 15 admissions group b involved patients died due underlying cardiac disease reflecting severity disease group b. terms safety several adult studies shown detrimental effects milrinone hemodynamic stability chronic heart failures prospective randomized milrinone survival evaluation13 ) trial revealed oral administration milrinone patients heart failure increased mortality induced serious adverse cardiovascular events including hypotension the outcomes prospective trial intravenous milrinone exacerbations chronic heart failure trial reported sustained hypotension requiring additional treatment common patients received milrinone infusion exacerbation chronic heart failure.14 however present study 1 6.7% 15 admissions group b needed reduction milrinone dose due decrease blood pressure incidence hypotension lower reported previously adult data furthermore 3 0.4% 715 admissions group experienced hypotension required reduction milrinone infusion rate this result consistent previous pediatric data reported infrequent occurrence hypotension milrinone treatment group cardiac surgery.10 milrinone use known associated postoperative arrhythmia adults increased mortality morbidity cardiac surgery.15 arrhythmia concern following milrinone use pediatric population well smith et al.16 recently reported approximately half pediatric patients receiving milrinone cardiac surgery experienced arrhythmia present study various arrhythmias occurred 70 9.8% 715 admissions group a. however 3 0.4% admissions required modification milrinone infusion manage arrhythmias our finding consistent studies,17)18 indicating incidence arrhythmia due milrinone use pediatric patients relatively low cardiac surgery postoperative arrhythmia associated age cardiopulmonary time aortic cross clamping time type repair.19)20 present study initial infusion rate maintenance infusion rate duration milrinone treatment associated development arrhythmia however consistent previous findings longer cardiopulmonary time affected development arrhythmia group table 6 junctional ectopic tachycardia common type arrhythmia cardiac surgery.20 present study incidence rate junctional ectopic tachycardia group 5.7% this result accordance previous studies reported incidence rate junctional ectopic tachycardia cardiac surgery range 1.4% 14.7%.21)22 relationship junctional ectopic tachycardia milrinone use elucidated thus far.23 study adults showed atrial arrhythmia developed frequently patients chronic heart failure received milrinone treatment.14 however independent cause effect relationship milrinone arrhythmia pediatric patients heart failure yet established five 33.3% 15 admissions group b involved patients mainly developed ventricular arrhythmia present study significant difference initial infusion rate maintenance infusion rate duration milrinone treatment patients without arrhythmia group b. fact heart failure due myocarditis dilated cardiomyopathy increased vulnerability patients tachyarrhythmia conduction disturbance.24 ichikawa et al.25 reported 3 7 patients fulminant myocarditis developed ventricular tachycardia ventricular fibrillation friedman et al.26 also documented high incidence rate arrhythmia pediatric idiopathic dilated cardiomyopathy the incidence rate thrombocytopenia present study lower previous studies ten 1.4% 715 admissions group involved patients developed thrombocytopenia milrinone treatment required platelet transfusions ramamoorthy et al.17 previously reported milrinone treatment resulted high incidence 58% thrombocytopenia platelet count 100000/dl often necessitate platelet transfusions bishara et al.18 documented 12.7% admissions developed thrombocytopenia milrinone treatment however difficult identify milrinone induced thrombocytopenia various factors could confound observations including cardiac surgery cardiopulmonary bypass known associated thrombocytopenia results hemodilution mechanical disruption.27 present study patients developed thrombocytopenia longer cardiopulmonary bypass time aorta clamping time thus patients complex heart disease longer bypass times cardiac surgery would likely develop thrombocytopenia in contrast amrinone first phosphodiesterase inhibitor used known adverse effect platelets milrinone alter platelet count function patients cardiac surgery.28 fact two 13.3% patients group b developed thrombocytopenia could due complications hemophagocytic lymphohistiocytosis fungal sepsis rather due milrinone use the utility chronic continuous milrinone infusion heart failure bridge therapy heart transplantation proposed recent adult study.6 mcmahon et al.29 demonstrated long term support milrinone safe effective infants cardiomyopathy awaiting heart transplantation outpatient continuous parenteral inotropic therapy including milrinone also used inotropic dependent children advanced heart failure.30 although studies used small patient populations incidence complications sufficiently low indicate safe effective potential milrinone use infants children heart diseases this study retrospective design control group containing patients receive milrinone moreover arrhythmias could included due study retrospective nature furthermore exclusion criteria study relatively strict appropriately clarify efficacy safety milrinone use reduce confounding factors patients would susceptible milrinone use could included surgically treated patients congenital heart disease also considered natural improvement cardiac function corrective operation could confounding factor evaluating efficacy milrinone use study finally echocardiographic data including ejection fraction fractional shortening used evaluate milrinone efficacy due retrospective study design if echocardiographic data tissue doppler imaging findings available accurate evaluation hemodynamic effects milrinone would possible this largest retrospective study date evaluate safety efficacy long term milrinone use 3 days pediatric patients cardiac diseases such long term milrinone use common actual clinical practice milrinone generally used 35 hours infants children heart disease our data revealed use milrinone 3 days effective preventing low cardiac output cardiac surgery combined inotropes this study retrospective design control group containing patients receive milrinone moreover arrhythmias could included due study retrospective nature furthermore exclusion criteria study relatively strict appropriately clarify efficacy safety milrinone use reduce confounding factors patients would susceptible milrinone use could included surgically treated patients congenital heart disease also considered natural improvement cardiac function corrective operation could confounding factor evaluating efficacy milrinone use study finally echocardiographic data including ejection fraction fractional shortening used evaluate milrinone efficacy due retrospective study design if echocardiographic data tissue doppler imaging findings available accurate evaluation hemodynamic effects milrinone would possible this largest retrospective study date evaluate safety efficacy long term milrinone use 3 days pediatric patients cardiac diseases such long term milrinone use common actual clinical practice milrinone generally used 35 hours infants children heart disease our data revealed use milrinone 3 days effective preventing low cardiac output cardiac surgery combined inotropes

background and objectivesmilrinone is often used in children to treat acute heart failure and prevent low cardiac output syndrome after cardiac surgery . due to the lack of studies on the long - term milrinone use in children , the objective of this study was to assess the safety and efficacy of the current patterns of milrinone use for 3 days in infants and children with heart diseases.subjects and methodswe retrospectively reviewed the medical records of patients aged < 13 years who received milrinone for 3 days from january 2005 to december 2012 . patients ' characteristics including age , sex , height , weight , and body surface area were recorded . the following parameters were analyzed to identify the clinical application of milrinone : initial infusion rate , maintenance continuous infusion rate , total duration of milrinone therapy , and concomitantly infused inotropes . the safety of milrinone was determined based on the occurrence of adverse events such as hypotension , arrhythmia , chest pain , headache , hypokalemia , and thrombocytopenia.resultswe assessed 730 admissions ( 684 patients ) during this period . ventricular septal defects were the most common diagnosis ( 42.4% ) in these patients . milrinone was primarily used after cardiac surgery in 715 admissions ( 97.9% ) . the duration of milrinone treatment varied from 3 to 64.4 days ( 7 days in 149 admissions ) . ejection fraction and fractional shortening of the left ventricle improved in patients receiving milrinone after cardiac surgery . dose reduction of milrinone due to hypotension occurred in only 4 admissions ( 0.5% ) . although diverse arrhythmias occurred in 75 admissions ( 10.3% ) , modification of milrinone infusion to manage arrhythmia occurred in only 3 admissions ( 0.4% ) . multivariate analysis indicated that the development of arrhythmia was not influenced by the pattern of milrinone use.conclusionmilrinone was generally administered for 3 days in children with heart diseases . the use of milrinone for 3 days was effective in preventing low cardiac output after cardiac surgery when combined with other inotropes , suggesting that milrinone could be safely employed in pediatric patients with heart diseases .