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total 8,333 type 1 diabetes cases 9,947 controls 3,997 families genotyped rs10272724 using taqman supplementary methods cases diagnosed type 1 diabetes 17 years age mean age diagnosis 7.8 years juvenile diabetes research foundation wellcome trust diabetes inflammation laboratory genetic resource investigating diabetes study http://www.childhood-diabetes.org.uk/grid.shtml controls obtained british 1958 birth cohort n 6,899 http://www.cls.ioe.ac.uk/studies.asp?section=000100020003 wtccc uk blood service ukbs sample collection n 3,048 10,12 stata version 10 statacorp lp college station tx used perform association analyses http://www.stata.com rs10272724 hardy weinberg equilibrium unaffected parents control subjects p 0.05 case control data modeled using logistic regression disease status outcome variable counts minor allele coded 0 1 2 independent variable assuming multiplicative allelic effects model families analyzed using transmission disequilibrium test 13 supplementary methods the interdependency rs10272724 rs4948088 7p12 region examined stepwise logistic regression peripheral blood mononuclear cells pbmcs purified heparinized blood diluted 1:1 pbs without ca mg gibco invitrogen carlsbad ca 15 ml aliquots layered onto 10 ml aliquots lympholyte cedarlane laboratories ltd burlington ontario followed centrifugation 800 g 20 min room temperature the harvested pbmc layer washed twice ice cold pbs centrifuged 300 g 10 min 4c pellets resuspended trizol invitrogen stored 80c aliquots 10 10 cells ml total rna 1 10 pbmcs trizol prepared using chloroform extraction followed purification rneasy mini kit qiagen hilden germany according manufacturer instructions rna quality assessed using agilent 2100 bioanalyser concentration evaluated nanodrop thermo scientific waltham first strand dna synthesis carried 1 g rna using superscript iii rt kit oligo dt invitrogen quantitative q)pcr primers probe designed two transcripts ikzf1 herein referred qpcr assays contained 5 l 1:10 dilution oligo dt primed cdna prepared described 20 l assays cycle threshold ct values measured using 7900ht abi prism applied biosystems carlsbad ca analyzed using sds v2.1 software abi qpcr reactions run triplicate ct transcript level qpcrs calculated using ikzf1 isoform 1 isoform 2 qpcr ct value minus single copy gene 2 microglobulin qpcr ct value expression values compared via one way anova using prism software graphpad software inc la jolla ca correlation rs10272724 expression three types cell lines primary fibroblasts epstein barr virus immortalized lymphoblastoid cell lines phytohemagglutinin stimulated primary cells derived umbilical cord samples 75 newborns western european origin via gencord project examined silico 14 using publicly available hapmap online gene expression variation genevar resource http://www.sanger.ac.uk/resources/software/genevar/ nine probes passed quality control assessment supplementary table 1 evaluated correlation mrna expression rs10272724 genotype linear regression using genevar 2.0.1 java tool 15 supplementary methods a p 0.0056 significance threshold used within cell type based bonferroni correction testing nine transcripts blood qpcr experiments collected 88 nondiabetic donors rs10272724 44 tt 33 ct 11 cc selected pregenotyped bioresource processed within 4 hours www.cambroidgebioresource.org.uk all dna samples collected ethical approval national health service cambridgeshire research ethics committee written consent obtained individuals a total 8,333 type 1 diabetes cases 9,947 controls 3,997 families genotyped rs10272724 using taqman supplementary methods cases diagnosed type 1 diabetes 17 years age mean age diagnosis 7.8 years juvenile diabetes research foundation wellcome trust diabetes inflammation laboratory genetic resource investigating diabetes study http://www.childhood-diabetes.org.uk/grid.shtml controls obtained british 1958 birth cohort n 6,899 http://www.cls.ioe.ac.uk/studies.asp?section=000100020003 wtccc uk blood service ukbs sample collection n 3,048 10,12 stata version 10 statacorp lp college station tx used perform association analyses http://www.stata.com rs10272724 hardy weinberg equilibrium unaffected parents control subjects p 0.05 case control data modeled using logistic regression disease status outcome variable counts minor allele coded 0 1 2 independent variable assuming multiplicative allelic effects model families analyzed using transmission disequilibrium test 13 supplementary methods the interdependency rs10272724 rs4948088 7p12 region examined stepwise logistic regression peripheral blood mononuclear cells pbmcs purified heparinized blood diluted 1:1 pbs without ca mg gibco invitrogen carlsbad ca 15 ml aliquots layered onto 10 ml aliquots lympholyte cedarlane laboratories ltd burlington ontario followed centrifugation 800 g 20 min room temperature the harvested pbmc layer washed twice ice cold pbs centrifuged 300 g 10 min 4c pellets resuspended trizol invitrogen stored 80c aliquots 10 10 cells ml total rna 1 10 pbmcs trizol prepared using chloroform extraction followed purification rneasy mini kit qiagen hilden germany according manufacturer instructions rna quality assessed using agilent 2100 bioanalyser concentration evaluated nanodrop thermo scientific waltham first strand dna synthesis carried 1 g rna using superscript iii rt kit oligo dt invitrogen quantitative q)pcr primers probe designed two transcripts ikzf1 herein referred qpcr assays contained 5 l 1:10 dilution oligo dt primed cdna prepared described 20 l assays cycle threshold ct values measured using 7900ht abi prism applied biosystems carlsbad ca analyzed using sds v2.1 software abi qpcr reactions run triplicate ct transcript level qpcrs calculated using ikzf1 isoform 1 isoform 2 qpcr ct value minus single copy gene 2 microglobulin qpcr ct value expression values compared via one way anova using prism software graphpad software inc la jolla ca correlation rs10272724 expression three types cell lines primary fibroblasts epstein barr virus immortalized lymphoblastoid cell lines phytohemagglutinin stimulated primary cells derived umbilical cord samples 75 newborns western european origin via gencord project examined silico 14 using publicly available hapmap online gene expression variation genevar resource http://www.sanger.ac.uk/resources/software/genevar/ nine probes passed quality control assessment supplementary table 1 evaluated correlation mrna expression rs10272724 genotype linear regression using genevar 2.0.1 java tool 15 supplementary methods a p 0.0056 significance threshold used within cell type based bonferroni correction testing nine transcripts blood qpcr experiments collected 88 nondiabetic donors rs10272724 44 tt 33 ct 11 cc selected pregenotyped bioresource processed within 4 hours www.cambroidgebioresource.org.uk all dna samples collected ethical approval national health service cambridgeshire research ethics committee written consent obtained individuals the minor allele rs10272724 c near ikzf1 protective type 1 diabetes odds ratio 0.87 95% ci 0.830.91 p 4.8 10 table 1 supplementary table 2 no evidence association rs10272724 sex age diagnosis obtained p 0.1 samples overlapped used previous gwa study type 1 diabetes 10 however sample sets used barrett et al ( 10 unique samples effect direction overall significance increased suggesting effect solely attributable original samples table 1 the minor allele rs10272724 also protective families type 1 diabetes i.e. transmitted affected offspring table 1 relative risk 0.87 95% ci 0.810.93 p 7.6 10 combined results indicate minor allele c rs10272724 7p12.2 convincingly associated reduced risk type 1 diabetes p 1.1 10 ( 10 reported replicated association rs4948088 c type 1 diabetes 7p12.1 region 554 kb downstream ikzf1 however snp marking confirmed type 1 diabetes locus http://www.t1dbase.org/page/regions ld rs10272724 ikzf1 0.02 r 0.0001 found regression analysis two effects independent snps improve model snp included p 5.5 10 association rs10272724 c near ikzf1 8,333 type 1 diabetes cases 9,947 control subjects 3,997 families type 1 diabetes maf minor allele frequency rr relative risk * evidence deviation multiplicative allelic effects model obtained p 0.33 p values assuming multiplicative allelic effects reported the overall p value obtained combining p value case control sets family transmission disequilibrium test using fisher method combined probability ( 10 analyzed three datasets gwa study two overlap samples current study used illumina 550 k snp chip genotype rs10272724 set 1 4 genotypes 99.6% concordant illumina platform taqman 3,850 cases 3,772 controls genotyped using technologies affymetrix 500 k mapping array genotypes neighboring snps used impute rs10272724 genotypes set 2 barrett et al rs10272724 genotyped affymetrix t1dgc type 1 diabetes genetics consortium wtccc wellcome trust case control consortium the relative abundance two different sets ikzf1 transcripts mrna extracted pbmcs isolated 88 nondiabetic individuals assessed using qpcr determine association rs10272724 alleles gene expression no evidence allele specific expression obtained p 0.1 fig the probe originally used illumina ilmn_1676575 contains two high frequency snps target rs62447207 g rs62447208 c g ld rs10272724 r 0.76 rendering unreliable evidenced absent ikzf1 probe latest genevar data study dimas et al next correlation rs10272724 genotype expression nine transcripts genes within 1 mb rs10272724 three types cell lines tested using latest genevar dataset dimas et al no correlation observed rs10272724 expression five neighboring genes supplementary fig 1 association ikzf1 expression rs10272724 c genotype 88 unaffected individuals ct calculated using ikzf1 isoform 1 isoform 2 qpcr ct value minus single copy gene 2 microglobulin b2 qpcr ct value we provide evidence minor allele rs10272724 c near perfect ld minor c susceptible allele rs4132601 g protective type 1 diabetes of nearby genes region ikzf1 appeared likely candidate causal gene type 1 diabetes region given causal role c known role lymphocyte development however analysis revealed previously reported correlation ikzf1 mrna expression rs4132601 may inaccurate given complications probe used data accessed papaemmanuil et al furthermore ikzf1 genotype phenotype correlation rs10272724 confirmed qpcr analysis pbmcs ikzf1 attractive candidate causal gene type 1 diabetes functional link rs10272724 ikzf1 may yet elucidated examining specific isoforms ikaros we note qpcr assay evaluated expression two transcripts conserved across 10 splice variants ikzf1 spanning six seven identified active dominant negative isoforms protein in addition many allele specific effects gene expression known tissue cell type specific may even restricted particular phases development another related gene af4/fmr2 family member 3 aff3 associated type 1 diabetes 10 j. cooper c.w j.a.t unpublished observations report also confirms second genetic link diseases aff3 implicated susceptibility allele rheumatoid arthritis rs10865035 rs9653422 16 highlighting connection autoimmunity lymphoid cancers our finding ikzf1 marks third ikaros family member associated type 1 diabetes others transcription factors ailios ikzf3 chromosome 17q21.2 eos ikzf4 chromosome 12q13.2 10,17 whose targets include bcl-2 foxp3 respectively ikaros family members interact coordinate functions immunologic development homeostasis 18 important explore effect interactions disease etiology the 30 reported interaction partners ikaros family members http://www.t1dbase.org suggest role ikzf1 type 1 diabetes could subtle yet far reaching interactions histone deacetylase chromodomain helicase dna binding families proteins suggest chromosome remodeling events could involved 11,19 ikaros interactions notch 18 stat 20 protein families also suggest signaling events affect cell activation maturation could affect ultimate development diabetogenic leukemia protected nondiabetogenic leukemia susceptible cell repertoire thus investigation warranted elucidate phenotypic effect genetic feature marked rs10272724 impact ikzf1 role ikaros autoimmunity	objectiveikzf1 encoding ikaros , an essential regulator of lymphopoiesis and immune homeostasis , has been implicated in the development of childhood acute lymphoblastic leukemia ( c - all ) . because recent genome - wide association ( gwa ) studies have linked a region of the 3-utr of ikzf1 with c - all susceptibility , we tested whether ikzf1 is associated with the autoimmune disease type 1 diabetes.research design and methodsrs10272724 ( t > c ) near ikzf1 at 7p12 was genotyped in 8,333 individuals with type 1 diabetes , 9,947 control subjects , and 3,997 families of european ancestry . association was tested using logistic regression in the case - control data and by the transmission disequilibrium test in the families . expression data for ikzf1 by rs10272724 genotype were obtained using quantitative pcr of mrna / cdna generated from peripheral blood mononuclear cells from 88 individuals , whereas expression data for five other neighboring genes were obtained from the online genevar dataset.resultsthe minor allele of rs10272724 ( c ) was found to be protective from type 1 diabetes ( odds ratio 0.87 [ 95% ci 0.830.91 ] ; p = 1.1 1011 ) . rs10272724 was not correlated with levels of two transcripts of ikzf1 in peripheral blood mononuclear cells.conclusionsthe major susceptibility genotype for c - all confers protection from type 1 diabetes . our finding strengthens the link between autoimmunity and lymphoid cancers . further investigation is warranted for the genetic effect marked by rs10272724 , its impact on ikzf1 , and the role of ikaros and other family members , ailios ( ikzf3 ) and eos ( ikzf4 ) , in autoimmunity .
homocysteine amino acid sprung prominence past decades elevated homocysteine also served early marker insulin resistance due effects insulin homocysteine metabolism renal clearance these relationships homocysteine disease states nonpregnant adult population extrapolated link pregnancy specific conditions gestational diabetes mellitus hypertensive disorders pregnancy homocysteine levels decline pregnancy levels lowest second trimester pregnancy increase second half third trimester pregnancy hence samples taken within strict time frame 4 weeks 8 12 weeks gestation would better success correlating homocysteine levels pregnancy outcome minimising gestational age bound variation homocysteine in addition maternal complications hypertensive disorders pregnancy gestational diabetes mellitus develop much later timing sample collection 12 weeks would sufficiently predate onset complications serum homocysteine levels pregnancy linked preeclampsia 46 recurrent abortions 79 low birth weight evidence conflicting studies stating serum homocysteine values correlation maternal fetal outcome hence need study shed light conflicting opinions regarding effect homocysteine levels maternal fetal outcomes to correlate levels homocysteine late first trimester pregnancy 812 weeks maternal fetal outcome pregnancy especially regard development hypertensive disorders pregnancy gestational diabetes mellitus estimate homocysteine levels late 1st trimester 812 weeks correlate prior history first second third trimester pregnancy losses ii hypertensive disorders pregnancy gestational diabetes mellitus iii fetal malformations iv preterm delivery birth weight correlate homocysteine levels present pregnancy parameters namely hypertensive disorder pregnancy ii gestational diabetes mellitus iii pregnancy loss iv amniotic fluid volume meconium staining amniotic fluid v birth weight it prospective observational cohort study comprising antenatal women attended antenatal outpatient department tertiary care university level health centre the study started obtaining institutional ethics committee approval conducted august 2009 july 2011 110 women invited participate study 100 agreed participate study ten women refused participate study distant places institute hence could come early morning fasting state homocysteine test subjects enrolled 8 12 weeks gestation known diabetics hypertensives treatment excluded enrollment a questionnaire collected regarding age period gestation parity abortions respective period gestation whether induced spontaneous history previous fetal malformations history hypertensive disorders pregnancy gestational diabetes mellitus previous pregnancies birth weight previous children whether previous deliveries term preterm births venous blood samples taken overnight fasting serum homocysteine estimation serum separated centrifugation sera assayed homocysteine chemiluminescence assay technique using well calibrated fully automated chemiluminescence assay system advia centaur cptm immunoassay system siemens germany automated random access direct chemiluminescent immunoassay analyzer routine examination included blood pressure recordings pedal edema urine albumin sugar symphysio fundal height clinically amniotic fluid level status glucose challenge test done 32 weeks pregnancy abnormal 100 gram oral glucose tolerance test ogtt done diagnose gestational diabetes mellitus antenatal ultrasound done clinical suspicion iugr e.g. symphysio fundal height less 4 cm corresponding period gestation case malpresentations hypertensive disorders pregnancy risk factors iugr induction labour doppler ultrasound umbilical middle cerebral artery done case iugr preeclampsia assess risk fetal morbidity cases statistical analysis done using graphpad instat software using unpaired test comparison two parametrically distributed groups data unpaired test welch correction used comparison two parametrically distributed groups data unequal variances mann whitney u test used comparison two nonparametrically distributed groups data one way anova used two parametrically distributed groups data kruskal wallis test used comparison two parametrically distributed groups data p value 0.05 taken significant 0.001 taken highly significant of 100 antenatal women recruited 10 lost follow thus leaving 90 subjects whose outcomes analysed the ages subjects range 21 33 years mean age 24.76 2.6 years the bmi subjects ranged 15.5 kg 33.2 kg mean 21.70 6.23 there correlation homocysteine levels age bmi period gestation number folic acid tablets taken subjects of recruited 100 women 14 women past history hypertensive disorders pregnancy 5 women previous gestational diabetes mellitus 6 previous preterm delivery 2 previous fetal malformation there significantly elevated homocysteine levels p 0.0359 among women prior history hypertensive disorders pregnancy however difference homocysteine levels without past history gestational diabetes mellitus statistically different p 0.054 there statistically significant difference homocysteine levels history prior preterm deliveries p 0.8348 history previous fetal malformation p 0.078 table 1 of 100 antenatal women 27 women previous one 9 women previous two first trimester pregnancy losses 9 women previous one 3 previous two second trimester pregnancy losses 9 women previous one third trimester pregnancy loss there statistically significant elevation homocysteine levels history prior first trimester pregnancy losses p 0.1687 there statistically significant elevation homocysteine levels women history prior second trimester pregnancy losses p 0.0307 there highly significant elevation homocysteine levels women history prior third trimester pregnancy losses p 0.0001 comparing women history prior pregnancy losses trimester pregnancy losses trimester there highly significant elevation homocysteine levels latter group table 2 there significant correlation prior birth weights serum homocysteine levels table 2 the present pregnancy outcome 90 women completed follow 10 women lost follow analysed of 90 women 18 developed hypertensive disorders pregnancy hdp 7 developed gestational diabetes mellitus gdm 2 patients fetus congenital malformation 8 patients pregnancy loss including 2 stillbirths of 84 antenatal women whose delivery outcomes analysed 18 women oligohydramnios 17 women meconium stained amniotic fluid 11 women delivered low birth weight babies birth weight 2500 gm the homocysteine levels statistically elevated went develop hdp develop hdp p 0.0011 there significant difference p 0.6312 homocysteine levels developed develop gdm the power study detect difference gdm 0.42 table 3 there significant elevation homocysteine levels p 0.0002 among suffered pregnancy loss compared live birth current pregnancy there statistically significant difference homocysteine levels p 0.6621 fetus congenital malformation morphologically normal fetus there statistically significant increase homocysteine levels women oligohydramnios comparing women normal amniotic fluid levels p 0.001 women meconium stained amniotic fluid higher homocysteine levels clear amniotic fluid p 0.0037 the serum homocysteine levels significantly elevated p 0.0224 women gave birth low birth weight babies whose babies weighed 2500 grams birth table 4 serum homocysteine significantly correlated age subjects agreement another indian study das et al serum homocysteine levels significantly associated body mass index concordance study han et al there significant variation mean period gestation samples taken serum homocysteine concentrations this may due factor time window samples taken short study murphy et al dodds et al homocysteine levels longitudinally pregnancy suggests homocysteine levels may stabilised 8 weeks gestation onward middle second trimester reduction homocysteine levels prior 8 weeks rise homocysteine levels third trimester there significant correlation homocysteine levels number folic acid tablets taken correlation prior studies 4 16 the difference homocysteine levels prior first trimester losses reach statistical significance study however prior pregnancy losses taken together difference homocysteine levels statistically significant statistical significance held true prior second third trimester losses this compared studies also showed prior early pregnancy losses 8 9 17 stillbirths reflected higher homocysteine levels those prior hypertensive disorders pregnancy also increase homocysteine levels concordance studies 18 19 prior preterm birth significantly associated homocysteine levels contrast study kramer et al saw association preterm birth higher homocysteine levels proposed mechanism decidual vasculopathy placenta due higher homocysteine level could proven study the serum homocysteine levels different previous fetal malformation contrast hordaland homocysteine study showed increased incidence malformations particularly neural tube defects mothers elevated homocysteine levels there declining trend prior birth weights higher homocysteine levels confirmed studies with reference index pregnancy serum homocysteine levels significantly different went develop hypertension pregnancy remained normotensive conformance prior studies 57 20 post priori power calculation shown power detect difference hypertensive disorder pregnancy 0.95 indicates present study adequately powered show elevated homocysteine associated development hypertensive disorders pregnancy the serum homocysteine levels significantly different developed gestational diabetes mellitus maintained normal glucose tolerance similar study idzior walu et al however contrast study tarim et al found significantly elevated homocysteine level antenatal women gestational diabetes mellitus nevertheless much conclusion drawn present study post priori power calculated 0.42 the serum homocysteine levels different fetuses congenital malformations normal fetuses conformance study wang et al this concordance several studies also showed increase rate spontaneous abortions stillbirths 18 24 pregnancies elevated homocysteine levels the difference homocysteine levels oligohydramnios normal amniotic fluid level status clear meconium stained amniotic fluid shown statistically significant study however lack previous studies show association however taken extrapolation higher incidence preeclampsia 57 20 25 fetal growth restriction impairment placental transport documented previous studies this also taken extrapolation increased incidence hypertensive disorders pregnancy associated placental insufficiency the difference serum homocysteine levels low birth weight babies whose birth weight 2500 grams statistically significant this conformance studies 26 28 one study contradicted stating statistical difference the priori power calculation study based prior study serum homocysteine levels hypertensive disorders pregnancy due paucity data serum homocysteine levels gestational diabetes the post priori power calculation 0.42 indicates study may power detect difference homocysteine levels gestational diabetes the number cases small definite conclusions derived study however study first kind ethnic population developing country further studies needed strengthen conclusions though number folic acid tablets taken prior sample collection homocysteine quantified memory recall patients ) number folic acid tablets taken patients sample collection rest pregnancy may confounding factor especially due fact though folic acid routinely recommended first trimester focus shifts iron second third trimester notwithstanding fact many iron preparations contain folic acid addition iron this limitation study since homocysteine values vary folate b12 levels serum homocysteine levels late first trimester 8 12 weeks pregnancy significantly associated prior pregnancy losses particularly second third trimesters prior hypertensive disorders pregnancy reference current pregnancy increased serum homocysteine levels also significantly associated hypertensive disorders pregnancy pregnancy loss oligohydramnios meconium stained amniotic fluid low birth weight however raised homocysteine levels significantly associated body mass index gestational diabetes mellitus fetal malformations neither past pregnancies current pregnancy	aim . to revisit the role of first trimester homocysteine levels with the maternal and fetal outcome . methods . this was a cohort study comprising 100 antenatal women between 8 and 12 weeks of gestation . serum homocysteine levels were checked after overnight fasting . results . there were significantly elevated homocysteine levels among women with prior history of hypertensive disorders of pregnancy and prior second or third trimester pregnancy losses . there was no significant difference in homocysteine levels among women with previous gestational diabetes mellitus , preterm deliveries , or fetal malformations . homocysteine levels were significantly elevated in those who developed hypertensive disorder of pregnancy , oligohydramnios , and meconium stained amniotic fluid , had a pregnancy loss , or delivered a low birth weight baby . there was no significant difference in homocysteine levels for those who developed gestational diabetes mellitus . conclusions . increased first trimester serum homocysteine is associated with history of pregnancy losses , hypertensive disorders of pregnancy , and preterm birth . this is also associated with hypertensive disorders of pregnancy , pregnancy loss , oligohydramnios , meconium stained amniotic fluid , and low birth weight in the current pregnancy . this trial is registered with clinicaltrials.gov ctri/2013/02/003441 .
sudden onset sensorineural hearing loss occurs unilaterally incidence bilateral involvement less 5%.1 various causes infection vascular event coagulation disorders neoplasm demyelinating disease related sudden sensorineural hearing loss however cases causes idiopathic.2 although rarely reported deafness also attributed vertebrobasilar ischemia.3 internal auditory artery iaa provides main blood supply cochlear nerve cochlea the iaa usually branch anterior inferior cerebellar arteries aica however could originate posterior inferior cerebellar arteries pica directly basilar artery due absolute absence collateral blood supply high energy metabolism inner ear particularly vulnerable vertebrobasilar ischemia.4 although sudden hearing loss due vertebrobasilar ischemia associated combined neurologic signs symptoms vertebrobasilar ischemia also develop isolated sudden sensorineural hearing loss we report uncommon case sudden bilateral sensorineural hearing loss related vertebrobasilar occlusion without neurologic deficit a 64-year old patient admitted emergency room complaint sudden bilateral hearing loss two days earlier patient suddenly developed vertigo vomiting sequentially noticed bilateral hearing loss following day the patient non insulin dependent diabetes mellitus hypertension history heavy smoking previous history hearing impairment head trauma meningitis autoimmune diseases ototoxic drugs neurological examination no abnormal findings external auditory canal eardrum observed examination using otoscope blood tests including complete blood count serum electrolyte liver function test urea nitrogen creatinine high sensitivity c reactive protein hscrp showed normal results pure tone audiogram showed severe sensorineural hearing loss 73 decibels db left side 86 db right side fig brain magnetic resonance image diffusion weighted imaging mri dwi mr angiography mra fig 2 showed multifocal cerebellar infarction bilateral pica territory bilateral vertebral basilar artery occlusion respectively occlusion right proximal vertebral artery basilar artery severe stenosis left distal vertebral artery observed transfemoral cerebral angiography fig we concluded bilateral iaa might compromised basilar artery occlusion resulting bilateral sensorineural hearing loss sometimes iaa also branch pica basilar artery whose occlusion would directly cause hypoperfusion iaa the patient treated anticoagulation heparin warfarin three months changed aspirin two weeks later follow pure tone audiogram recorded improvement sides 58 db left 71 db right fig rapid notice event initiation proper management critical prevention grave results although various neurological deficits dysarthria numbness weakness ataxia occur mainly vertebrobasilar ischemia isolated bilateral sensorineural hearing possible rare.5 previous studies reported incidence vertebrobasilar occlusion sudden sensorineural hearing loss approximately 1.2% 1.4% patients vertebrobasilar occlusive disease bilateral hearing loss.6 7 case cause isolated bilateral sensorineural hearing impairment might iaa territory ischemia tranfemoral cerebral angiography also showed occlusion right proximal vertebral artery basilar artery severe stenosis left distal vertebral artery current report mechanism sudden bilateral hearing loss atheromatous plaque within basilar artery extended aica orifice profound degree hypoperfusion aicas may caused selective injury inner ear another possible mechanism isolated bilateral sensorineural hearing impairment could symptom basilar artery pica occlusion although auditory system including inner ear auditory nerve usually supplied iaa branch aica iaa arise pica directly basilar artery.3 inner ear vulnerable ischemia following reasons first inner ear supplied end artery auditory system auditory nerves internal auditory several anastomosing vessels in addition cochlea requires higher energy work vestibular structure.6 verebrobasilar ischemia could poor prognosis severe truncal ataxia evolve locked syndrome coma patients eventually died.8 9 recommended treatment anticoagulation total stenosis intracranial arteries however began anticoagulation therapy prevention ongoing cerebral infarction patient resolved 2 weeks.10 ) as mentioned earlier despite rareness occlusion stenosis vertebrobasilar artery aica pica could lead bilateral sensorineural hearing loss when attempting determine etiology isolated bilateral deafness kept mind clinicians consider possibility vertebrobasilar occlusive disorder especially patients risk factors stroke presenting neurologic signs	isolated bilateral deafness is a rare but possible symptom of vertebrobasilar ischemia , primarily due to occlusion of the anterior inferior cerebellar arteries or their branch , the internal auditory artery . we reported on uncommon case of sudden bilateral sensorineural hearing loss without typical neurological symptoms resulting from vertebrobasilar ischemia . we performed the available examinations , including otoscopy , laboratory tests , and pure tone audiogram , however we were not able to identify the cause of bilateral sensorineural hearing loss . brain magnetic resonance image showed the cerebellar infarction of the posterior inferior cerebellar artery territory . brain magnetic resonance angiography showed bilateral vertebral and basilar artery occlusion . we suggest vertebrobasilar ischemia as a cause of sudden isolated deafness .
micronutrients known play important role health development effective immune system tropical subtropical regions schistosomiasis global health burden 200 million people infected one five schistosoma trematode species 1 4 5 schistosoma haematobium causative agent urogenital schistosomiasis widely distributed africa simultaneously according global progress report vitamin mineral deficiency half africa population lack critical vitamins minerals deficiencies iron vitamin rank among top 10 leading causes death developing countries disease a recent study nigeria showed infection s. haematobium affected growth nutritional status children it clear micronutrient supplementation though programmes expanded programme immunisation epi child health days help reduce 5 mortality stated aim millennium development goal 5 growing calls integrated approaches improving human health it important characterise interaction micronutrient deficiencies immune response schistosomiasis public health programs plan interventions accordingly helminth infection including infection schistosomes modulates host immune response manifesting diminished allergic responses amelioration autoimmune disease chronic parasitic infection 911 immunomodulation mediated regulatory cells treg direct contact stimulation il-10 production 12 13 while switch th2 occurs helminth infection effective antiparasitic response unclear whether superimposition regulatory responses primarily benefits worms host downregulation inflammatory response would reduce host mediated immunopathology also reduce protection 9 14 these effects seen diminished allergic response amelioration autoimmune disease chronic parasitic infection traditionally vitamin known role vision deficiency resulting xerophthalmia leading cause preventable childhood blindness however wide range physiological functions essential haematopoiesis prevention anaemia well immune function it acquired foods liver milk cheese eggs green leaves carrots ripe mangos vitamin implicated development th2 th17 treg responses activation retinoid receptors retinoic acid activates foxp3 transcription factor stimulates development nave cells treg[1517 hypovitaminosis immunodeficient state linked decreased antibody production typically diminished th2 antibodies ige igg1 iga it produced skin 7-dehydrocholesterol reacts uvb radiation form vitamin d3 modified liver form 25(oh vitamin d3 converted active metabolite 1,25(oh)2 vitamin d3 kidney they metabolised liver manner cutaneously derived vitamin d3 a role suggested vitamin diseases immunological aetiology psoriasis multiple sclerosis diabetes mellitus it suppresses th1 cytokines ifn- il-2 upregulates il-4 create th2 polarisation vitamin stimulate treg production tgf-1 cd25 expression cd4 cells 2224 it also diminishes expression dendritic cell dc costimulatory markers cd40 cd80 cd86 linked treg induction 14 23 anaemia affects 1.62 billion people worldwide around 500 million people iron deficiency anaemia causal relationship infection s. japonicum iron deficiency anaemia established it linked increased infectious mortality morbidity caused chronic infection 27 28 its relationship infection complex pathogen host use body iron stores it shown iron supplementation active infection increase infectious load pathogens 27 29 experimental studies mice found high iron indices significantly increased fibrosis around egg granulomata iron deficiency associated igg1 ige treg responses whereas iron supplementation linked th1 responses decreased il-10 30 31 the soluble transferrin receptor stfr diagnostic tool differentiating iron deficiency anemia ida anemia chronic disease since ferritin levels reflect amounts stored iron stfr reflects functional iron compartment a studies shown recent review data collected zimbabwe 1980 2006 showed significant proportion preschool children school children adult women lactating pregnant experienced malnutrition significant proportions groups suffering vitamin iron deficiencies the aim study determine relationship micronutrients vitamin iron well measure inflammatory responses c reactive protein crp schistosome specific cytokine levels zimbabweans exposed s. haematobium infection the study received ethical institutional approval medical research council zimbabwe university zimbabwe respectively permission conduct work province obtained provincial medical director informed consent assent obtained participants parents guardians prior enrolment study project aims procedures explained community school children teachers prior study survey conducted amongst compliant participants after sample collection participants offered treatment standard dose 40 mg kg body weight antihelminthic drug praziquantel the study conducted two rural villages mashonaland east province zimbabwe 3130e 1745s s. haematobium endemic participants part larger immunoepidemiology study carried 2002 2005 study area described detail elsewhere drinking water collected open wells bathing washing conducted two main rivers villages most families maintain garden located near river water collected watering crops schools surveyed close proximity rivers all samples used study obtained baseline 2002 selected using following criteria 1 participants life long residents area assessed questionnaire 2 received antihelminthic treatment prior study 3 provided least two urine 2 stool samples consecutive days allow parasitological diagnosis 4 test negative soil transmitted helminth s. mansoni well negative hiv plasmodium falciparum 5 provided blood sample obtain sera furthermore sera samples used analyses used previously therefore defrosted first time following criteria samples 40 people aged 754 years 13 male 27 female ) data subsequently separated 3 age groups 710 years n 6 1120 years n 23 21 years n 11 represent typical age infection profile s. haematobium shown figure 1(a parasitology samples least 2 urine 2 stool samples collected 3 three consecutive days 20 ml venous blood collected participant stool samples processed following kato katz procedure detect s. mansoni eggs intestinal helminths urine filtration method used detect s. haematobium eggs urine samples serum samples obtained 20 ml venous blood participant frozen stored duplicate 20c field transferred 80c freezer laboratory one complete set samples subsequently transported frozen zimbabwe uk stored 80c defrosted first time use study small aliquots blood used prepare thick thin smears microscopic detection plasmodium parasites the parasite specific cytokines ifn- marker th1 responses il-4 il-5 markers th2 responses il-10 marker regulatory responses measured enzyme linked immunosorbent assays elisa supernatants obtained stimulation whole blood samples using cercarial egg adult schistosome antigens following published methods spontaneous cytokine production determined unstimulated controls containing media alone mitogen concanavalin cona used positive control restimulations values cytokines obtained media alone incubations subtracted antigen specific restimulations remove effects background cytokine production statistical analyses micronutrients c reactive protein crp measured using enzyme linked immunosorbent assay elisa kits according manufacturers instructions serum transferrin receptor stfr marker iron deficiency required lymphocyte activation proliferation ferritin marker iron status rises inflammation 27 38 measured elisa kit bioquant cat crp inflammatory marker measured elisa kit anogen cat retinol binding protein measure vitamin status assayed using elisa kit phoenix pharmaceuticals cat # ek-028 28 25(oh vitamin used assess inactive vitamin status although kit immunodiagnostik cat vitamin status described using previously published ranges replete 50.00 nmol l mild deficiency 25.0049.99 nmol l moderate deficiency 12.5024.99 nmol l severe deficiency 12.49 nmol l world health organisation reference range ferritin used female normal range 15.0150.0 g r&d systems provided 2.597.5 percentile range 8.728.1 nmol l stfr survey 225 ethnically diverse participants sexes their mean value afro carribeans significantly higher ethnic groups there published reference range rbp although world health organisation produced retinol reference ranges use public health 43 44 the ratio stfr log ferritin stfr f index suggested alternative estimate body iron also calculated study used statistical analyses statistical analyses host infection intensity recorded infection status infected uninfected cytokine absorbencies square root transformed levels micronutrients log transformed satisfy assumptions parametric tests order determine if relationship micronutrients immune responses differed schistosome infected versus uninfected people multivariate analysis variance manova conducted the dependent variables transformed micronutrient data independent variables cytokine levels infection status infected uninfected age categorical 710 years 1120 years 21 years sex categorical male female the effects interactions infection status micronutrients also included manova model sequential sums squares used calculate test statistics potentially confounding effects variables could allowed testing effects infection status entered last single effects list schistosome infection prevalence study population 60% 95% ci 4375% mean infection intensity 39.3 eggs/10 ml urine sem 13.5 range 0362 eggs/10 ml urine infection intensity followed typical schistosome age infection pattern rising age peak childhood declining thereafter figure 1(a the study population mean rbp 0.23 ng ml range 00.63 ng ml 25(oh vitamin titres population low compared published values 32.8% n 12 population classified vitamin replete 50.00 nmol l 17.9% n 7 mildly deficient 2549.90 nmol l 10.3% n 4 moderately deficient 12.5024.90 nmol l 38.5% n 15 severely deficient 12.49 levels crp within normal range 28.6% n 10 participants elevated stfr based 95 percentile data provided assay detailed methods section the statistical analyses showed sex affected levels ferritin significantly lower females significant effect levels micronutrients table 1 age significantly affected levels rbp rbp levels falling age r 0.315 p 0.033 shown figure 1 affect levels micronutrients crp although figure 1(b shows differences age profile crp levels statistical analyses show allowing variables sex example age significant differences crp levels 2 age groups overall significant positive association rbp levels parasite specific il-10 p 0.049 0.314 well ferritin parasite specific il-4 p 0.035 0.317 in cases relationship cytokine levels micronutrients varied schistosome infection status shown table 1 thus levels vitamin showed significant negative correlation il-4 egg positive children association egg negative children figure 2(a levels parasite specific ifn- showed significant positive correlation stfr egg negative people negative nonsignificant association egg positive people figure 2(b egg positive people levels parasite specific il-5 went ferritin levels went egg positive people although later association significant figure 2(c when considering ratio stfr levels ifn- il-4 went stfr f index egg positive people egg negative people shown figures 2(d 2(e study describes micronutrient status rural black zimbabwean population characterises relationships micronutrients immune responses schistosomiasis study showed vitamin deficiency population levels micronutrients markers inflammation within normal ranges the global micronutrient report 2001 classified zimbabwe vitamin deficiency prevalence 1015% the study population easy access good dietary sources micronutrients including fortified foods margarine vegetable oils study period fortified vita well home grown vegetables iron supplementation pregnant women ante natal clinics targeted vitamin supplementation commenced zimbabwe 2 years current study conducted study serum retinol levels declined age contradictory reports primary aged school children zimbabwe kenya 47 48 show retinol levels increasing age work rbp levels exercise programs south korean women revealed larger decrease older women younger women structured exercise regime this consistent finding rbp decreased age since study captures wider age range 2 previous studies primary school children however major occupation amongst population subsistence farming likely physically active therefore clear whether observations represent normal decline rbp age whether interaction physical activity age rbp level found association s. haematobium infections serum retinol levels zimbabwe similar observations current study interestingly friis et al found strong negative association s. mansoni infection serum retinol levels zimbabwe kenya suggests intestinal niche s. mansoni infection may interfere vitamin absorption 47 48 however experimental studies show vitamin deficiency leads reduced schistosome specific antibody responses may suggest vitamin deficiecy leads susceptibility s. mansoni infections however participants study negative s. mansoni therefore excluded confounding factor it also shown trans retinoic acid atra binds retinoic acid receptors induce foxp3 expression polarizing immune responses towards regulatory phenotype our finding rbp correlated il-10 suggests vitamin may important augmenting schistosome specific regulatory responses vitamin produced surprising data 38.5% subjects severely deficient there paucity vitamin surveys africa compared conducted western countries since clinical examination conducted study impossible say whether deficiencies observed study results associated pathology remained asymptomatic production pre vitamin d3 occurs skin influence ultraviolet light most studies vitamin levels caucasian populations reference osteoporosis it possible findings may explained ethnic differences skin pigmentation skin uv penetration 41 51 given reference ranges come studies osteoporosis may applicable zimbabwean population nonetheless remain important starting point analysis suggest work required examine biological relevance categories immunology study vitamin levels egg negative children showed significant positive association il-4 levels consistent role vitamin upregulating il-4 polarize responses towards th2 phenotype iron deficiency one prevalent micronutrient deficiencies world affecting least half pregnant women young children developing countries survey conducted ministry health child welfare 1997 9% surveyed population pregnant women lactating women preschool children adult males ) had depleted iron stores ferritin time study pregnant postpartum women offered iron supplementation local healthcare providers thus pregnancy childbirth related iron blood loss may explain male participants significantly higher levels ferritin study while ferritin levels within normal ranges stfr levels elevated 28.6% population ferritin indicator stored iron reserves body stfr indicates functional iron component body becomes elevated soon onset iron deficiency ferritin often decreased iron deficiency anaemia raised inflammatory conditions 27 39 however observed normal crp levels excluded excess inflammation participants similarly lack association schistosome infection intensity status levels stfr implies schistosome infection explain elevated levels stfr population the measures body iron stfr f index showed negative association ifn- il-4 egg positive people il-5 levels showed positive association ferritin people iron supplementation shown increase dendritic cell stimulation promote th1 responses also increased burden immunopathology already infected however increased ifn- seen iron deficiency role preserving iron stores 27 28 thus population inverse association measures body iron cytokines ifn- il-4 may adaptive preserving iron stores schistosome infection the study showed levels vitamin iron within normal ranges deficiency vitamin 67.2% study population well elevated levels stfr 28.6% participants thus 2 indicators iron levels suggested although levels stored iron within normal levels normal ferritin levels levels functional iron measure stfr may reduced participants schistosome infection intensity status associated levels micronutrients altered relationship parasite specific il-4 il-5 measures iron levels ferritin stfr cohort studies following larger group people cycle antihelminthic treatment clarify effects helminth infection micronutrient levels subsequent effect immune responses	micronutrients play an important role in the development of effective immune responses . this study characterised a populations exposed to schistosome infections in terms of the relationship between micronutrients and immune responses . levels of retinol binding protein ( rbp ; vitamin a marker ) , vitamin d , ferritin and soluble transferrin receptor ( stfr ) , and c reactive protein ( crp ) were related to levels of schistosome specific cytokines ( ifn- , il-4/5/10 ) in 40 zimbabweans ( 754 years ) exposed to schistosoma haematobium infection . 67.2% of the participants were deficient in vitamin d. rbp levels were within normal ranges but declined with age . the two indicators of iron levels suggested that although levels of stored iron were within normal levels ( normal ferritin levels ) , levels of functional iron ( stfr levels ) were reduced in 28.6% of the population . schistosome infection alone was not associated with levels of any of the micronutrients , but altered the relationship between parasite - specific il-4 and il-5 and levels of ferritin and stfr .
posterior reversible encephalopathy syndrome pres refers clinico radiological entity characterized headache confusion visual disturbances seizures posterior transient changes neuroimaging we report child pres revealing post streptococcal acute glomerulonephritis psgn a 9-year old girl presented er history low grade fever 7 days sudden onset headache 2 days altered sensorium three episodes tonic clonic seizures since previous day loss vision past 12 h. examination afebrile irritable altered sensorium mild puffiness face her blood pressure bp 136/100 mm hg 95 percentile age she focal neurological deficits signs meningeal irritation she started anti hypertensive sublingual nifedepine fluid salt restriction anti edema measures anticonvulsants supportive care investigations revealed hemoglobin 10.6 gm dl total count 18 500 cells mm polymorphs 87% lymphocytes 10% platelets 404 000 cells mm esr 9 mm c reactive protein 0.6 mg dl raised blood urea nitrogen 40 mg dl creatinine 0.65 mg dl serum electrolytes liver function tests normal the urine collected admission cola colored urinalysis revealed plenty rbcs albuminuria 2 computed tomography ct brain revealed symmetric occipital hypodense lesions cerebral edema figure 1 anti streptolysin titer positive 571 iu ml complement c3 level low 40 mg dl computed tomography brain admission showing areas hypodensity bilateral occipital lobes white matter mild edema bp gradually returned normal range slowly regained vision sensorium within 10 h hospitalization imaging appearances complete restoration visual function following normalization bp diagnosis pres psgn made follow ct scan 2 weeks first study showed complete resolution previous abnormal lesions figure 2 1-year periodic follow unit child recurrence symptoms follow ct scan brain 2 weeks first study revealed complete resolution white matter abnormality occipital lobes posterior reversible encephalopathy syndrome also known reversible posterior leukoencephalopathy syndrome rpls initially described hinchey et al 1996 clinico radiological entity characterized neurological signs headache seizures vomiting altered mental status visual disturbances especially cortical blindness focal neurological deficits radiological abnormalities occipital white matter usually bilateral characterized cerebral edema hypodense signals ct scan hyperintense signals t2 weighted images mri the common presenting symptoms headache seizure altered consciousness cortical blindness hypertensive encephalopathy pre eclampsia eclampsia systemic lupus erythematosus wegener granulomatosis minimal change nephrotic syndrome chronic renal failure post transplantation hemolytic uremic syndrome acute intermittent porphyria thrombotic thrombocytopenic purpura vasculitis malignancies hypercalcemia oxybutynin intravenous immunoglobulins organ transplantation certain immunosuppressive cytotoxic drugs among known conditions associated pres two possible mechanisms proposed pathophysiology pres vasospasm due acutely increased bp ii loss autoregulation first hypothesis it suggested vasospasm contributes ischemia cytotoxic edema regions arterial border zone the second recent hypothesis supported diffusion images suggesting dilation develops cerebral arterioles due autoregulatory failure objective cerebral autoregulation keep blood flow constant protect brain changes bp however sudden severe increases bp impair autoregulation lead arteriolar vasodilatation endothelial dysfunction breakdown blood brain barrier leading extravasations plasma red blood cells causing vasogenic edema lesions pres predilection parieto occipital region posterior cerebral arterial circulation supplied vertibro basilar system lower level sympathetic innervation therefore frequently involved the role neuro imaging establish initial diagnosis exclude causes neurological symptoms signs pres noncontrast ct ncct sufficient make diagnosis proper clinical setting revealing areas low attenuation posterior white matter mri brain bilateral symmetrical edema parieto occipital region hyperintense t2-weighted fluid attenuated inversion recovery flair sequences hypointense t1-weighted sequences diffusion weighted imaging dwi differentiate condition major diseases infarction diffusion restricted pres occurs commonly setting known hypertension use immunosuppressive agents though association psgn pres reported earlier,[1012 pres revealing acute glomerulonephritis extremely rare children case the girl presented neurological symptoms found hypertensive later developed gross hematuria admission subsequently diagnosed acute glomerulonephritis our case highlights possibility cortical blindness may develop complication acute glomerulonephritis children prevention occurrence neurological deficits children acute glomerulonephritis hypertensive encephalopathy requires careful evaluation appropriate management hypertension conclusion it important consider diagnosis children presenting encephalopathy seizures appropriate clinical settings pres treatable reversible cause acute encephalopathy blindness long early diagnosis appropriate treatment made without prompt treatment syndrome may lead permanent brain injury neurological sequelae chronic epilepsy we need aware unusual neurological complication early recognition may improve prognosis	the association between hypertensive encephalopathy and cortical blindness in children with acute glomerulonephritis is extremely rare . we report the case of a 9-year old girl who presented with headache , seizures , altered sensorium , hematuria , and transient cortical blindness as a complication of hypertensive encephalopathy which showed complete reversal following normalization of blood pressure and an underlying post - infectious acute glomerulonephritis was revealed .
homeostasis fundamental concept physiology hence subject greatest interest medicine 13 present review aspects concept possible developments could impact also clinical practice analysed our proposal based classical assumption interstitial fluid isf internal medium multicellular organisms background central aspect discussed namely concept hierarchic role isf various organs triggering homeostatic responses especially involving overriding controls particular propose brain isf highest hierarchic role human beings providing optimal environment brain cell survival complex functions hence allowing central nervous system cns carry complex whole body integrative actions i.e. operate uppermost controller allows free independent life higher vertebrates background crucial role kidneys internal medium homeostasis revised according proposal homer smith put forward fifty years ago extraordinary book 4 matter fact homer smith pointed basis evolutionary observations functional interconnections brain kidneys internal medium homeostasis basic requisite free independent life higher vertebrates hence surmised cns operates uppermost controller internal medium homeostasis exclusively especially thanks synergistic interactions kidney the clinical evidence supports view discussed reported recent studies 5,6 in particular review brain kidney synergistic roles h2o na balance brain temperature control discussed actually data presented supporting view two parameters interrelated deep effects cns higher integrative actions furthermore concept allostasis hence set range optimal values internal medium parameters assumed 7 view developed considering possible functional meaning rhythmic oscillations chemico physical parameters inside set range according proposal considered basic component homeostatic control thus present proposal suggests isf represents real internal medium since maintenance homeostasis several instances appropriate rhythms chemico physical parameters within appropriate set range main factor free independent life higher vertebrates in particular main focus present review suggestion h2o na balance brain temperature play crucial role certain brain integrative actions a special emphasis given rhythmic oscillations within set range important modulatory actions psychic homeostasis as matter fact psychic homeostasis see section entitled body psychic homeostasis definition refers complex behavioural bodily responses optimizing inter alia interactions human subject socio cultural environment i.e. called supra systems underlined psychic homeostasis sometimes override bodily homeostasis regulatory mechanisms i.e. controls aimed optimize human interactions external physical environment 7,8 the need characterize complexity human led distinction two elements soma psyche 9 thus proposed two highly complementary homeostatic control processes operation human beings somatic physiological homeostasis via integrative actions different apparatuses capable maintaining important chemico physical parameters internal milieu within optimal set ranges allowing free independent life organism ii psychic homeostasis aimed equilibrated mental condition via proper resetting action different instances inner world social environment subject harmonize agreement view freud proposed principle psychic homeostasis basic concept supporting meta psychology famous book interpretation dreams 10 indicate psychic homeostasis proper set range corresponding psychic state subjective well term eudaimonia also mentioned eudaemonia consists words eu ( good daimn spirit proposed thus could described condition dynamic balance different appeals within psychic sphere subject also front challenges social physical environment these aspects expanded 11 concept predictive psychic homeostasis designates capability create via integrated actions various brain body mechanisms psycho physical state readiness anticipates potential threats thus predictive psychic homeostasis avoiding possible future allostatic psycho physical overloads basic relevance eudaimonia internal milieu homeostasis 8,11 the survival value predictive psychic homeostasis emphasised evidence sometimes override bodily homeostasis regulatory mechanisms 7,8 it noted body homeostasis psychic homeostasis often jointly conditioned pattern endocrine signaling 11,12 particular alterations anterior pituitary hormones leading somatic disturbances demonstrated stress mood disorders including major depression 13 thus hypothalamic pituitary adrenocortical hormones deep effects body homeostasis psychic homeostasis interesting point modulated circadian secretion rhythms 14,15 in words human cns high integrative actions link together human basic physiology subject supra systems play basic role psychic homeostasis thus human psychic homeostasis bodily homeostasis two inseparable aspects health such view reminds aphorisms ancient medicine philosophy proposed soul serenity eudaimonia i.e. good spirit see also discussion primary aim subject well obviously eudaimonia deeply dependent gratifying interactions individual human socio cultural environment 16,17 the need characterize complexity human led distinction two elements soma psyche 9 thus proposed two highly complementary homeostatic control processes operation human beings somatic physiological homeostasis via integrative actions different apparatuses capable maintaining important chemico physical parameters internal milieu within optimal set ranges allowing free independent life organism ii psychic homeostasis aimed equilibrated mental condition via proper resetting action different instances inner world social environment subject harmonize agreement view freud proposed principle psychic homeostasis basic concept supporting meta psychology famous book interpretation dreams 10 indicate psychic homeostasis proper set range corresponding psychic state subjective well term eudaimonia ( also mentioned eudaemonia consists words eu good daimn spirit proposed thus could described condition dynamic balance different appeals within psychic sphere subject also front challenges social physical environment these aspects expanded 11 concept predictive psychic homeostasis designates capability create via integrated actions various brain body mechanisms psycho physical state readiness anticipates potential threats thus predictive psychic homeostasis avoiding possible future allostatic psycho physical overloads basic relevance eudaimonia internal milieu homeostasis 8,11 the survival value predictive psychic homeostasis emphasised evidence sometimes override bodily homeostasis regulatory mechanisms 7,8 it noted body homeostasis psychic homeostasis often jointly conditioned pattern endocrine signaling 11,12 in particular alterations anterior pituitary hormones leading somatic disturbances demonstrated stress mood disorders including major depression 13 thus hypothalamic pituitary adrenocortical hormones deep effects body homeostasis psychic homeostasis interesting point modulated circadian secretion rhythms 14,15 words human cns high integrative actions link together human basic physiology subject supra systems play basic role psychic homeostasis thus human psychic homeostasis bodily homeostasis two inseparable aspects health such view reminds aphorisms ancient medicine philosophy proposed soul serenity eudaimonia i.e. good spirit see also discussion primary aim subject well obviously eudaimonia deeply dependent gratifying interactions individual human socio cultural environment 16,17 the french physiologist claude bernard 18131878 introduced concept internal environment organism 18 upon walter cannon 18711945 proposed concept homeostasis a crucial aspect obviously definition internal medium characterization distinctive features physiological terms 19 initially bernard postulated blood milieu interieur internal environment exchanging substances operating optimal environment cells metabolism higher animals thus proposed concept fixity constancy internal environment essential vital processes stating fixity milieu supposes perfection organism external variations instant compensated equilibrated the stability internal environment condition free independent life 20 later interstitial fluid environment cells multicellular organism exchange proposed concept homeostasis introduced cannon the new term defined follows 21 constant conditions maintained body might termed equilibria that word however come fairly exact meaning applied relatively simple physico chemical states closed systems known forces balanced the coordinated physiological processes maintain steady states organism complex peculiar living beings involving may brain nerves heart lungs kidneys spleen working cooperatively suggested special designation states homeostasis it means condition condition may vary relatively constant homeostasis least narrow sense preserving status quo regulation achieve viability resistance change furthermore cannon adapted idea homeostasis organism whole hence referring physiological psychological aspects control mechanisms mentioned broadening homeostasis concept psychic aspects peculiar relevance human considered present review let us discuss detail concept allostasis introduced 1988 sterling 7 development aspects concept homeostasis 22 in fact allostasis points living systems endowed adaptability property hence control mechanisms operate continuous adjusting change simply restoring rather altering equilibrium settings order face optimal fashion new environmental inputs thus set point controlled parameter rather set range maintained fig allostasis describes processes organisms actively maintain dynamic steady state conditions basic parameters necessary simply survival rather optimal interactions environment it underlined allostatic mechanisms also adapt organisms probable future loads bayesian approach obviously especially true organisms endowed complex cns thus concept allostasis introduced underline physiological psychological change adaptation diverse present surmised future circumstances obviously behavioural physiological anticipatory responses probable future events emphasize crucial role complex cns particularly responses allowing called predictive allostasis 1,78,16,2326 we also mention another far sighted proposal cannon since underlined internal environment cells exchange simply watery environment rather fluid matrix whose chemical also physical characteristics temperature pressure basic importance it noted fluid matrix hence aqueous extracellular matrix ecm forming internal medium product organism play basic role intercellular communication processes 2730 the evidence internal medium particular ecm produced organism according functional needs implies broader view homeostasis since self construction internal medium way related concepts introduced 1970s varela et al 31 discussed others stating 3133 living system system capable self reproduction self maintenance regenerative network processes take place within boundary making regenerates cognitive adaptive interactions medium 33 thus living system characterized two notions 3335 first one autopoiesis term indicating ability system transform external matter energy internal process self maintenance production components autopoiesis therefore concerned internal structure describes system organized network interactions capable cyclically reproducing components allow system self perpetuation ii second one called cognition indicate interaction environment implemented basis internal logic living system environment words prescribe determine changes organism structure living system previous history perturbations determine reactions new perturbation induce cognition therefore concerns relationship system environment describes system able sense external world order produce response perturbations either self correction disturbed organization homeostasis reorganizing different self perpetuating network interactions adaptability there course various levels cognition corresponding different levels life complexity simple mechanisms cell sentience 36 complex functions performed nervous systems this view captures essence cellular life recognizing life cyclic process produces components turn self organize process within boundary making such self constructed machine continuously operates maintain critical chemico physical parameters within suitable set range spite perturbing influences pointed wiener classical book 37 ) mechanisms allowing processes maintenance values critical parameters within suitable set ranges allow survival living beings notwithstanding external environment changes described according cybernetic models middle past century norbert wiener 18941964 pointed concept homeostasis common animals automatic systems 37 thus defined cybernetics entire field theory communication control living beings automatic systems 1940 1950 's cybernetics crucial influence birth various modern sciences control theory computer science information theory automata theory artificial intelligence artificial neural networks cognitive science computer modelling simulation science dynamical systems artificial life however disciplines become fully independent cyberneticists felt need develop field distinguish approach emphasizing autonomy self organization cognition mechanistic control strategies followed control engineering computer science in early 1970 effort became known second order cybernetics 38 provided thoughtful revision concepts particular relevance biology physiology particular negative feedback fb type control central homeostasis cybernetics since explain living automatic system operate maintaining steady state spite disrupting influences external environment fig 1 fb control described follows let us suppose stress external environment acts upon system organism system fb control a sensor detects stress signal converts signals meaningful internal control mechanisms organism a controller compares signals desired set points issues error signals discrepancies thus error signal refers difference optimal value variable set point value returned homeostatic mechanism(s persisting perturbation the error interpreted activator triggers appropriate response effectors restore value variable close set point according realistic view within suitable set range fig as pointed living several regulatory mechanisms continuously activated produce homeostatic responses hence analyzing allostatic controls following aspects least considered redundancy inter dependence since several negative feedbacks directly indirectly involved control functional parameter functional parameters strictly interdependent e.g. blood volume arterial blood pressure ii push pull controls e.g. glucagon insulin allowing precise control parameter iii russian doll organization controls increasing miniaturization 3941 thus possible recognize fb control systems set apparatuses level level organs level tissues level cells level molecular networks the crucial role overriding controls played cns via interactions peripheral apparatuses especially parameters arterial blood pressure involved facing challenging conditions e.g. fight flight conditions 4248 taken together stated homeostasis implies regulated activation several dynamic potentially predictive multilevel processes organized according russian doll pattern 32,42,43,49,50 furthermore proposed brain body medicine cns plays crucial role homeostasis interacting practically peripheral organs 42,5153 context brain kidney interactions h2o na brain temperature control interrelated parameters basic importance cns integrative actions discussed discussed assumption also surmised deductions based evolutionary background during middle past century norbert wiener 18941964 pointed concept homeostasis common animals automatic systems 37 thus defined cybernetics entire field theory communication control living beings automatic systems 1940 1950 's cybernetics crucial influence birth various modern sciences control theory computer science information theory automata theory artificial intelligence artificial neural networks cognitive science computer modelling simulation science dynamical systems artificial life however disciplines become fully independent cyberneticists felt need develop field distinguish approach emphasizing autonomy self organization cognition mechanistic control strategies followed control engineering computer science in early 1970 effort became known second order cybernetics 38 provided thoughtful revision concepts particular relevance biology physiology particular negative feedback fb type control central homeostasis cybernetics since explain living automatic system operate maintaining steady state spite disrupting influences external environment fig 1 fb control described follows let us suppose stress external environment acts upon system organism system fb control a sensor detects stress signal converts signals meaningful internal control mechanisms organism a controller compares signals desired set points issues error signals discrepancies thus error signal refers difference optimal value variable set point value returned homeostatic mechanism(s persisting perturbation the error interpreted activator triggers appropriate response effectors restore value variable close set point according realistic view within suitable set range fig 1 pointed living several regulatory mechanisms continuously activated produce homeostatic responses hence analyzing allostatic controls following aspects least considered redundancy inter dependence since several negative feedbacks directly indirectly involved control functional parameter functional parameters strictly interdependent e.g. blood volume arterial blood pressure ii push pull controls e.g. glucagon insulin allowing precise control parameter iii russian doll organization controls increasing miniaturization 3941 thus possible recognize fb control systems set apparatuses level level organs level tissues level cells level molecular networks the crucial role overriding controls played cns via interactions peripheral apparatuses especially parameters arterial blood pressure involved facing challenging conditions e.g. fight flight conditions 4248 taken together stated homeostasis implies regulated activation several dynamic potentially predictive multilevel processes organized according russian doll pattern 32,42,43,49,50 furthermore proposed brain body medicine cns plays crucial role homeostasis interacting practically peripheral organs 42,5153 context brain kidney interactions h2o na brain temperature control interrelated parameters basic importance cns integrative actions discussed as discussed assumption also surmised deductions based evolutionary background as stated general premise proposed brain isf plays highest hierarchic role among isf different organs human body triggering homeostatic responses fundamental importance strong assumption deny relevance holistic view human body proposed brain body medicine 42 aimed suggesting frame organize data indicating isf dyshomeostasis reduces great extent cns integrative actions allow free independent life mentioned support assumption focus analysis two parameters namely h2o na brain temperature control cns kidney synergistic interactions introduction subject preliminary analysis proposed complex fluid cellular movements among various brain fluid compartments since involved metabolic support neurons glial cells clearance waste molecules brain also brain interactions systemic apparatuses interesting study brinker et al published useful diagram showing complex fluid cellular exchanges brain fluid compartments 54 refer proposal actually according view possible organize brain fluid compartments distinguishing major cerebrospinal fluid csf circulation black arrows fig 2 inter compartments fluid circulation blue arrows fig 2 csf intra ventricular local circulation characterized gentle ebbs broken arrows fig 2 schematic representation suggests special hub status isf view multiple connections fluid compartments furthermore privileged status isf pointed limiting barriers regulate cellular fluid exchanges compartments actually isf protected highly selective barrier cerebral blood circulation permeable barrier formed gap junctions pia ependymal layer brain tissue microarchitecture e.g. tortuosity viscosity brain ecm csf furthermore also pointed isf virchow robin space vrs separated glial barrier also cells move isf indicated fig 2 csf operates interface major minor circles addition csf exchanges signals isf directly also indirectly via reciprocal interactions vrs thus csf secretion composition circulation central importance isf homeostasis as far secretion csf concerned choroid plexus cp proposed main locus secretion clearance csf thus cp blood csf barrier secretes purifies csf generates intracranial pressure maintains csf composition therefore cp secretory epithelium plays basic role brain homeostasis integrative actions via multiple transport secretory functions support csf homeostasis fluid dynamics 55 far csf composition is concerned important compare least main chemico physical parameters plasma extracellular fluid ecf two highly selective barriers separate csf isf blood separated easily permeable boundaries thus isf highest hierarchic order among brain isf csf also considered view continuous renewal circulation crucial fluid compartment brain integrative functions good mirror brain isf hand each contribute plasma composition according volume composition access plasma thus brain isf also view blood brain barrier bbb greatly contribute plasma composition notwithstanding high hierarchic order these aspects illustrated fig 2 table main chemico physical parameters plasma ecf csf presented far csf circulation i.e. third circulation according cushing 56 concerned shown adult cp secretes csf flows ventricles subarachnoid space top brain csf flowing lumbar sac the exit csf mainly blood arachnoid granulations also lymph system nasal cribriform plate via spinal nerve roots 55 however csf flow unidirectional since shown pulsatile flow also characterized movements throughout entire brain local fluid exchanges isf circumventricular organs cvos vrs furthermore underlined csf gentle bidirectional ebbs flows create mixing 55 also shown single layer ciliated ependymocytes contact csf beat periodic manner generating localized microscale beating cilia effects near wall csf dynamics fig 2 action may contribute clearing debris ventricle walls may enhance mixing may particularly relevant neuroendocrine communication 57 even signal detection 36 thus short distance volume transmission vt)-signalling rely upon action ependymal cilia close walls lateral ventricles long distance vt signalling could mainly driven wall motion cp pulsation hence csf dynamics centre regions ventricles according tide hypothesis 58 thus suggested distinguish major csf circulation classical one cp arachnoid granulations local csf micro circulation mainly confined close ciliated walls ventricles former plays role nourishing liquor long distance pathway vt signal migration latter one mainly involved short distance migration vt signals csf flow mediated neuronal guidance 57,59,60 furthermore csf circulation around blood vessels penetrates subarachnoid space vrs allowing cell exchange blood brain as proposed bechter et al 6062 csf also diffusion pathway pathogenic agents causing neuropsychiatric diseases 63 actually shown blood borne inflammatory cells enter brain via vrs via cp clinical evidence supports relevance immunological crosstalk periphery intrathecal immunity neurological psychiatric diseases 54,64 the fluid movements barriers driven osmotic hydrostatic gradients active transporter processes aquaporins transporters play fundamental role control fluid exchange glial endothelial cp barrier particular the water influx vrs hence interstitial flow regulated aquaporin-4 localized end feet astrocytes 65 it interesting note fluid movements vrs depend respiratory cardiac pressure pulsations important component tide hypothesis vt signal diffusion brain 58 a special role tanycytes brain body interactions also proposed since tanycyte like cells characteristic feature cvos display well organized tight junctions around cell bodies represent bbb displaced vascular ventricular side 66 thus tanycytes may play important role regulating exchange blood csf isf hence regulating brain body interactions particularly organs deeply involved control internal medium kidney the assumption peculiar brain kidney interactions finds indirect support comparative physiology evolutionary studies in famous fascinating book cited homer smith 4 proposed following processes indicate parallel evolution nervous system kidneys fig 3 increased complexity renal apparatus allowed progressively precise control volume composition internal medium ii precise control volume composition internal medium allowed establishment progressively complex nervous system iii organism endowed complex cns become capable multidimensional allostatic controls i.e. complex dynamic predictive homeostasis particularly chemico physical parameters highly relevant cns integrative actions accordingly aspects discussed complex cns operates allow interconnections brain kidneys homeostatic controls sodium concentrations brain temperature as far plasma sodium concentrations concerned noted parameter restrict set range 135 meq l na < 147 meq l also hyponatremia causes important cns symptoms e.g. amnesias headaches epilepsy 5 far cerebral temperature concerned noted brain deep structures 12c body core temperature thus blood cerebral circle lower temperature deep brain structures hence cerebral blood flow besides providing nutrients brain allowing clearance metabolic waste products also function absorbing heat especially active brain regions 6770 the osmotic regulation water homeostasis body core temperature functionally related since maintenance body water homeostasis critical preventing hyperthermia evaporative cooling efficient means dissipating excess body heat far water homeostasis is concerned control mainly achieved regulation water intake water loss kidneys the former achieved sensations thirst motivate water intake whereas latter regulated antidiuretic action vasopressin vasopressin also known antidiuretic hormone adh 5 secretion thirst stimulated increases osmolality ecf well decreases blood pressure and/or blood volume signals precipitated water depletion associated excess evaporative water loss required prevent hyperthermia thus deduced thermoregulation osmotic regulation water homeostasis functionally interdependent let us briefly mention two important recent contributions mechanisms involved integrated homeostatic control 71,72 actually adh enhances thermo sensitivity warm sensitive neurons decreases thermo sensitivity cold sensitive neurons such adh modulatory actions promote heat loss probably involved adh induced hypothermia 71 the basic role adh osmotic regulation water homeostasis cerebral homoeothermic control schematically summarized fig another mechanism involved integration thermal osmotic regulation water homeostasis also described based transient receptor potential vanilloid trpv family ion channels respond osmotic signals also stimulated increases body temperature 72 described recent study noda et al 6 least two independent sensing systems cvos involved monitoring osmolality body fluid volume namely na(x channels trp channels particular na(x channels demonstrated play role na sensors trp channels osmosensors channels also temperature sensitive let us briefly describe two molecular mechanisms involved control na h2o cerebral temperature na(x channels located perineuronal processes ependymal cells subfornical organ organum vasculosum lamina terminalis ovlt activated hypernatremia their activation causes reduction na assumption ii trpv channels trpv1 trpv4 expressed level supraoptic nucleus level ovlt these channels activated hyper osmolality also increases cerebral temperature in words brain regions particularly cvos central molecular mechanisms e.g. trpv allowing brain kidney interactions control ecf osmolality cerebral temperature 72 thus apart mechanism dependent adh modulatory actions hypothalamic thermo receptors via action integrate thermal osmotic regulation mechanism dependent tprv channels whose activation directly modulated fluid osmolality cerebral temperature also considered the triggering mechanisms also depends multiple neural humoral signals periphery the latter ones reach brain via cerebral circulation blood reach brain integrative centres particulatly located cvos since outside bbb 5466 in frame basic problem already faced claude bernard definition internal medium characterization distinctive features physiological terms propose hierarchic order among isf maintain brain isf real internal medium higher vertebrates since important isf triggering complex responses allowing free independent life particularly true human beings mentioned assumption deny holistic view human organism gives aspect brain body medicine recently investigated also surprising new aspect namely synergistic role brain gut microbiota 73 thus general relevance brain body interactions main subject investigations main highly focused subject paper brain circuits kidney functions modulate brain isf composition thus according proposal brain isf represents core fluid compartment provides optimal environment development survival together csf allows vt intercellular communications among brain complex cellular networks 58,74 thus brain isf likely crucial functional component multifaceted integrative cns actions involved dynamic predictive homeostatic mechanisms overriding controls the crucial role brain isf also indicated evidence exchange signals brain fluid compartments highly regulated way fig our view brain isf highest hierarchic role triggering dynamic homeostatic responses involved balance volume sodium concentrations ecf well cerebral temperature control as discussed suggested two functionally interrelated parameters play crucial role high level integrative actions cns involved control psychic state agreement view many clinical studies demonstrate correlations water sodium balance homoeothermic balance psychic conditions subject actually reported psychic stresses increase plasma csf levels cortisol also adh 75 ii adh plasma levels increased depressed patients 76 iii epidemiological studies demonstrated correlation depression habitats high salinity 77 iv schizophrenic patients alterations control body temperature 78 v rpv1 channels beside responding osmotic signals also activated cerebral temperature 6,72 level cerebral cortex altered depression 79 it introduced term psycho physic allostasis indicate responses aimed maintenance internal medium homeostasis also broader condition well subject hence eudaimonia 16,17 see section body psychic homeostasis this condition well especially depends interactions systems organism supra systems thus eudaimonia depend interactions human external physical environment even interactions subject socio cultural environment according proposal brain isf mirror fluid csf highest hierarchic role since allow optimal conditions cns integrative actions in particular body fluid core temperature controls two chemico physical parameters essential free independent life human beings possible cns operates optimal conditions furthermore proposed several instances appropriate oscillatory rhythm often exclusively circadian rhythm chemico physical parameter within appropriate set range essential component allostasis thus several instances load error result discrepancy internal medium value simply set range values appropriate oscillatory rhythm chemico physical parameter scrutiny a consequence assumption dyshomeostasis actually present even chemico physical parameter scrutiny within appropriate set range inappropriate rhythmic oscillations thus careful analysis chemico physical parameters dynamic patterns considered plasmatic level also csf level matter fact interesting observing concentration rhythms sodium differentially regulated fig 5 csf 80 comparisons sodium concentrations rhythms systemic circulation 81 this aspect clinical implications since shown correlation exists rising levels csf sodium levels timing migraine onset 80 also since recently stated water sodium homeostasis inextricably coupled cns integrative actions 82 regard neuroscience describes inverse relationship intensity neuropil function amount water contains different shrinkage ecm according neuronal activity 30,82,83 discussed variations ecm perviousness profound effects vt signals diffusion 29,30,74 hence also regulate exchange signals isf blood isf csf isf vrs thus exchanges blood born brain born vt signals depend also extent ecm hydration composition 30,82,83 ) could one important feature characterizing brain kidney interactions since mentioned integrative centres feedback mechanisms involved na water cerebral temperature homeostasis localized cvos level outside bbb separated barriers isf background bases recently published data 6,72 ) it proposed na osmolality cerebral temperature continuously monitored brain particular cvos level strictly regulated thanks brain kidney interactions maintain optimal set range brain isf turn necessary prerequisite brain integrative actions furthermore basis clinical data mentioned proposed na osmolality cerebral temperature interconnected parameters playing fundamental role psychic allostasis thus surmised clinical evaluations parameters paramount importance psychic homeostasis subject could modulated optimizing interactions socio cultural environment lives well psycho therapy words could proposed potential relevance monitoring internal medium na cerebral temperature psycho therapy treatments like ones administrated patients suffering post traumatic stress disorders 16,8486 thus could relevant evaluate physical internal medium parameters psychological eudaimonia therapeutic effects produced addressing patient inner speech way favoring predictive psychic allostasis peaceful scenarios this could lead better dealing stressing actions supra systems traumatic memory traces face 23,85,86	in this review , the aspects and further developments of the concept of homeostasis are discussed also in the perspective of their possible impact in the clinical practice , particularly as far as psychic homeostasis is concerned . a brief historical survey and comments on the concept of homeostasis and allostasis are presented to introduce our proposal that is based on the classical assumption of the interstitial fluid ( isf ) as the internal medium for multicellular organisms . however , the new concept of a hierarchic role of isf of the various organs is introduced . additionally , it is suggested that particularly for some chemico - physical parameters , oscillatory rhythms within their proper set - ranges should be considered a fundamental component of homeostasis . against this background , we propose that the brain isf has the highest hierarchic role in human beings , providing the optimal environment , not simply for brain cell survival , but also for brain complex functions and the oscillatory rhythms of some parameters , such as cerebrospinal fluid sodium and brain isf pressure waves , which may play a crucial role in brain physio - pathological states . thus , according to this proposal , the brain isf represents the real internal medium since the maintenance of its dynamic intra - set - range homeostasis is the main factor for a free and independent life of higher vertebrates . furthermore , the evolutionary links between brain and kidney and their synergistic role in h2o / na balance and brain temperature control are discussed . finally , it is surmised that these two interrelated parameters have deep effects on the central nervous system ( cns ) higher integrative actions such those linked to psychic homeostasis .
transfusion red blood cell rbc concentrates critically ill patients remains controversial generated much research debate medical literature a recent large noninferiority randomized clinical trial adds important piece quite complicated puzzle stable critically ill anemic hemoglobin 9.5 g dl children 3 days 14 years age study demonstrated restrictive strategy threshold hemoglobin concentration 7 g dl significantly decreased transfusion requirements without increasing adverse outcome defined composite death development new progressive organ failure compared liberal strategy threshold hemoglobin 9.5 g dl anemia common critically ill patients results large number rbc transfusions several studies reported 50% adult children hospitalized intensive care unit received rbc transfusions 2 4 interestingly observational studies reported hemoglobin level rather clinical physiological factors drives transfusion decision the adequacy hemoglobin concentration given clinical situation depends whether sufficient amount oxygen carried tissues meet metabolic requirements the optimal hemoglobin threshold rbc transfusion different populations especially critically ill patients remains unknown the study lacroix colleagues confirms results reported two randomized trials evaluated impact restrictive strategy outcome critically ill adults preterm infants using 30-day mortality primary outcome 838 euvolemic adult critically ill patients hbert colleagues demonstrated restrictive transfusion strategy least effective liberal one in addition applying liberal transfusion strategy resulted significantly higher multiple organ dysfunction score composite outcome taking account 30-day mortality number organ failures this deleterious effect might attributed fact rbc units transfused study leukocyte reduced contrast rbc units used study lacroix colleagues two studies adults premature infants one meta analysis randomized controlled trials reported leukoreduced rbc transfusion could significantly improve outcome high risk patients 8 10 it decided therefore repeat prospective controlled randomized study compare hemoglobin thresholds 7 versus 9 g dl using composite primary outcome including death home discharge survival severe retinopathy bronchopulmonary dysplasia brain injury cranial ultrasound 451 infants birth weight 1,000 g kirpalani and interestingly thresholds developed study based whether infant receiving respiratory support although specified study performed 1999 included canadian centers may reasonably assumed authors used leukoreduced rbc units the results study contrast bell colleagues reported smaller trial n 100 infants restrictive transfusion group likely intraparenchymental brain hemorrhage periventricular leukomalacia however combination pre specified outcome study powered primary outcome number transfusions studies use restrictive approach associated decreased number transfusions decrease number patients exposed rbc transfusion using liberal approach achieve higher hemoglobin concentration attempt increase oxygen delivery thus tissue oxygenation stable critically ill patients appear associated significant clinical benefit several authors suggested rbc storage process could affect ability rbcs transport deliver oxygen phenomenon responsible lack apparent improvement tissue oxygenation transfusion human studies effects stored rbcs scarce controversial nine healthy volunteers undergoing acute isovolemic hemodilution differences ability transfused fresh stored 5 hours stored 3 weeks rbcs reverse neurocognitive deficit observed acute anemia critically ill patients the effect rbc storage gastric mucosal oxygenation remains controversial randomized multicenter pilot trial hbert colleagues did observe differences mortality rates life threatening complications patients transfused fresh median age 4 days versus old median age 19 days rbcs study lacroix colleagues average length storage 16.0 10 days strategy groups the effect rbc storage time primary outcome evaluated stable critically ill patients hemoglobin concentration ranging 6 7 10 g dl increased evidence restrictive transfusion approach based predefined hemoglobin concentration influence outcome the decision transfuse patients would therefore depend primarily clinical judgment taking account ability patient increase cardiac output oxygen extraction level tissue oxygen demand it remains demonstrated high risk patients symptomatic transfusion strategy effective possibly superior hemoglobin based transfusion strategy this aim ongoing focus study comparing two strategies patients 50 years age older undergo surgical repair hip fracture clinical evidence cardiovascular disease cardiovascular risk factors although study lacroix colleagues adds important piece puzzle still remains incomplete	in stable critically ill children , the adoption of a restrictive transfusion strategy based on a predefined hemoglobin threshold of 7 g / dl significantly decreased transfusion requirements without affecting outcome . these results strengthen previous observations made in volume resuscitated adults when a similar blood transfusion strategy was used . it also indirectly corroborates studies reporting the beneficial effects of leukoreduction of red blood cell ( rbc ) transfusion units on patient outcome . this study indicated that the maintenance of a higher hemoglobin concentration with rbc transfusion in an attempt to increase tissue oxygen delivery is not associated with a clinical benefit . this may be related to the storage process , which could affect the ability of rbcs to transport and deliver oxygen to the tissues . this point , however , remains controversial . it should also be remembered that increasing hemoglobin concentration will not always result in a greater oxygen delivery , as transfusion related increased blood viscosity could be associated with a reduction in blood flow . further research should compare a symptomatic transfusion strategy to a hemoglobin - based strategy on the outcome of high risk patients .
removal infected carious dentin exacting procedure routinely accomplished tooth preparation prior placing restoration although explorer verified hardness equal normal dentin traditionally considered ideal endpoint excavation caries indicator dyes developed provide objective easily recognized visual differentiation endpoint.14 dyes also distinguish outer layer soft highly infected carious dentin deeper layer somewhat softened uninfected lightly infected dentin.5,6 caries detector kuraray america ny ny caries finder red danville materials san ramon ca two representative products consisting 1% acid red 52 dye sulforhodamine b propylene glycol.7 recent approach minimizing unwanted staining caries indicator dyes change solvent dye compound the rationale based upon two studies showed diminished diffusion porous tissues dyes dissolved higher molecular weight solvents.810 instead propylene glycol mw=76 pg mixture pg water used many currently marketed caries dye products new formulations using larger molecules polypropylene glycol mw=300 example ppg proposed 2005 a us patent application filed type caries detecting solution.11 application discloses range inventive examples including solutions containing various mixtures ppg molar weight 300 polyethylene glycol molar weights 400 4000 pg glycerin water two new caries indicator dye products available japan caries check red caries check blue nishika co. yamanashi jp consisting 1% acid red 52 brilliant blue dye 300 mw ppg a studies indicate least indirectly ppg based dye solutions may provide conservative excavation endpoint final excavated surfaces determined pg based dye solution ppg based dye solution compared using micro vickers hardness mvh found ppg dye determined group significantly softer pg dye determined group mean mvh 32.7 vs. 44.7).12 since hardness generally increases increasing depth dentin carious lesions result would suggest shallower conservative endpoint ppg dye determined specimens.3 groups found free bacteria histologically concluded ppg dye determined endpoint would preferable however since hardness generally decreases increasing depth normal dentin clinical interpretation hardness differences somewhat obscured after initial report studies incorporating laser fluorescence comparisons pointed toward similar conclusion least permanent teeth the rationale using laser fluorescence values dd diagnodent kavo usa assess differences excavation endpoints based upon study spectral autofluorescence characteristics carious lesions well general guidelines interpretation dd values detecting carious lesions occlusal fissures.1315 extracted carious teeth shown mean mvh significantly lower dd values significantly higher ppg dye determined group versus pg dye determined group.16 another study similar result found group mean dd value permanent teeth primary teeth.17 another study using extracted teeth containing acute chronic carious lesions also found mean dd value higher ppg dye determined group versus pg dye determined group.13 clinical study result regarding dd values confirmed permanent teeth primary teeth.8 one studies also found specimens first excavated endpoint indicated ppg based dye could subsequently stained pg based dye suggesting ppg based dye solutions may indicate conservative endpoint excavation.13 direct confirmation apparently conservative endpoint indicated ppg based dyes necessary several reasons first although initial studies demonstrate statistically significant difference mean mvh dd value sample groups clear whether difference exists carious lesions certain ones addition although microhardness generally increase increasing depth dentin carious lesion relationship microhardness depth neither linear constant tooth tooth.18 similarly although dd values generally decrease increasing depth dentin carious lesion inverse relationship linear certainly constant tooth tooth.19 true unexcavated lesion surface across pg dye guided excavation front.19 light variables assess clinical implications cavity preparation necessary investigate differences actual physical locations surfaces created ppg dye guided excavation created pg dye guided excavation the purpose study determine difference location caries dye staining endpoint indicated 1% acid red 52 dye pg versus indicated 1% acid red 52 dye ppg freshly extracted human permanent posterior teeth containing primary dentin carious lesions dye solutions made completely dissolving 0.100 g acid red 52 sulforhodamine b s-9012 sigma chemical co. st louis mo 10.00 ml propylene glycol sigma p-1009 10.00 ml polypropylene glycol triol type mw=300 160 17605 wako chemicals usa richmond va room temperature solutions stirred hand ten minutes vortex mixed two minutes twenty four hours later freshly extracted unrestored human permanent posterior teeth primary occlusal carious lesions collected irb exempt protocol teeth stored sterile distilled water 4c two weeks prior processing the outer surface specimen cleaned soft bristle toothbrush sterile distilled water sectioned horizontally dentino enamel junction root portion discarded pulp tissue removed crown portion two opposing axial surfaces ground flat parallel perpendicular previous horizontal section plane using 8 240 grit carborundum disc mounted water lubricated surface polisher model 900 electron microscopy sciences hatfield pa preparation splitting continuous fine groove cut 1 mm deep center ground axial surface running occlusogingivally connecting across occlusal surface approximately bisecting external surface carious lesion the groove made 1 thin diamond disc mounted lowspeed handpiece provide identical reference marks split tooth halves two six orientation notches 2 mm deep made 57 carbide bur across perpendicular fine groove various locations region carious lesion the crown specimens fractured along groove using 3/8 steel chisel mallet yielding two segments containing split surface showing carious lesion cross section one two surfaces crown specimen chosen random stained ppg based dye pg based dye two drops dye applied ten seconds rinsed running tap water ten seconds surface blotted damp dry cotton gauze square observed 2.6x loupe magnification specimen pairs discarded fractured along fine groove missing tooth structure lesion observed dentin lesion extended pulp chamber lesion dark permit differentiation red dye staining lesion less 1 mm dentin previously unobserved restoration detected of 41 specimens originally collected 18 accepted analysis controls three 18 fractured specimen pairs stained surfaces 1% sulforhodamine b pg color digital images made fracture surface using digital microscope camera optem zoom-100 qioptiq rochester ny dp-11 olympus america melville ny 10x magnification ring light illumination eke schott fostec auburn ny ) image files created following settings white balance 3000k resolution set hq 17121368 pixels iso 100 ring light brightness 70 1/15 sec exposure images saved as.jpg files standardize orientation fracture surface relative camera both a machinist square fastened stand base fix position removable aluminum block specimens mounted using thin layer boxing wax linear calibration millimeter grid fixed block image pairs analyzed using digital image analysis software program image pro discovery 4.5 media cybernetics silver spring md for specimen one two image pairs opened flipped left right magnified 3x using graphic tablet digital pen intuos 3 wacom vancouver wa pulpal extent red dye staining the image pair opened magnified 3x pulpal extent dye staining marked one pixel wide blue line this accomplished selecting rectangular region interest one image included blue yellow line well millimeter reference grid edge aluminum mounting block reference notches specimen surface the selected area copied pasted image using 50% translucency setting paste operation providing means visually align two image pairs reference notch edges aluminum mounting block edge permitting blue yellow marked lines clearly seen the distance yellow blue lines measured using software linear measurement tool 2x magnification calibration based millimeter grid image distance measured line line l l distance five locations beginning center lesion two additional measurements either side spaced 0.5 mm apart perpendicular occlusally located line recorded millimeters two decimals this measurement protocol repeated 15 experimental samples two three control samples providing total 150 experimental ten per sample 50 five ten per sample control l l distance measurements for control 6 experimental 15 specimen image pairs mean l l distance values calculated using means a weighted average calculated combined control group combined experimental group the weighted averages based adjustment six fifteen mean l l distance values specimen group variance individual l l distance values within group a 95% confidence interval calculated weighted averages evaluate test method 3-factor anova specimen measurement replication rank transformed data was carried control experimental data individual specimens control 6 experimental 15 using repeated measurements test pair 5 replication measurement protocol 2 prior anova data control experimental groups analyzed normality using shapiro wilk test all statistical analysis used sas v9.1 software sas institute cary nc for 12 15 experimental specimen image pairs line corresponding ppg dye staining located occlusally shallower throughout length line corresponding pg dye staining two image pairs the ppg dye staining line predominately located occlusally areas two lines coincident pg dye staining line shallower for two specimen image pairs true iterations image analysis protocol specimen # 4 image pair pg dye staining line shallower 12% first iteration 51% second iteration line length coincident 11% first iteration specimen 8 image pair the pg dye staining line shallower 14% 19% line length coincident 5% 13% respectively for one specimen image pair 1 dye staining lines coincident 2% line distance one iteration elsewhere ppg dye staining line shallower mean l l distances small ranging 0.0377 mm 0.0952 mm mean l l distances larger controls ranging 0.153 mm 0.506 mm individual distances ranged 0.12 mm 0.66 mm table 3 presents data weighted averages means control experimental specimen image pairs control specimen image pairs the weighted average l l distance 0.70 mm 95% confidence interval 0.51 mm 0.89 mm versus 0.298 mm l l distance 95% confidence interval 0.2140 mm 0.357 mm experimental group the weighted average l l distance experimental group four times control group overlap 0.151 mm two confidence intervals the shapiro wilk test normality indicated control data normally distributed p=.1226 experimental data normally distributed p=.0003 therefore anova ranks used detect effects groups significance level p=.05 the anova ranks detected significant effect specimen measurement replication control data table 4 summarizes anova ranks results effects control experimental groups the 0.298 mm weighted average l l distance experimental specimens clinically relevant since possible remove dentin increments magnitude potentially resulting conservative cavity preparations even preventing unnecessary pulp exposures instances this advantage somewhat limited however 0.3 mm represents perhaps one two careful applications hand excavator round bur l l distance ranged considerably 0.12 mm 0.66 mm within specimens aggressive excavation technique exceeding 0.3 mm even less per increment advantage conservative ppg based caries dye endpoint would often negated however cases careful excavation using ppg based dye could actually prevent exposure deep lesions approaching pulp carious lesions differ type amount bacterial load nutrient availability morphology dentin varies according location age reaction pattern considerable variation would expected l l distances among specimen sets primary teeth chronic lesions active lesions root lesions lesions associated restorations the results study interpreted caution especially clinical application since difference found dd values excavation surfaces created using pg based versus ppg based dyes primary teeth two previous studies may l l distance difference exists primary teeth for reason present study needs repeated primary teeth.8,17 solvents solvent mixtures well dyes sulforhodamine b may produce different results would also need tested fractured dentin surface used present study does include smear layer would sometimes produced clinically burs hand excavators may therefore indicate conservative endpoint since smear layer might stain dye originated elsewhere preparation therefore present study may represent idealized staining result compared clinical situations the differences weighted averages control experimental groups well results anova ranks analysis indicate present method useful differentiating staining endpoints caries dyes the method able detect relatively small l l distance approximately four times average error seen control group small groups specimen effect detected anova would expected clinical specimens varying lesion location activity size etc effect detected control group almost experimental group p=0.0510 also expected due lesser variations measurement orientation versus dentin tubule orientation example effect detected either group indicating acceptable degree consistency runs future studies errors might reduced precise machining splitting groove orientation notches color corrected thresholding stained specimen surface present study light pink staining encountered dye stained fracture surface was treated non stained therefore dye stain demarcation line drawn shallow light pink staining border red light pink staining previous studies using dd mvh detect endpoint differences pg based versus ppg based caries dyes light pink staining pg group sometimes kept place sometimes removed prior surface testing.8,13,16,17 present study dye stain demarcation line drawn border non stained light pink stained dentin l l distances would greater instances further study indicated determine tendency ppg based dyes stain dentin light pink characterize areas according hardness bacterial load etc long term clinical trials showing improved clinical outcomes dye based excavation endpoints versus conventionally determined endpoints let alone one type dye solution in fact clinical studies comparing outcomes excavation methods general quite limited in one clinical study restorations primary teeth differences found one year regarding marginal adaptation secondary caries chemo mechanical excavation group compared conventional hand excavation group.20 another study restorations primary teeth followed six months difference detected survival rate restorations chemo mechanical excavation group compared conventional bur excavation group.21 factors restoration longevity margin integrity tooth structure integrity pulpal health secondary caries relevant considerations regard ppg based dye excavation also compared excavation methods chemo mechanical polymer bur fluorescence aided excavation vitro clinically.2224 studies completed optimal endpoint excavation carious dentin remain matter debate based primarily indirect evidence under experimental conditions compared pg based sulforhodamine b caries dye solution ppg based dye solution provides significantly shallower excavation endpoint 0.298 mm 95% confidence interval 0.240 mm	objectivesthis study determined the difference in the location of the caries dye staining endpoint of 1% acid red dye in propylene glycol versus that of 1% acid red dye in polypropylene glycol.methodsfreshly extracted permanent molar crowns with primary occlusal carious lesions were chisel - split axially to expose the lesion in cross - section on both halves . one half was stained with propylene glycol - based dye and the other with polypropylene glycol - based dye . for the control group , both halves were stained with propylene glycol - based dye . the dye staining front was marked on digital images of the stained split surfaces , and the images were aligned using reference notches . the distance between the marked staining front lines was measured in five locations , and the measurement protocol was repeated . weighted averages and a 95% confidence interval for the distance between marked staining front lines were calculated for the control and experimental groups.resultsthe weighted average distance for the experimental group ( 0.298 mm , 95% confidence interval 0.240 mm 0.357 mm ) was about four times that of the control group ( 0.070 mm , 95% confidence interval 0.051 mm 0.089 mm ) . generally , the marked staining line for the polypropylene glycol - based dye specimens was located shallow ( occlusal ) to the propylene glycol - based staining line ( range 0.12 mm to 0.66 mm).conclusionsthe staining endpoint of 1% acid red dye in polypropylene glycol is shallower than that of 1% acid red dye in propylene glycol . the method is useful for comparing staining endpoints of caries dye formulations . ( eur j dent 2008;2:2936 )
	heterogeneous diffusion dynamics of molecules play an important role in many cellular signaling events , such as of lipids in plasma membrane bioactivity . however , these dynamics can often only be visualized by single - molecule and super - resolution optical microscopy techniques . using fluorescence lifetime correlation spectroscopy ( flcs , an extension of fluorescence correlation spectroscopy , fcs ) on a super - resolution stimulated emission depletion ( sted ) microscope , we here extend previous observations of nanoscale lipid dynamics in the plasma membrane of living mammalian cells . sted - flcs allows an improved determination of spatiotemporal heterogeneity in molecular diffusion and interaction dynamics via a novel gated detection scheme , as demonstrated by a comparison between sted - flcs and previous conventional sted - fcs recordings on fluorescent phosphoglycerolipid and sphingolipid analogues in the plasma membrane of live mammalian cells . the sted - flcs data indicate that biophysical and biochemical parameters such as the affinity for molecular complexes strongly change over space and time within a few seconds . drug treatment for cholesterol depletion or actin cytoskeleton depolymerization not only results in the already previously observed decreased affinity for molecular interactions but also in a slight reduction of the spatiotemporal heterogeneity . sted - flcs specifically demonstrates a significant improvement over previous gated sted - fcs experiments and with its improved spatial and temporal resolution is a novel tool for investigating how heterogeneities of the cellular plasma membrane may regulate biofunctionality .
lipolysis describes hydrolysis triacylglycerols tgs commonly referred fat mid-19 century the great french physiologist claude bernard bernard 1856 noted pancreatic juice mammals able efficiently degrade fat form butter oil his observation led partial characterization pancreatic fat splitting ferment balser balser 1882 langerhans langerhans 1890 flexner flexner 1897 the importance lipolysis general metabolism became apparent whitehead whitehead 1909 discovered fat tgs could enter cells unhydrolyzed form absolute requirement tg hydrolysis cellular uptake release fatty acids fas and glycerol defines three processes vertebrate physiology lipolysis essential gastrointestinal lipolysis mediates catabolism dietary fat vascular lipolysis responsible hydrolysis lipoprotein associated tgs blood intracellular lipolysis catalyzes breakdown tgs stored intracellular lipid droplets lds subsequent export fas adipose tissue metabolism nonadipose tissues although fundamental aspects lipolysis understood early took century identify isolate characterize main fat splitting ferments called lipases since 1900 the chief lipolytic enzymes gastrointestinal tract lingual lipase gastric lipase pancreatic lipase pancreatic lipase related proteins 1 2 3 vascular tg hydrolysis depends lipoprotein lipase lpl hepatic tg lipase intracellular lipolysis tgs involves neutral ph optimum around ph 7 acid lipases present lysosomes ph optimum ph 45 well characterized neutral tg hydrolases include adipose triglyceride lipase atgl hormone sensitive lipase hsl whereas lysosomal acid lipase lal important lipase lysosomes besides active serine site enzymes share obvious structural homologies unrelated pancreatic lipase family lipolysis catabolic branch fa cycle provides fas times metabolic need removes present excess fas essential substrates energy production synthesis lipids including membrane lipids lipids involved cellular signaling accordingly uni- multicellular organisms able synthesize fas de novo endogenous fas carbohydrate and/or protein metabolites despite fundamental physiological importance oversupply fas is highly detrimental increased concentrations nonesterified fas disrupt integrity biological membranes alter cellular acid base homeostasis elicit generation harmful bioactive lipids these effects turn impair membrane function induce endoplasmic reticulum er stress mitochondrial dysfunction inflammation cell death collectively deleterious effects subsumed term lipotoxicity unger et al 2010 countermeasure essentially cells able detoxify nonesterified fas esterification glycerol yield inert tgs additionally higher organisms store fas specialized organ i.e. adipose tissue supplies fas high demand tissues liver muscle exogenous fas carefully regulated balance fa esterification tg hydrolysis creates efficient buffer system allowing sufficient fa flux without nonphysiological increases cellular nonesterified fa concentrations moreover fa cycling creates metabolic intermediates utilized anabolic processes extra- intracellular signaling molecules we summarize recent advances understanding enzymatic mechanisms lipolytic process patho)physiological impact lipolysis energy homeostasis cellular signaling neutral hydrolysis tgs fas glycerol requires three consecutive steps involve least three different enzymes atgl catalyzes initial step lipolysis converting tgs diacylglycerols dgs hsl mainly responsible hydrolysis dgs monoacylglycerols mgs mg lipase mgl hydrolyzes mgs in adipose tissue atgl hsl responsible 90% tg hydrolysis schweiger et al 2006 although nonadipose tissues also express atgl hsl expression levels low tissues raising question whether lipases additionally required efficient lipolysis 2004 villena et al 2004 zimmermann et al 2004 belongs family patatin domain containing proteins including nine human eight murine members the patatin domain originally discovered lipid hydrolases potato plants named abundant protein potato tuber patatin members family act phospholipases proteins officially named patatin like phospholipase domain containing protein a1 a9 pnpla19 wilson et al 2006 unfortunately name misleading implies members family phospholipases however several pnpla proteins minor phospholipase activity appropriate designation family orthologous enzymes found essentially eukaryotic species including vertebrates invertebrates plants fungi active site enzyme contains unusual catalytic dyad s47 d166 within patatin domain rydel et al 2003 this domain comprises 180 aa embedded within 250 aa sandwich structure protein nh2-terminal half the cooh terminal half predominantly regulatory function contains predicted hydrophobic region ld binding duncan et al 2010 schweiger et al loss region increases specific vitro activity atgl artificial tg substrates blunts intracellular activity due inability truncated enzyme bind cellular lds regulation atgl expression enzyme activity complex lass et al 2011 atgl mrna expression elevated peroxisome proliferator activated receptor ppar agonists glucocorticoids fasting whereas insulin food intake decrease expression more recently shown mtor complex 1-dependent signaling reduces atgl mrna levels chakrabarti et al 2010 conversely activation foxo1 sirt1-mediated deacetylation activates lipolysis increasing atgl mrna levels sirt1 silencing opposite effect chakrabarti et al 2011 the abundance atgl hsl mrna always correlate cellular lipase activity for example isoproterenol tumor necrosis factor- reduce atgl hsl mrna levels adipocytes kralisch et al 2005 conversely stimulate lipase activities fa glycerol release discrepancy enzyme mrna levels activities is explained extensive posttranslational regulation atgl hsl discussed at least two serine residues atgl phosphorylated s406 s430 murine enzyme bartz et al 2007 in contrast hsl see atgl modification protein kinase pka)-dependent zimmermann et al 2004 sul recently showed amp activated kinase ampk phosphorylates s406 leading increased hydrolytic activity murine atgl ahmadian et al 2011 the role ampk regulation lipolysis controversial data showing ampk induces gaidhu et al 2009 yin et al 2003 inhibits daval et al 2005 gauthier et al 2008 effect chakrabarti et al 2011 lipolysis interestingly nematode caenorhabiditis c. elegans ampk mediated phosphorylation atgl-1 worm ortholog mammalian atgl different phosphorylation sites inhibits tg hydrolysis narbonne roy 2009 delays consumption tg stores prolongs life span stress induced dauer larval stage ( cgi-58 full hydrolase activity lass et al 2006 cgi-58 originally discovered screen comparing proteomes humans c. elegans the gene officially named hydrolase domain containing protein-5 abhd5 owing presence hydrolase domain commonly found esterases thioesterases lipases however cgi-58 unlikely exhibit hydrolase activity due fact asparagine-153 n153 cgi-58 replaces nucleophilic serine residue required active site enzymatically functional members esterase thioesterase lipase family interestingly substitution n153 serine convert cgi-58 lipid hydrolase tgs dgs mgs short fa glycerol esters a. lass et al unpublished epidermis skin cgi-58 may also stimulate another currently unknown tg hydrolase distinct atgl radner et al 2010 importantly two laboratories showed cgi-58 least vitro exhibits enzymatic activity acylcoa dependent acylglycerol-3-phosphate acyltransferase agpat ghosh et al it may affect phosphatidic acid lysophosphatidic acid signaling brown et al 2010 recently ( yang et al 2010b discovered specific peptide inhibitor atgl the protein originally identified blood mononuclear cells act g0 g1 transition cell cycle consistent function named g0g1 switch protein 2 g0s2 human murine g0s2 predicted primary structure 103 aa protein found many tissues highest concentrations adipose tissue liver consistent lipase activities g0s2 expression low adipose tissue fasting increases feeding yang et al 2010b conversely fasting ppar-agonists increase hepatic g0s2 expression zandbergen et al 2005 the protein localizes multiple cellular compartments including lds cytoplasm er mitochondria the different localizations may reflect multiple functions g0s2 regulating lipolysis cell cycle possibly apoptosis via ability interact mitochondrial antiapoptotic factor bcl2 welch et al 2009 in vitro ld binding inhibition atgl depend physical interaction nh2-terminal region g0s2 involving aa 2742 patatin domain atgl lu et al 2010 elucidation whether g0s2 also regulates tissue specific lipolysis vivo require characterization g0s2 transgenic knockout mouse models ld associated proteins participate cgi-58-mediated regulation atgl figure 1 left hormonally nonstimulated white brown adipocytes perilipin-1 interacts cgi-58 preventing binding thus induction atgl upon -adrenergic stimulation protein kinase pka phosphorylates perilipin-1 multiple sites including critical serine-517 residue causing release cgi-58 thus -adrenergic stimulation pka induces atgl activity phosphorylation perilipin-1 direct enzyme phosphorylation consistent model frameshift mutants perilipin-1 humans l404fs v398fs fail bind cgi-58 leading unrestrained lipolysis partial lipodystrophy hypertriglyceridemia insulin resistance gandotra et al 2011 atgl mediated tg hydrolysis nonadipose tissues high fa oxidation rates muscle liver follows another mechanism tissues perilipin-1 replaced perilipin-5 figure 1 right fasting perilipin-5 recruits atgl cgi-58 lds direct binding enzyme coactivator formation ternary complex involves cooh terminal region perilipin-5 aa 200463 granneman et al 2011 recent data suggest involved interaction lds mitochondria inhibits atgl mediated tg hydrolysis wang et al 2011 whether perilipins-2 -3 -4 also interact either atgl cgi-58 disputed overexpression perilipin-2 hepatocyte cell lines inhibits atgl activity restricting physical access lds direct protein protein interaction probably required bell et al 2008 listenberger et al 2007 recently several groups reported pigment epithelium derived factor pedf induces tg hydrolysis adipose tissue muscle liver via atgl borg et al 2011 ; pedf widely expressed 50 kd protein noninhibitory serpin family serine protease inhibitors filleur et al 2009 it exhibits large spectrum bioactivities including antiangiogenic antitumorigenic neuroprotective antioxidative antiinflammatory effects pedf binds atgl activates enzymatic activity borg et al 2011 notari et al 2006 although mechanism remains clarified atgl activation pedf may involved pathogenesis insulin resistance development hepatosteatosis another important aspect atgl regulation identified genetic analyses ld formation drosophila d. melanogaster l2 cells beller et al 2008 guo et al compelling results showed atgl delivery lds requires functional vesicular transport absence essential protein components transport machinery adp ribosylation factor 1 arf1 small gtp binding protein 1 sar1 guanine nucleotide exchange factor golgi brefeldin resistance factor gbf1 deficiency coatamer protein coat complex ii atgl translocation lds blocked enzyme remains associated er soni et al 2009 the process requires physical binding atgl gbf1 ellong et al 2011 in early 1960s noted lipolytic activity present adipose tissue induced hormonal stimulation landmark paper published d. steinberg group vaughan et al 1964 ) although classic work originally noted hsl much better dg hydrolase tg hydrolase standard textbook knowledge perpetuated conclusion hsl rate limiting catabolism fat stores adipose many nonadipose tissues view required revision hsl deficient mice efficiently hydrolyzed tgs osuga et al 2000 hsl deficient mice showed signs tg accumulation either adipose nonadipose tissues instead accumualted large amounts dgs many tissues suggesting vivo enzyme important dg- tg hydrolase haemmerle et al 2002 although originally somewhat controversial rydn et al 2007 accepted atgl responsible initial step lipolysis human adipocytes hsl rate limiting catabolism dgs bezaire et al 2009 in addition dgs hsl also hydrolyzes ester bonds many lipids e.g. tgs mgs cholesteryl esters retinyl esters short chain carbonic acid esters fredrikson et al 1986 highest mrna protein concentrations found white adipose tissue wat brown adipose tissue bat low expression detected many tissues including muscle testis steroidogenic tissues pancreatic islets holm et al 2000 alternative exon usage leads tissue specific differences mrna protein size holst et al in adipose tissue hsl protein comprises 768 aa unlike atgl orthologous enzymes found across eukarya hsl less ubiquitous phylogenetically for example hsl ortholog known birds c. elegans d. melanogaster saccharomyces s. cerevisiae interestingly closest structural relatives hsl found prokaryotes e.g. lipase 2 moraxella ta144 langin et al 1993 functional studies delineated hsl nh2-terminal lipid binding region hydrolase fold domain including catalytic triad regulatory module containing known phosphorylation sites important regulation enzyme activity holm et al 2000 since atgl hsl hydrolyze tgs coordinated manner unexpected share many regulatory similarities adipose tissue hsl enzyme activity strongly induced -adrenergic stimulation whereas insulin strong inhibitory effect while -adrenergic stimulation regulates atgl primarily via recruitment coactivator cgi-58 see hsl major target pka catalyzed phosphorylation strlfors belfrage 1983 other kinases including ampk extracellular signal regulated kinase glycogen synthase kinase-4 ca calmodulin dependent kinase also phosphorylate hsl modulate enzyme activity lass et al the enzyme least five potential phosphorylation sites s660 s663 appear particularly important hydrolytic activity anthonsen et al 1998 enzyme phosphorylation affects enzyme activity moderately approximate 2-fold induction full activation hsl must gain access lds adipose tissue mediated perilipin-1 simultaneously hsl pka also phosphorylates perilipin-1 six consensus serine residues result hsl binds nh2-terminal region perilipin-1 thereby gaining access lds miyoshi et al 2007 ; shen et al 2009 wang et al 2009 together hsl phosphorylation enzyme translocation lds coupled atgl activation cgi-58 result 100-fold increase tg hydrolysis adipocytes figure 1 for example receptor interacting protein 140 rip-140 shown induce lipolysis binding perilipin-1 increasing hsl translocation lds activating atgl via cgi-58 dissociation perilipin-1 ho et al 2011 in nonadipose tissues skeletal muscle hsl activated phosphorylation response adrenaline muscle contraction watt et al 2006 these tissues lack perilipin-1 remains determined alternative mechanisms regulate hsl access lds insulin mediated deactivation lipolysis associated transcriptional downregulation atgl hsl expression kershaw et al 2006 kralisch et al additionally insulin signaling results phosphorylation activation various phosphodiesterase pde isoforms pkb akt enoksson et al 1998 pde catalyzed hydrolysis camp inhibition pka actions halt lipolysis preventing phosphorylation hsl perilipin-1 activation translocation hsl activation atgl cgi-58 in addition peripheral action insulin also acts centrally via sympathetic nervous system inhibit lipolysis wat elegant studies scherer coworkers scherer et al 2011 showed increased insulin levels brain inhibit hsl perilipin phosphorylation leading reduced hsl atgl activities mgl considered rate limiting enzyme breakdown mgs derived extracellular tg hydrolysis lpl intracellular tg hydrolysis atgl hsl intracellular phospholipid hydrolysis phospholipase c membrane associated dg lipase the enzyme localizes cell membranes cytoplasma sakurada noma 1981 lds unpublished data mgl received significant attention following realization glycerophospholipid derived mg 2-arachidonylglycerol 2-ag major agonist endocannabinoid signaling inactivated hydrolytic activity mgl see mg signaling the importance mgl efficient degradation mgs recently confirmed mutant mouse models chanda et al 2010 schlosburg et al 2010 taschler et al lack mgl impairs lipolysis associated increased mg levels adipose nonadipose tissues alike mgl shares homology esterases lysophospholipases haloperoxidases contains consensus gxsxg motif within catalytic triad s122 a239 h269 mouse mgl typical lipases esterases very recently crystal structure mgl solved bertrand et al 2010 ; the enzyme exhibits classic fold hydrolases crystallizes dimer exhibits wide hydrophobic access catalytic site an apolar helix domain lid covers active site mediates interaction mgl membrane structures recruitment substrate experiments atgl deficient mice small molecule hsl inhibitors revealed atgl hsl responsible 90% lipolytic activity wat cultured adipocytes schweiger et al 2006 in nonadipose tissues contribution neutral lipases catabolism stored tgs may prominent for example liver fasted mice atgl accounts less 50% neutral tg hydrolase activity reid et al 2008 this activity physiologically important atgl deficient mice develop hepatosteatosis haemmerle et al however pronounced remaining activity hepatic tg hydrolase(s atgl deficient mice indicates lipases contribute highly dynamic turnover tgs this view supported observation mice lacking atgl liver apparent defect vldl biogenesis wu et al 2011 although assembly secretion hepatic vldl particles require substantial mobilization hepatic tg stores hsl also poorly expressed hepatocytes several members carboxylesterase lipase family pnpla family suggested potential tg hydrolases one carboxyl esterase-3/triglyceride hydrolase-1 ces-3/tgh-1 ortholog human ces-1 gained major interest recent characterization ces-3/tgh-1-deficient mice provided compelling evidence enzyme participates assembly secretion hepatic vldl wei et al 2010 how biological function conforms strict luminal localization tgh-1 er remains elucidated structural relatives atgl within pnpla family also considered potential tg hydrolases for example pnpla4 -5 exhibit tg hydrolase dg transacylase retinylester hydrolase activity vitro kienesberger et al the member highest homology atgl adiponutrin pnpla3 50% aa identity within patatin domain adiponutrin originally discovered nutritionally regulated adipose specific transcript unknown function baulande et al 2001 interest adiponutrin increased tremendously h. hobbs colleagues found strong genetic association nonsynonymous aa change i148 adiponutrin susceptibility develop nonalcoholic fatty liver disease nafld romeo et al 2008 several groups confirmed extended important finding showing robust associations i148 alcoholic- nonalcoholic liver disease hepatic fibrosis liver cirrhosis krawczyk et al 2011 tian et al 2010 ; the close similarity atgl well presence conserved structural motifs typical lipases esterases sandwich structure gxsxg motif within catalytic dyad suggest lipase function adiponutrin accordance assumption several groups reported adiponutrin acts tg hydrolase additionally exhibits dg transacylase activity et al 2010 huang et al 2011 jenkins et al 2004 lake et al however expression profile generated response fasting feeding induction adiponutrin gene expression srebp1a c chrebp argued vivo role adiponutrin lipolysis dubuquoy et al 2011 et al 2010 kershaw et al was also confounded pnpla3-deficient mice exhibited detectable phenotype lipid lipoprotein energy metabolism basantani et al overexpression i148 variant adiponutrin caused tg accumulation et al 2010 whereas overexpression wild type adiponutrin liver created obvious phenotype et al 2010 in addition classical lipolysis extralysosomal neutral lipases tgs cholesteryl esters also hydrolyzed lal lal thought catabolize primarily lipoprotein associated lipids subsequent receptor mediated endocytosis fusion lysosomes accordingly contribution lal activity lipolysis intracellular lds considered relevant given lysosomal localization lal intuitively obvious lipids lds would enter lysosomes addressing singh colleagues reported compelling evidence linking lipolysis macroautophagy singh et al 2009a macroautophagy lysosomal pathway degrades superfluous damaged organelles well cytoplasmic inclusions misfolded protein aggregates levine kroemer 2008 these cytoplasmic cargos trapped inside double membrane vesicles autophagosomes ultimately fuse lysosomes contents degraded subsequently lipids aa released cytosol contribute energy aa supply times starvation thus along lipolysis macroautophagy one two conserved responses organismal cellular fasting 2009a found addition conventional neutral lipases autophagy lds required fasting induced lipolysis murine liver cultured hepatocytes they showed recruitment microtubule associated protein 1 light chain 3 lc-3 formation regional membrane conjugation autophagy related protein 7 atg7 gives rise double membrane vesicles engulf portions cytoplasmic lds autolipophagosomes the autolipophagosomes ultimately fuse lysosomes lipid content degraded lal chronic fat feeding impairs autophagic removal lipid stores liver prompting excessive hepatic lipid deposition 2010a strengthened findings showing hepatic atg7 expression severely impaired ob ob mice contributing hepatosteatosis animals while effects autophagy genetically obese mice mice fed high fat diets seem consistent role autophagy lipid metabolism normal mice remains controversial first autophagy appears predominantly relevant liver abnormally long fasting periods normally shorter fasting periods hepatic fat content increases due induction adipose tissue lipolysis increased fa supply liver consistent prediction hotamisligil colleagues observe hepatic steatosis changes serum tg fa levels lean mice following sirna mediated suppression atg7 arguing lipoautophagy involved yang et al 2010a second hepatosteatosis result atg7 deficiency observed studies although atg7 deficiency leads severe liver enlargement controversial whether tgs accumulate in fact uchiyama colleagues reported hepatic atg7 deletion upon starvation inhibits ld formation vivo vitro leads lower hepatic tg content shibata et al consistent role lc3 ld formation rnai mediated suppression lc3-expression prevented ld formation panel different hepatic nonhepatic cell lines interestingly lc3 localized surface lds authors argued lipidation lc3 phosphatidylethanolamine formation lc3-ii initial step autophagosome formation autophagy also required ld formation potential role autophagy lipogenesis lipolysis consistent finding external administration fas induces rather inhibits autophagy lds formed fasting liver tang et al 2011 a role autophagy lipogenesis also became evident analysis adipose tissue atg7-deficient mice assuming lipolytic defect speculated ablation autophagy adipocytes would result obese phenotype zechner madeo 2009 in contrast however adipose specific knockout atg7 resulted lean mice reduced adipose mass enhanced insulin sensitivity elevated rate -oxidation singh et al 2009b the adipocytes contained smaller multilocular lds exhibited normal basal lipolysis line inhibition autophagy cultured adipocytes using atg7 sirna blocked tg accumulation singh et al these data argue currently poorly understood role autophagy biogenesis lds interestingly adipose specific atg7-deficient mice display reduced wat mass bat mass increases baerga et al 2009 ; argued inhibition white adipocyte differentiation may lead defect lipogenesis blocked autophagy may promote wat bat transdifferentiation summary autophagy may pleiotropic roles lipid metabolism depending cell- tissue type liver autophagy may contribute lipolysis high fat diet prolonged fasting autophagy appears involved adipocyte differentiation lipogenesis lipolysis the role autophagy breakdown fat lipolytically active tissues muscle macrophages steroidogenic cells remains determined textbook knowledge tells us tgs efficient way store large amounts fas energy reserve consistent view cellular lds long seen relatively inert storage depot fat adipose tissue mobilized times increased energy demand this view changed realized 1 lds present essentially cell types including mere energy storage seem main purpose 2 lds particularly nonadipose tissues undergo dynamic changes formation degradation 3 lds represent reservoir bioactive lipids lipid derived hormones adipose nonadipose tissues role neutral lipid metabolism signaling gained substantial interest noted increased cellular tg concentrations strongly associated insulin resistance skeletal muscle liver cohen et al the relatively inert nature tgs makes unlikely interfere directly insulin signaling concept tgs culprit also supported called athletes paradox endurance athletes accumulate tgs lds skeletal myocytes untrained individuals yet muscle highly insulin sensitive similarly mice lack atgl accumulate large amounts fat numerous tissues including skeletal muscle cardiac muscle liver kidneys macrophages exhibit increased insulin sensitivity haemmerle et al 2006 ; increased insulin sensitivity observed despite fact atgl deficiency leads insulin secretion defect pancreatic islets peyot et al 2009 humans atgl deficiency leads neutral lipid storage disease myopathy nlsdm similar lipid phenotype observed atgl deficient mice fischer et al 2007 patients lacking atgl coactivator cgi-58 develop neutral lipid storage disease also exhibit severe skin defect neutral lipid storage disease ichthyosis nlsdi lefvre et al 2001 date defective pancreatic insulin production alterations insulin sensitivity reported patients nlsdm nlsdi conclusion cellular tg content marker insulin resistance certain physiological conditions regulator insulin signaling besides powerful role energy substrates precursors lipids fas fa derivatives bind activate members nuclear receptor family transcription factors control expression genes involved lipid energy homeostasis inflammation the ppar family consists four members ppar ppar-1 -2 ppar also designated ppar ppar ppar highly expressed oxidative tissues regulate genes involved substrate delivery substrate oxidation oxidative phosphorylation oxphos in contrast ppar important lipogenesis lipid synthesis highest expression levels wat the full transcriptional activity ppars requires binding cognate lipid ligands heterodimerization another nuclear receptor retinoid x receptor rxr interaction number transcriptional coactivators including ppar coactivator-1 pgc-1 in addition fas lipid ligands also described activate ppars acyl coas glycerol phospholipids eicosanoids fas involved signaling originate import exogenous fas circulating fa albumin complexes lpl mediated hydrolysis plasma vldl chylomicrons endogenous de novo synthesis recently shown neither source fa generate ppar ligands directly rather cycle fa esterification rehydrolysis required haemmerle et al 2011 ) lipolysis impaired atgl deficient mice exhibit severe defect ppar signaling oxidative tissues liver ong et al 2011 macrophages chandak et al 2010 bat ahmadian et al 2011 the dramatic phenotype observed cardiac muscle haemmerle et al 2011 the reduced expression ppar target genes atgl knockout animals causes severe mitochondrial dysfunction decreased rates substrate oxidation oxphos massive cardiac lipid accumulation lethal cardiomyopathy within months birth hsl deficiency also associated moderately decreased ppar target gene expression generate comparable cardiac phenotype indicating specific importance atgl activity generation ppar ligands ligand precursors nlsdm nlsdi humans due deficiency atgl cgi-58 respectively may also lead reduced ppar signaling defective oxphos although proven experimentally assumption stems finding nlsdm patients also develop systemic tg accumulation cardiomyopathy many patients this condition lethal undergo heart transplantation hirano et al 2008 importantly least mice mitochondrial defect prevented application ppar activators wy16453 fenofibrate haemmerle et al 2011 treatment atgl deficient mice leads increased ppar signaling disappearance cardiac steatosis improved mitochondrial function oxphos well prolonged survival whether pharmacological ppar activation also beneficial patients nlsdm currently known remains promising possibility in addition instrumental role atgl ppar signaling enzyme may also affect ppar function ( festuccia et al 2006 showed rosiglitazone mediated ppar activation lipid accumulation associated increased lipolysis wat rats increased lipolysis due induction atgl mgl although seems counterintuitive lipolysis induced increased tg synthesis conceivable step required promote ppar-activated expression lipogenic genes moreover fact hsl deficiency also leads downregulation ppar target gene expression wat shen et al 2011 zimmermann et al 2003 it well established plasma cellular fa concentrations correlate positively increased insulin resistance boden shulman 2002 increased cellular concentrations nonesterified fas particularly palmitate drive synthesis lipotoxic lipids ceramides interfere functional insulin signaling summers 2010 additionally fas directly indirectly via increased production reactive oxygen species activate redox sensitive serine kinases turn inactivate insulin response vallerie hotamisligil 2010 yet fa species seem inhibitory effect insulin signaling whereas palmitate consistently decreases insulin response palmitoleate actually enhances insulin signal liver muscle cao et al 2008 its effects insulin signaling liver muscle suggest fa lipokine endocrine function additionally conceivable hepatic palmitoleate also contributes insulin sensitization paracrine fashion whether lipolysis contributes generation palmitoleate fas downstream effect insulin signaling requires additional studies atgl deficient mice low plasma fa concentrations highly insulin sensitive arguing protective role reduced lipolysis low fa levels whether low plasma fas hsl deficient mice also affect insulin sensitivity controversial mulder et al 2003 park et al 2005 voshol et al the potential dgs act second messengers discovered approximately 50 years ago researchers realized dgs affect many metabolic mitogenic activities via activation protein kinase c pkc metabolic regulation involves suppression insulin signaling via phosphorylation insulin receptor substrate-1 leading insulin resistance muscle liver samuel et al 2010 only one dg stereoisomer 1,2-diacyl sn glycerols 1,2-dgs able activate pkcs whereas others 1,3-diacyl sn glycerols 1,3-dgs 2,3-diacyl sn glycerols 2,3-dgs lack bioactivity boni rando 1985 1,2-dgs activate conventional novel pkc isoforms recruitment enzymes plasma membrane receptor activated c kinase rack proteins turban hajduch 2011 accordingly stereo specific location specific preconditions required dgs activate pkcs classical signaling 1,2-dgs derive phospholipase c plc)-mediated hydrolysis phosphatidylinositol-4,5-phosphate plasma membrane products enzymatic reaction 1,2-dgs inositol-1,4,5-phosphate ip3 potent second messengers whereas 1,2-dgs remain plasma membrane associated ip3 dissociates induces ca release er required addition 1,2-dgs activation conventional pkcs although plcs generate correct stereoisomer 1,2-dgs correct cellular location pkc activation remains controversial whether cellular sources also contribute production signaling 1,2-dgs de novo synthesis via dual acylation sn glycerol-3-phosphate acyl coa glycerol-3-phosphate acyltransferases gpats acyl coa acylglycerol-3-phosphate acyltransferases agpats subsequent dephosphorylation phosphatidic acid phosphatidic acid phosphohydrolases papases also leads formation 1,2-dgs figure 3 however pathway dg synthesis restricted er membranes accordingly model proposing activation pkc er associated 1,2-dgs needs include pkc localization er contact sites plasma membrane er membrane third potential source dgs derives lipolysis ld associated tgs atgl figure 3 however unpublished observations showed enzyme preferentially hydrolyzes sn-1 sn-2 ester bonds sn-3 esters this indicates atgl generates 1,3-dgs 2,3-dgs 1,2-dgs accordance subsequent hydrolysis 1,3-dgs 2,3-dgs hsl enzyme stereo preference hydrolysis fas sn-3 position dgs rodriguez et al 2010 in tgs hsl preferably hydrolyses sn-1(3 ester bonds fredrikson belfrage 1983 therefore additionally questionable whether ld associated dgs would dissociate lds participate recruitment activation pkc plasma membrane this seems unlikely lipolytically generated dgs act signaling mediators recent review shulman colleagues samuel et al 2010 ) summarized numerous animal human studies providing evidence cellular dg concentrations account development lipid induced insulin resistance type 2 diabetes lipodystrophy conditions consistent hypothesis mice lacking dg kinase- major enzyme inactivates dg signal increased dg levels increased insulin resistance chibalin et al 2008 however considering structural complexity dg species localization different cellular compartments general correlation total cellular dg concentrations insulin resistance seems unlikely this supported studies increased total cellular dg concentrations mutant mouse models associated insulin resistance for example hsl deficient mice accumulate large amounts dgs adipose many nonadipose tissues due defective dg catabolism yet studies agree lead pkc hyperactivation severely defective insulin response mulder et al 2003 park et al 2005 voshol et al similarly cgi-58 silencing liver leads increased dg levels normal chow diet increased high fat diet glucose tolerance insulin sensitivity brown et al 2010 taken together determination specific 1,2-dg concentrations plasma membrane may provide reliable predictor lipid induced pkc mediated insulin resistance total cellular dg concentrations the signaling potential mgs recognized found phospholipid derived mg 2-ag activates cannabinoid receptors cbr thereby regulating food intake lipid metabolism energy homeostasis the endocannabinoid system ecs refers group neuromodulatory lipids endocannabinoids ecs two g protein coupled receptors cbr1 cbr2 enzymes involved synthesis degradation ecs di marzo 2009 the best characterized ecs n arachidonoyl ethanolamine aea anandamide 2-ag their biological effect mimicked -tetrahydrocannabinol thc major psychoactive component marijuana the ecs regulates diverse spectrum physiological processes including motor function pain appetite cognition emotional behavior immunity nervous system 2-ag acts retrograde messenger inhibiting presynaptic neurotransmitter release alger kim 2011 ) subsequently 2-ag internalized presynaptic terminal inactivated mgl reaction forming glycerol arachidonic acid the ecs active neurons nonneuronal cells immune cells hepatocytes adipocytes treatment obese patients cbr1-antagonist rimonabant christopoulou kiortsis 2011 studies animal models lacking cbr1 revealed blockade ecs reduces food intake decreases lipogenesis increases energy consumption conversely overactive ecs central orexigenic effect reduces energy expenditure promoting lipid deposition peripheral tissues like liver wat cota 2008 biological effects obese patients may overactive ecs stimulates appetite promotes lipid deposition perkins davis 2008 it generally assumed signaling 2-ag originates degradation glycerophospholipids containing arachidonic acid sn-2 position figure 3 various isoforms plc generate 1,2-dgs see subsequently hydrolyzed dg lipase dagl 2-ag whether hsl also participates hydrolysis plasma membrane associated 1,2-dgs generate 2-ag known current evidence suggests least two isoforms dagl dagl dagl exist brain liver bisogno et al 2003 mice lacking dagl exhibit substantial decrease brain spinal cord 2-ag levels whereas dagl appears important peripheral tissues liver gao et al 2010 whether catabolism arachidonic acid containing tgs lds atgl hsl also contributes cellular 2-ag arachidonic acid pool known recent studies using mgl specific small molecule inhibitor jzl184 mgl knockout mice provided compelling evidence mgl major enzyme degradation 2-ag mgs esterified long chain fas chanda et al 2010 schlosburg et al 2010 taschler et al animals lacking mgl mice treated jzl184 show abnormally high amounts various mg species brain peripheral tissues brain lack mgl activity leads 20-fold increase 2-ag suggesting mgl deficiency could lead hyperactivation ecs indeed jzl184 treatment mice provoked cannabimimetic effects mice including analgesia hypothermia hypomotility long et al however genetic ablation mgl mice result hyperactive ecs obvious phenotype this surprising observation explained desensitization brain cbr1 leading functional antagonism highlights important role 2-ag retrograde neurotransmitter chanda et al 2010 ; 2010 obviously increased brain 2-ag concentrations provoke counter regulatory mechanisms similar observed animals chronically fed cbr agonists lichtman martin 2005 although mgl deficiency mice produce cannabimimetic effects lack mgl activity substantially affects lipolysis metabolism adipose tissue nonadipose tissues taschler et al 2011 mgl deficiency results accumulation mgs reduction circulating tg glycerol levels fasted animals unexpectedly contrast proposed role ecs obesity related metabolic diseases mgl knockout mice exhibit improved insulin sensitivity glucose tolerance fed high fat diet cause finding may complex considering mgl deficiency associated desensitized cbrs investigation mice lacking mgl specifically brain peripheral tissues help unravel question whether central peripheral effects cause attenuation insulin resistance the first observation indicate lipolysis linked efficient cell cycle progression reported yeast s. cerevisiae yeast expresses three tg lipases patatin domain containing family termed tgl3 5 czabany et al 2007 tgl4 functional ortholog mammalian atgl kurat et al 2006 deletion tgl3 tgl4 abolishes virtually cellular tg lipase activity causes marked delay entry cell division cycle starved cells upon refeeding kurat et al 2009 tgl4 activated via phosphorylation cyclin dependent kinase cdk1/cdc28 ortholog mammalian cdc2 this suggests tg levels oscillate cell division cycle either deposit de novo synthesized fas tgs conversely provide fas phases increased demand tgl4 phosphorylation activation occur g1/s transition cell division cycle coincides bud emergence requires increased amounts membrane lipids pah1 phosphorylation inactivation occur g2/m transition cell cycle indicating window exists cell cycle initial step lipogenesis lipolysis may operate parallel this feasible activities confined different organelles namely er lds respectively the specific checkpoint proteins regulate cell cycle progression response lipolysis currently unknown recent evidence shows synthesis phosphatidylinositol pi precursor signaling molecules cell cycle regulation yeast e.g. ip3 inositol containing ceramides strongly depends intact lipolysis gaspar et al 2011 thus cell cycle regulated tg lipolysis may provide critical precursors signaling molecules cell division a highly interesting study recently demonstrated mgl promotes oncogenic properties mammalian cancer cells nomura et al 2010 the authors demonstrated overexpression disruption mgl activity increased decreased respectively proliferation cancer cells mgl highly expressed aggressive tumor cell lines primary tumors the study also provided evidence mgl influences tumor proliferation metabolic effects rather cbr dependent mechanisms growth tumor cells response mgl knockdown impaired addition exogenous nonesterified fas mice fed high fat diet this led conclusion mgl affects concentration fa derived tumorigenic lipid metabolites lpa pge2 although involved lipid signal(s requires identification studies clearly designate mgl interesting target cancer therapy lipolytic signaling may also causally involved pathogenesis cancer associated cachexia cac recent study das et al ( das et al 2011 demonstrated atgl deficient mice protected tumor induced loss adipose tissue skeletal muscle atgl deficient mice maintained body weight composition despite increased circulating factors induce lipolysis muscle proteolysis apoptosis e.g. tnf interleukin-6 zinc--glycoprotein 1 this suggests lipolysis integrated signal transduction network eventually leads loss adipose tissue muscle this view also consistent observation activity lipolytic enzymes release fas glycerol increased adipose tissue cancer patients cachexia agustsson et al 2007 das et al 2011 rydn et al it also unclear whether signal originates lipolysis one tissue adipose tissue promotes wasting endocrine manner whether wasting requires autonomous lipolysis tissues affected wasting although underlying mechanism yet defined study suggests inhibition lipolysis may help prevent cachexia patients cancer chronic diseases recent discoveries enzymes regulatory factors led revision perception lipolysis additionally begun address role lipolytic products intermediates cellular signaling important topics future investigations include 1 better understanding biochemical factors processes coordinately regulate lipolytic machinery response hormonal activators inhibitors 2 physiological function lipolysis numerous nonadipose tissues tissue specific differences lipolytic mechanisms 3 characterization lipolytic signals molecular mechanisms effects gene transcription cell cycle cell growth the recent examples lipases affecting tumor proliferation cancer associated cachexia emphasize potential importance lipolysis human disease	lipolysis is defined as the catabolism of triacylglycerols stored in cellular lipid droplets . recent discoveries of essential lipolytic enzymes and characterization of numerous regulatory proteins and mechanisms have fundamentally changed our perception of lipolysis and its impact on cellular metabolism . new findings that lipolytic products and intermediates participate in cellular signaling processes and that lipolytic signaling is particularly important in many nonadipose tissues unveil a previously underappreciated aspect of lipolysis , which may be relevant for human disease .
prospective investigation conducted fleischhackl coworkers reported previous issue critical care sets determine whether young students physical cognitive skills implement cardiopulmonary resuscitation cpr investigation the average time last class cpr instruction evaluation session 120 days it clear whether large gap time initial instruction skills testing may affected testing performance except good performance could indicate good retention students tested also included special learning needs may skew examination results unfavorable direction nevertheless outcomes generally good investigators demonstrated students young 9 years able effectively learn cpr skills including automated external defibrillator deployment correct recovery position emergency calling adults physical strength may limited depth chest compressions ventilation volumes perhaps key finding skills retention good these findings consistent studies none students aged 9 10 years could compress chest depth recommend guidelines 45% students aged 13 14 years old could studies also found retraining cpr performance improve school aged children although study fleischhackl coworkers specifically address retraining would interesting know well students would retained learned skills several months later well known cpr skills rapidly deteriorate initial training intuitively higher number persons trained cpr skills given community frequently performed example los angeles relative percentage citizens trained cpr estimated relatively low small percentage bystanders performed cpr 1.4% hospital cardiac arrest victims survived however 10-fold improvements survival rates 15% reported seattle frequency bystander performed cpr one highest nation in essence one effective means improving surviving hospital cardiac arrest attempt train individuals across given community experience shown captive audiences training school systems major component when closely examining numbers survival improvements linear may actually logarithmic young children ages 10 14 years account approximately 15% population usa main target age group cpr except perhaps drowning incidents however multiple benefits teaching school aged children cpr beside concept capturing entire generations cpr trained citizens children older 10 years age teachable capable abstract thought coordination physical strength perform cpr the cpr kits currently promoted american heart association designed train individuals young 8 years old less half hour it demonstrated using kit contains self instructional video inflatable manikin promotes retention also multiplier effect one study found distributing cpr training kits students aged 12 14 years resulted another 2.5 persons trained per student furthermore early training lay foundation sense social obligation reinforce cpr knowledge follow training time student graduates high school cpr skills well engrained easily called upon emergency situation if government agencies enforced mandatory age appropriate cpr first aid training schools similar schools practice evacuation file drills one could imagine impact could number individuals capable intervening hospital cardiac arrest turn number lives saved	the usefulness of basic cardiopulmonary resuscitation ( cpr ) training in school systems has been questioned , considering that young students may not have the physical or cognitive skills required to perform complex tasks correctly . in the study conducted by fleishhackl and coworkers , students as young as 9 years were able to successfully and effectively learn basic cpr skills , including automated external defibrillator deployment , correct recovery position , and emergency calling . as in adults , physical strength may limit the depth of chest compressions and ventilation volumes given by younger individuals with low body mass index ; however , skill retention is good . training all persons across an entire community in cpr may have a logarithmic improvement in survival rates for out - of - hospital cardiac arrest because bystanders , usually family members , are more likely to know cpr and can perform it immediately , when it is physiologically most effective . training captured audiences of trainees , such as the entire work - force of the community or the local school system , are excellent mechanisms to help achieve that goal . in addition to better retention with new half hour training kits , a multiplier effect can be achieved through school children . in addition , early training not only sets the stage for subsequent training and better retention , but it also reinforces the concept of a social obligation to help others .
also shown type laryngoscopic blade influences degree hemodynamic response videolaryngoscopes shown varying results pentax aws pentax corporation tokyo japan attenuated response whereas glidescope saturn biomedical system inc burnbaby canada shown similar hemodynamic response compared macintosh laryngoscopy endotracheal intubation however studies evaluating hemodynamic response c mac video laryngoscope karl storz gmbh co. kg tuttlingen germany endotracheal intubation hence compared hemodynamic response oral endotracheal intubation using mccoy c mac laryngoscopy conventional macintosh laryngoscopy adult patients posted elective surgery general anesthesia one recent study shown c mac videolaryngoscopy needed less duration laryngoscopy successful intubation compared macintosh laryngoscopy even lateral position duration laryngoscopy expected variable affect degree hemodynamic response endotracheal intubation hence hypothesized mccoy c mac laryngoscopy produces attenuated hemodynamic response laryngoscopy oral endotracheal intubation compared macintosh laryngoscopy with institute ethics committee approval csp med/14/feb/12/34 dated 13 03 2014 informed consent patients prospective randomized parallel group study carried the procedures followed accordance ethical standards institutional research ethics committee standards helsinki declaration 1975 revised 2000 we included ninety american society anesthesiologists asa patients 1840 years age posted elective surgery general anesthesia pregnant women patients undergoing emergency surgery airway abnormalities anticipated difficult airway mallampati class iii iv thyromental distance 6 cm inter incisor distance <3 cm cervical instability excluded study in addition patients laryngoscopy lasted 30 one intubation attempt needed also excluded the study population randomly allocated three groups namely group n 30 laryngoscopy macintosh laryngoscope blade size 3 control group group b n 30 laryngoscopy mccoy laryngoscope blade size 3 group c n 30 laryngoscopy c mac video laryngoscope blade randomization done computer generated random numbers concealed sealed envelope technique this done separate anesthesiologist involved performing laryngoscopy data collection study laryngoscopy intubation performed single senior anesthesiologist cases familiar experienced intubation using mccoy c mac laryngoscope endotracheal tubes size 8.5 mm males 7.5 mm females used the endotracheal tubes loaded stylet shaped hockey stick fashion patients standard monitoring done electrocardiogram ii v leads noninvasive blood pressure pulse oximetry phillips intellivue mp50 philips healthcare netherlands after preoxygenation 3 min 100% oxygen anesthesia induced midazolam 1 mg fentanyl 2 mcg kg thiopentone 5 mg kg intravenously maintained sevoflurane 2% 100% oxygen checking mask ventilation vecuronium 0.1 mg kg administered intravenously end 3 min etco2 maintained 40 mmhg avoid effects hypercarbia hemodynamic variables study period no medications administered procedures performed 10 min data collection period endotracheal intubation the study parameters monitored heart rate hr systolic blood pressure sbp diastolic blood pressure dbp mean arterial pressure map the parameters measured following intervals baseline bl induction intubation t0 1 min t1 3 min t3 5 min t5 10 min t10 intubation the first reading parameters connecting monitor inside operating room preoxygenation taken bl reading all study parameters collected documented observer blinded type laryngoscope used other parameters measured duration laryngoscopy stop clock independent observer duration laryngoscopy defined time insertion laryngoscope oropharynx till appearance first etco2 curve intubation response defined hemodynamic changes terms hr sbp dbp map occurs immediately within 10 min oral endotracheal intubation significant hemodynamic response would warrant intervention defined study change hr blood pressure 20% change bl decrease blood pressure hr treated injection ephedrine 6 mg intravenous boluses sample size calculation done based pilot study done us prior study ten patients group comparing hemodynamic response laryngoscopy oral endotracheal intubation macintosh mccoy c mac videolaryngoscope comparison macintosh c mac group needed sample size 25 group detect effect size 10 mmhg systolic pressure standard deviation sd 12.8 power 80% alpha error 0.05 whereas comparison macintosh mccoy group needed sample size 23 patients group detect effect size 13.6 mmhg systolic pressure sd 16 power 80% alpha error 0.05 sample size calculation based data previous study comparing hemodynamic response macintosh mccoy laryngoscopy also arrived similar sample size the collected data analyzed spss windows version 16.0 spss inc chicago il usa describe data descriptive statistics mean and hr dbp demographic data normal distribution whereas sbp map skewed distribution the demographic data analyzed one way analysis variance find significant difference bivariate samples independent groups unpaired sample test used normal data mann whitney u test skewed data for repeated measures repeated measures anova adjustment multiple comparisons control type error bonferroni test used normal data friedman followed wilcoxon signed rank test skewed data statistical tools p 0.05 considered significant level those patients needed intervention ephedrine excluded study since subsequent readings would affected administration the demographic data terms age weight height similar groups table 1 there statistically significant difference bl values study parameters among three groups comparison demographic data among groups studying group separately group macintosh statistically significant increase study parameters study intervals intubation compared bl value tables 2 3 whereas group b mccoy statistically significant increase hr response 1 min interval t1 bl value p 0.003 time intervals significant rise bl study parameters tables 2 3 comparison mean heart rate systolic blood pressure group b group c group comparison mean diastolic blood pressure mean arterial pressure group b group c group statistically significant increase hr 1 min t1 p 0.001 3 min t3 p 0.004 interval bl hr group c. whereas statistically significant increase dbp p 0.01 map p 0.03 t1 interval compared bl group c c mac time intervals rise significant fall values compared bl value tables 2 3 table 2 compares changes hr sbp group b group c group a. difference hr 3 min interval t3 intubation group group c statistically significant t(58 2.782 p 0.008 the hr significantly higher group c compared group 3 min t3 interval time intervals significant difference hr comparing group b group c group a. significant difference sbp observed comparing group group c u 294 p 0.01 r 0.42 1 min t1 intubation intervals statistically significant difference sbp comparing group b group c group a. table 3 compares changes mean dbp mean artery pressure group b group c group a. statistically significant difference dbp observed group group c t(58 2.301 p 0.03 1 min interval t1 intubation time intervals statistically significant changes dbp comparing group b group c group a. statistically significant difference mean artery pressure observed comparing group group c u 320 p 0.04 r 0.35 1 min interval t1 intubation intervals there statistically significant changes map comparing group b group c group a. we found c mac laryngoscope higher hemodynamic response tracheal intubation compared conventional macintosh laryngoscopy intubation asa patients comparing macintosh mccoy laryngoscopy found significant difference terms hemodynamic response orotracheal intubation two laryngoscopic methods some previous studies shown difference hemodynamic response mccoy laryngoscope conventional macintosh laryngoscopy one study comparing mccoy macintosh laryngoscope found mccoy group less hemodynamic response fentanyl included premedicant difference fentanyl used premedicant study macintosh mccoy group show significant increase study parameters decreasing trend intubation this attributed difference inclusion criteria compared studies namely asa status age group unlike earlier studies included asa patients belonging 1840 years age group study a recently published study compares hemodynamic response endotracheal intubation macintosh c mac videolaryngoscope cardiac surgical patients they found significant change two groups terms hemodynamic response laryngoscopy endotracheal intubation this particular study done heterogeneous cardiac surgical patients varied cardiac pathology coming cabg valvular surgeries etc the patients drugs beta blockers would influenced degree hemodynamic response endotracheal intubation study shown c mac increased hemodynamic response intubation compared macintosh laryngoscopy endotracheal intubation the difference study population would contributed difference outcome two studies the major limitation difficulty blinding study design could led potential bias study however ensured separate anesthesiologist knowing type laryngoscopy involved data collection secondly learning curve new technique laryngoscopy c mac videolaryngoscope established would affected hemodynamic response endotracheal intubation the authors avoid potential bias would happen wide variable group asa ii patients included such patients may conditions hypertension diabetes hypothyroidism affect hemodynamic response oral endotracheal intubation furthermore conducting entire study controlled hypertensives technically difficult recruit patients well standardize confounding factors drug therapy moreover authors felt attenuation hemodynamic response endotracheal intubation also important asa patients providing general anesthesia our study showed mccoy macintosh laryngoscopies similar hemodynamic response direct laryngoscopy endotracheal intubation c mac video laryngoscopy endotracheal intubation increased hemodynamic response conventional macintosh laryngoscopy intubation patients undergoing general anesthesia	background and aims : earlier studies have shown that the type of laryngoscope blade influences the degree of hemodynamic response to endotracheal intubation . the aim of the study was to evaluate the hemodynamic response to oral endotracheal intubation with c - mac laryngoscopy and mccoy laryngoscopy compared to that of macintosh laryngoscopy in adult patients under general anesthesia.material and methods : this is a prospective randomized parallel group study . ninety american society of anesthesiologists i patients were randomly allotted into three groups . group a macintosh laryngoscopy ( control group ) . group b laryngoscopy with mccoy laryngoscope . group c laryngoscopy with c - mac video laryngoscope . heart rate ( hr ) , systolic blood pressure ( sbp ) , diastolic blood pressure ( dbp ) , and mean arterial pressure ( map ) were monitored at baseline ( just before induction ) , just before intubation ( t0 ) , 1 min ( t1 ) , 3 min ( t3 ) , 5 min ( t5 ) , and 10 min ( t10 ) after intubation . intergroup comparison of study parameters was done by unpaired sample t - test for normal data and mann - whitney u - test for skewed data . for within - group comparison , the repeated measures of anova for normal data and friedman followed by wilcoxon signed rank test for skewed data were performed.results:in c - mac group , the hr was significantly higher than the macintosh group at 3 min after intubation , whereas sbp , dbp , and map were significantly higher at 1 min . mccoy group showed a similar response compared to macintosh group at all time intervals.conclusion:c-mac video laryngoscope has a comparatively greater hemodynamic response than macintosh laryngoscope .
take maximum aliquot 13 ml sample store -20 c labeled conical centrifuge tube measure record optical density sample placing couple drops urine refractometer filter sample 0.2 um filter measure volume sample according optical density 1.000 1.0091.00 ml1.010 1.0190.50 ml1.020 1.0500.25 ml 0.25 ml h2o specified volume transferred reactivial containing following internal standards 500 nanomoles nmoles 3 creatine 10 nmoles d3 methylmalonic acid 100 nmoles following c3 lactate c3 pyruvate c2 n glycine d3 serine d5 phenylalanine d11 hexanoylglycine n2 orotate d4 sebacic acid c6 glucose d6 inositol d5 tryptophan 20 microliters l 7.5 units/l solution urease calzyme laboratories catalog 116a0100 added sample flushed sealed co2 inert septum the sample held 37c 30 minutes carbon dioxide gas added 15 minute intervals maintain pressure 20 l urease solution added vial flushed carbon dioxide sample maintained 37c another 15 minutes 500 l 30:70 acetone methanol added rubber septum replaced teflon coated septum sample chilled -20 c 15 minutes solids removed centrifugation 1500 rpm x 10 minutes decanted clean 2.0 cc reactivial supelco sigma add triethylammonium trifluoroacetate tea tfa sigma follows 20 l 1.00 ml samples40 l 0.5 ml less samples 20 l 1.00 ml samples 40 l 0.5 ml less samples top acetonitrile place nitrogen stream 70 c constant volume achieved tea tfa remain 15 minutes repeat step 13 4 times precipitate forms 10 minutes top methylene chloride careful boil dry 4:00 minutes add mstfa n methyl n trimethylsilyltrifluoroacetamide thermal scientific following rates 150 l 1.00 ml samples200 l 0.50 ml less samples 150 l 1.00 ml samples 200 l 0.50 ml less samples cap nitrogen atmosphere incubate 70 c 1 hour transfer microvials nitrogen atmosphere analysis gas chromatograph /mass spectrometer place microvials automated injection agilent 5975 gc ms instrument temperatures injector 200 c interface 250 c oven 80 c 1 minute ramp 4 c minute 80 130 c ramp 6 c/ minute 130 200 c ramp 12 c/ minute 200 285 c hold 10 minutes mass spec source 230 c quad 150 c scan 50 650 amu 2.46 scans sec take maximum aliquot 13 ml sample store -20 c labeled conical centrifuge tube measure record optical density sample placing couple drops urine refractometer filter sample 0.2 um filter measure volume sample according optical density 1.000 1.0091.00 ml1.010 1.0190.50 ml1.020 1.0500.25 ml 0.25 ml h2o specified volume transferred reactivial containing following internal standards 500 nanomoles nmoles 3 creatine 10 nmoles d3 methylmalonic acid 100 nmoles following c3 lactate c3 pyruvate c2 n glycine d3 serine d5 phenylalanine d11 hexanoylglycine n2 orotate d4 sebacic acid c6 glucose d6 inositol d5 tryptophan 20 microliters l 7.5 units/l solution urease calzyme laboratories catalog 116a0100 added sample flushed sealed co2 inert septum the sample held 37c 30 minutes carbon dioxide gas added 15 minute intervals maintain pressure 20 l urease solution added vial flushed carbon dioxide sample maintained 37c another 15 minutes 500 l 30:70 acetone methanol added rubber septum replaced teflon coated septum sample chilled -20 c 15 minutes solids removed centrifugation 1500 rpm x 10 minutes decanted clean 2.0 cc reactivial supelco sigma add triethylammonium trifluoroacetate tea tfa sigma follows 20 l 1.00 ml samples40 l 0.5 ml less samples 20 l 1.00 ml samples 40 l 0.5 ml less samples top acetonitrile place nitrogen stream 70 c constant volume achieved tea tfa remain 15 minutes repeat step 13 4 times precipitate forms 10 minutes top methylene chloride careful boil dry 4:00 minutes add mstfa n methyl n trimethylsilyltrifluoroacetamide thermal scientific following rates 150 l 1.00 ml samples200 l 0.50 ml less samples 150 l 1.00 ml samples 200 l 0.50 ml less samples cap nitrogen atmosphere incubate 70 c 1 hour transfer microvials nitrogen atmosphere analysis gas chromatograph /mass spectrometer place microvials automated injection agilent 5975 gc ms instrument temperatures injector 200 c interface 250 c oven 80 c 1 minute ramp 4 c minute 80 130 c ramp 6 c/ minute 130 200 c ramp 12 c/ minute 200 285 c hold 10 minutes column 25 320 micron 0.5 micron film thickness db-5 mass spec source 230 c quad 150 c scan 50 650 amu 2.46 scans sec the urease method 1 cited 62 times medical literature various modifications matsumoto group 2,3 simplified procedure high throughput neonatal screening reported results 16000 patients kuhara others 4 7 reported use method several cases inborn error diagnosis follow rhead 8) also confirmed method utility clinical diagnosis follow inborn errors method applied urine bears knock mice elephants homogenates whole fruit flies larvae 9 culture media cryptococcus site directed mutagenesis also analyzed without urease step 10 the method applied human nutritional assessment medical students syndrome patients demented elderly veterans loading subjects oral doses amino acids tryptophan methionine isoleucine 11 all eight b vitamins assessed quantifying breakdown products three amino acids among require 8 vitamins point degradation the toxic effects pharmaceuticals mitigation vitamin supplementation reported 12 amniotic fluid samples normal syndrome pregnancies analyzed reported 13 15 the metabolic screening lab clia licensed clinical laboratory owned saint louis university non profit corporation dr shoemaker directly profit laboratory revenues may benefit indirectly laboratory productivity none methods techniques results normal ranges macros software libraries conclusions considered proprietary freely available interested parties	every infant born in the us is now screened for up to 42 rare genetic disorders called " inborn errors of metabolism " . the screening method is based on tandem mass spectrometry and quantifies acylcarnitines as a screen for organic acidemias and also measures amino acids . all states also perform enzymatic testing for carbohydrate disorders such as galactosemia . because the results can be non - specific , follow - up testing of positive results is required using a more definitive method . the present report describes the " urease " method of sample preparation for inborn error screening . crystalline urease enzyme is used to remove urea from body fluids which permits most other water - soluble metabolites to be dehydrated and derivatized for gas chromatography in a single procedure . dehydration by evaporation in a nitrogen stream is facilitated by adding acetonitrile and methylene chloride . then , trimethylsilylation takes place in the presence of a unique catalyst , triethylammonium trifluoroacetate . automated injection and chromatography is followed by macro - driven custom quantification of 192 metabolites and semi - quantification of every major component using specialized libraries of mass spectra of tms derivatized biological compounds . the analysis may be performed on the widely - used chemstation platform using the macros and libraries available from the author . in our laboratory , over 16,000 patient samples have been analyzed using the method with a diagnostic yield of about 17%--that is , 17% of the samples results reveal findings that should be acted upon by the ordering physician . included in these are over 180 confirmed inborn errors , of which about 38% could not have been diagnosed using previous methods .
patients referring hospitals emergency department ed needing immediate care comprise 78% patients minutes even seconds crucial patients since 75 85% mortality occurs first 20 min post events head injury most injuries either manage progress within first 10 min major decisions made time limit high number clients various clients lack background information limitation diagnostic interventions urgency selecting related treatment amongst ed features patients viewpoint the long waiting time interval resulting patients dissatisfaction emergency services major problem hospitals eds well pre hospital phases basically increase wait time one major reasons crowd eds resulting patients leave physicians evaluation delay treatment patients dissatisfaction jeopardizing lives hand a decrease wait time receive emergency services brings time treatment decrease hospitalization time interval lower treatment costs saving hospital resources meanwhile important criterion used evaluate eds patients waiting time receive diagnostic treatment services triage one system easily administrated manage time diagnosis treatment regard patients status triage process emergency disease injury classified patients referring eds order provide appropriate level treatment care prioritized transferred shortest possible time most times nurses first health staffs admitting patients diagnose problem administrate emergency care previous studies already conducted patients time waste eds regard satisfaction iran effect triage wait time decrease eds accordingly studies iran regarding waiting time discharge time emergency department instance study kashani hospital esfahan shown average time patients complete discharge process ed 4.9 h kerman showed mean wait time ed bahonar hospital 7 h. studies indicated long wait time directly affect patients dissatisfaction however effect triage wait time discharge time measure studies evaluation ed wait time interval patients point view may improve quality emergency care ed due feasibility lack similar study shahid rajaee hospital karaj present study designed investigate effect triage wait time receive treatment services patients satisfaction referring karaj ed this quasi experimental study conducted patients referring ed shahid rajaee hospital karaj 2009 experimental condition triage intervention made cases group vs. control group triage see according quasi experimental design wait time patient satisfaction dependent variables triage manipulated check effect groups considering wait time patient satisfaction its emergency department provides inpatient outpatient services internal cardiac traumatic patients care five nurses work morning shift four evening shift four nurses night shift considering previous similar studies due feasibility samples considered 600 means 300 cases 300 experiment group all patients experiment group triaged time entrance vs. control group triage patients come ed included study except needing cardiopulmonary resuscitation cpr time arrival vital signs need triage left study a questionnaire including demographic questions well two sections patient satisfaction time measurement used collect data age sex referral route time measurement included information concerning time arrival time first visit physician considered satisfaction measurement section contained 11 questions covering patients satisfaction ed services concerning personnel behavior admission existence facilities equipments ed staffs reaction time start emergency services it important beer mind data collection tool national standard questionnaire made ministry health medical education used already confirmed regarding validity reliability the principal researcher filled questionnaire getting consent clients intervention triage the data collected interview patients accompanying patients quite alert conscious using random block sampling method starting first day study conducting principle investigator attends ed first morning following evening night shift respectively questionnaire satisfaction filled time discharge transferring ward inpatients cases time leaving ed outpatients then data wait time first visit ed collected satisfaction services sought triage administrated after primary triage patients classified transferred ed visited general physician receive related care there two physicians present shift one class one referrals one outpatients class two three wait time measured early arrival patients triage room prioritizing triage system general physicians visit the data analyzed spss version 13 spss chicago il means test evaluate effect triage wait time receive treatment services experiment vs. control group mann whitney test used compare patients satisfaction test effect triage tow different groups the frequency sex male female education level illiterate primary school secondary school high school associate degree bachelor degree marital status single married divorces referral times ed first second compared experiment control groups the study approved ethics committee university social welfare rehabilitation tehran iran the interviewees signed informed consent form verbally consented participate study the study approved ethics committee university social welfare rehabilitation tehran iran the interviewees signed informed consent form verbally consented participate study table 1 compares background characteristics sex education level marital status referral times experiment control groups table shows regarding educational level close two thirds experiment group belong illiterate primary school compare half percent control group total comparison background characteristics among patients referring ed shahid rajaee hospital karaj iran experiment control groups 2011 table 2 presents time variable effect wait time receive ed physician first visit experiment control groups there significant difference mean wait time experiment control groups 10.69 min control vs. 8.91 min experiment group comparison mean median minimum maximum wait time patients referring ed shahid rajaee hospital karaj iran experiment control groups 2011 table 3 presents satisfaction experiment control groups reveals higher satisfaction triaged patients compared control group p 0.01 comparison mean satisfaction patients referring ed shahid rajaee hospital karaj iran experiment control groups 2011 table 2 presents time variable effect wait time receive ed physician first visit experiment control groups there significant difference mean wait time experiment control groups 10.69 min control vs. 8.91 min experiment group comparison mean median minimum maximum wait time patients referring ed shahid rajaee hospital karaj iran experiment control groups 2011 table 3 presents satisfaction experiment control groups reveals higher satisfaction triaged patients compared control group p 0.01 comparison mean satisfaction patients referring ed shahid rajaee hospital karaj iran experiment control groups 2011 this quasi- experimental study showed significant difference wait time patients satisfaction experiment triaged clients control groups received routine services miro et al also managed decrease wait time triage result wait time visiting patients decreased 6.8 min 4.5 min p 0.004 consistent findings study however earlier study focus patient satisfaction result triage moreover tamburlini et al regard evaluation triage function ed observed wait time patients crowding could decreased educating nurses establishment triage system ed this may also imply value nurse skills means continuous education related jobs important factor already pronounced reducing pre hospital time interval post crash events our study revealed triage could significantly resulted shorten wait time increase patients satisfaction experiment group study conducted patients satisfaction ed services wait time indicated important factor patients accompanying persons overall hossoein zadeh amer anderson edvin trial yielded similar results claimed wait time invert association patients satisfaction eds study conducted saudi arabia close two third subjects indicated wait time main reason patients dissatisfaction ed services observed significant association patients satisfaction wait time this also implies care wait time emergency services patients satisfaction researcher presence may affect personnel function possibly speed personnel means hawthorne effect however order deal confirmed results keep confidentially report hospital authorities moreover observations first 3 days left data order diminish bias although hawthorne effect might effect believed effect seems little in addition due lack enough alertness 6 patients principal investigator ask questions help patient accompanies however cases could affect result study generalization patient respondent conclusion triage could significantly decrease time interval patients arrival first visit physician increase patients satisfaction regard vital role triage education ed hospitals fact increase speed ed services triage improve quantity treatment services well patients satisfaction since reduction wait time interval patient satisfaction one important goal nurses emergency ward finding study may improve nursing performance relation work ed researcher presence may affect personnel function possibly speed personnel means hawthorne effect however order deal confirmed results keep confidentially report hospital authorities moreover observations first 3 days left data order diminish bias although hawthorne effect might effect believed effect seems little in addition due lack enough alertness 6 patients principal investigator ask questions help patient accompanies however cases could affect result study generalization patient respondent conclusion triage could significantly decrease time interval patients arrival first visit physician increase patients satisfaction regard vital role triage education ed hospitals fact increase speed ed services triage improve quantity treatment services well patients satisfaction since reduction wait time interval patient satisfaction one important goal nurses emergency ward finding study may improve nursing performance relation work ed	background : long wait time interval in emergency department ( ed ) of hospitals , from the patients point of view in ed is a major problem causing patients dissatisfaction and may result increasing in patient morbidity and indirectly nurses dissatisfaction . evaluation of wait time intervals in ed and giving nursing feedback may improve the quality of services , as well as patient satisfaction . the present study was designed to investigate the effect of nursing triage on receiving treatment of wait time interval and satisfaction of the patients referring to ed in shahid rajaee hospital.materials and methods : this study was conducted on patients those referring to shahid rajaee hospital in karaj , iran employing quasi experimental design d ividing in two experiment and control groups during 2009.this is a quasi - experimental study of which the data were collected by standard questionnaire covering patient satisfaction and measuring wait time . t - test , mann - whitney and frequency analysis were used to evaluate the effect of triage on wait time from receiving treatment services and patients satisfaction.results:the findings showed that there was a significant difference between experiment and control groups regarding wait time from receiving treatment services and patients satisfaction.conclusions:triage could significantly reduce the wait time interval between patients entrance to ed to receive treatment services and enhance patients satisfaction . it may help nursing in emergency ward to have better performance and indirectly their satisfaction .
weak acid ionization plays central role many chemical biological industrial processes measuring predicting free energy process i.e. pka values ) have become important experimental theoretical tools enabling control insight acid base chemistry ph dependent biomolecular transformations although large number theoretical methods developed predict pka values see recent reviews 1 2 references therein less attention given understanding molecular scale mechanism acid dissociation this largely due complexity cost analyzing full free energy surface involves chemical reaction also significant solvent solute reorganization instead pka methods rely use thermodynamic cycles break complex process deprotonation computationally tractable steps small molecules this cycle typically combines gas phase dissociation energy calculated high level quantum mechanical qm calculations de solvation free energies reactant product species calculated continuum solvent approaches gas phase energies quite accurate simple continuum description solvation free energies often requires parameter adjustment reproduce entropic enthalpic complexities inherent molecular solvation they improved hybrid approaches include number explicit water molecules solvation free energy analysis conjunction methodological refinements qm continuum solvent models enabled pka calculations small acids within units experimentally determined values in contrast suite methods developed predict biological pka values typically used thermodynamic cycle solute remains solvated environment each advantages drawbacks well discussed ref 2 however none yet demonstrated ability predict pka values within pka units experimental value test cases it suggested challenging moieties e.g. buried residues large pka shifts strong coupling conformational changes titration sites require methods better capture underlying physics these conclusions highlight interesting nuanced biomolecular system clear protonation states influence everything stability binding reactivity details influence still sometimes poorly understood few methods date simulated actual process interest exchange excess positive charge acid bulk water to involves calculating free energy surface proton dissociation bulk phase environment one learns molecular mechanism rate this requires three things 1 method describes underlying physics bond formation cleavage bulk phase environment 2 method efficient enough combined enhanced sampling approaches capture distribution phase space defines free energy condensed phase entropy energy often similar magnitude 3 reaction coordinate flexible enough track transferring excess charge defect the first requirements obviously filled qm approaches used handful helpful studies probe acid dissociation parrinello molecular dynamics cpmd calculate free energy profile histidine dissociation although chosen reaction coordinate limited analysis stopping beyond transition state able calculate correct relative pka value subtracting equivalent profile water autodissociation similarly park et al used cpmd combination metadynamics sample configurational space acetic acid bulk water while trajectories short sufficiently converge free energy surface able observe characterize multiple protonation deprotonation events these reactions occurred along well characterized pathway excess proton briefly shared acid solvating water they also noted existence shallow minimum free energy surface corresponding existence contact ion pair cip separated protonated state small energy barrier alternative approach still describes bond dissociation ab initio level uddin et al recently used qm mm calculate free energy surfaces several small molecules although obtained quite accurate pka values method describe mechanism dissociation since include one water molecule acid qm region hence method changes physical process dissociation delocalized charge defect proton transfer followed separation localized hydronium cation acid anion solvating mm environment just thermodynamic cycles results show sampling alternative pathway reactant product states yield accurate pka values small molecules another approach describes bond dissociation process reactive md rmd the efficiency models allows sample reactive dynamics much longer length time scales ab initio md since parametrized work mm force fields also avoid boundary issues suffered qm mm calculations both factors make rmd models ideal simulating reactions large complex systems slow dynamics proteins proton exchange membranes two important examples systems without sufficient sampling types systems final result strongly influenced initial conditions a common criticism rmd models approximations true quantum mechanical behavior system while certainly true functional form flexible enough parametrized correctly reactive model retain ability accurately reproduce potential free energy surfaces parametrized multistate empirical valence bond ms evb method rmd force field used characterize proton transport many condensed phase biological environments it especially well suited challenge acid ionization since inherently defines center excess charge used track reactions involving proton transport thereby avoiding issues geometric reaction coordinates although ms evb used study weak acids amino acid dissociation efforts involved larger degree empiricism since pka value needed fit msevb potential it long sought goal find procedure would minimize empiricism rmd models bulk property interest derived entirely quantum data combination extensive sampling this work reports achievement goal multiscale approach calculate free energy profile acid ionization based entirely qm data yields accurate absolute pka value an iterative procedure spirit adaptive force matching used sample reactive phase space obtain reference ab initio data qm mm forces fit rmd potential care taken modify functional form sufficiently flexible reproduce qm mm reference data principle capture essential physics our approach applied aspartic acid asp glutamic acid glu both amino acids play crucial roles proton ion transport biological channels pumps also commonly involved salt bridges influence protein dynamics structure binding we show accurate estimates pka values asp glu obtained resulting reactive models first time reactive model able accurately predict correct pka without explicitly parametrized finally discuss mechanistic description models provide acid deprotonation water emphasize models fit entirely qm mm data without adjustments match experimental pka hereafter refer multiscale reactive molecular dynamics ms rmd models it noted however ms rmd asp glu models parametrized work refined version ms evb3 hydronium model accurately describes proton solvation transport water ms rmd similar ms evb framework successfully used model proton solvation transport many aqueous systems the power approach lies ability describe electronic delocalization linear combination topologically distinct states given configuration for example state \|i could protonated amino acid box water figure 1a state \|j would coordinates topology describing cip solvated hydronium ion deprotonated amino acid figure 1b step simulation state search algorithm first determines possible states based geometric criteria calculates energy state the lowest energy state termed pivot state start state search algorithm next step since number waters therefore number possible states grows exponentially distance pivot state states first three solvation shells several different bonding topologies shown given set nuclear coordinates r. dashed lines surround protonated molecule defined bonding topology the reactive system described following hamiltonian:1where r vector describing nuclear coordinates hij sum mm potential terms state hij coupling states \|i \|j. details terms provided force field section with the hamiltonian defined way relative weight state described components eigenvector ci:2finally forces calculated using hellmann feynman theorem these forces passed standard md integrator velocity verlet free energy calculations require continuously varying reaction coordinate rc describe process interest the evb formalism provides convenient reference rc center excess charge cec):3 equation ri geometric center charge protonated molecule state ci relative weight state we use distance cec center mass asp glu carboxyl group describe progress deprotonation reaction the diagonal elements ms rmd hamiltonian matrix derived standard charmm mm force field the protonated form uses standard parameters exception acidic h bond bond is replaced morse potential allow dissociation:4where r bond length r0 parameters fit reproduce bond length frequency harmonic potential replaces still allowing reasonable bond dissociation energy deprotonated form amino acid uses standard charmm bonded nonbonded terms parameters since charmm force field originally intended use reactive simulations additional repulsive terms used carboxyl oxygens deprotonated model hydronium oxygen hydrogens these terms help correct overattraction close distances due use point charges the functional forms repulsions used ms evb3 hydronium model:56where b b b c c fitted parameters following logic previous work avoid parameter redundancy doo doh fixed values used ms evb3 the sum gaussians term eq 5 included help fitted potential reproduce correct asymmetric solvation structure around hydronium switching function used given eq 9 ref 28 the asp glu models designed work refined version ms evb3 force field herein referred msevb 3.1 this refinement uses functional forms hamiltonian revised parameters using genetic algorithm the fitting parameters optimized using original ab initio data sets well potential energy surface scans eigen ion level original ab initio calculations furthermore oxygen partial charge hydronium adjustable parameter charge hydrogens automatically determined maintain hydronium 1 total charge parameters force field presented supporting information study the limiting species de protonated asp glu models ms evb 3.1 solvated proton spc fw water ms rmd force field parametrized smoothly switch one protonated species another the asymmetry reaction necessitates several modifications original ms evb equations designed water mind the diagonal coupling term hij designed reproduce correct transition state geometry previous ms evb models used complex diagonal term describe symmetric reaction pathway two waters however asymmetry asp water system better fit simple gaussian potential:7where roh distance deprotonated asp oxygen excess proton the parameters determine shape size gaussian fit qm mm data practice protonation reactions occurring different species require constant energy term vii added deprotonated state this term accounts difference energy resulting different mm force fields without the protonated deprotonated asp potential energy surfaces would offset hundreds kilocalories per mole reaction would ever take place this difference due primarily electrostatics estimated subtracting coulomb energy favorable hydronium state containing favorable electrostatic interactions hydronium cation amino acid anion coulomb energy protonated neutral amino acid state figure 2 shows plot average value term function rc since vii controls relative stability protonated deprotonated states used past work tune behavior model reproduce experimental quantities pka current work an iterative fitting approach used rigorously determine value vii along ms rmd parameters plot difference coulomb energy protonated asp state lowest energy non asp state short distances it similar ways used previous work ms rmd models force matched aimd data there however important differences including use qm mm instead aimd use empirical functional forms instead tabulated potentials use iterative scheme sampling configuration space starting guessed hamiltonian these choices partially motivated success demonstrated adaptive force matching method wang co workers reactive hamiltonian order generate set configurations along reactive pathway next high level qm mm calculations performed collect atomic forces configurations the new reactive hamiltonian used generate new configurations via umbrella sampling process repeated parameters reach desired convergence details step discussed text due nonlinearity several reactive force field parameters the reactive model fit qm mm reference data using genetic algorithm minimize residual:8here nc na number configurations number atoms configuration respectively w(rij weight atom unless specified otherwise set 1 fij atomic force current ms rmd parameter set fijqm mm reference force qm mm calculation the fitting calculations run parallel used 4000 genomes parameter sets per generation lessen danger overfitting the first step followed uniformly distributed mutation scheme outlined section 3.1 ref 40 the range parameters chosen broad possible without allowing unreasonable values for example c3 diagonal term would unreasonable greater aspo once converged parameter set reached uniform distribution mutation scheme switched normally distributed scheme described section 3.2 ref 40 this scheme good quickly finding local minimum therefore used find best genome vicinity result first step since second scheme easily trapped local minima ideal use the combination described found quickly reliably converge optimum solution the discrete recombination scheme described section 2.2 ref 40 used mutation schemes the nature reactive model introduces additional complexity otherwise simple scheme vii directly controls depth protonated well relative deprotonated cip constant included states amino acid protonated the diagonal term acts broader range spanning protonated amino acid cip configurations also negligible effect cip dissociates in contrast repulsive terms applied deprotonated amino acid significant longer distances negligible distances transition state furthermore since vii repulsive terms added diagonal matrix elements tend correlated behavior fit simultaneously thus value vii first iteration generating new qm mm data chosen average value described figure 2 this value found within kilocalories per mole final value vii therefore good initial approximation holding value vii fixed diagonal repulsive terms fit full set qm mm reference forces once diagonal repulsive terms reach optimum value current value vii umbrella sampling used generate pmf model since vii effect important around transition state range rc values immediately surrounding transition state is chosen pmf configurations range used fit new value vii using new value vii diagonal repulsive terms refit vii held constant this procedure fits empirical model solely qm mm data results models correctly predict bulk phase pka values asp glu solution simulations asp glu include one solute molecule solvated 486 467 waters respectively reduce interactions charged backbone protonatable sites n termini capped acetyl group c termini capped methylamine the systems equilibrated npt ensemble 1 atm 310 k 200 ps changing nvt ensemble cubic box 24.55486 side asp 24.24938 glu all reactive simulations run modified version lammps simulation package the rc chosen distance cec center mass amino acid side chain carboxylic acid umbrella sampling used evenly sample rc asp system 25 windows spaced every 0.36 starting rc value 1.0 the glu system used 36 windows spaced every 0.25 20.0 kcal mol restraints production window was equilibrated 100 ps statistics collected 1.7 ns the pka calculated resulting pmf using following equation:9where w(r free energy pmf product simulation temperature boltzmann constant the integral calculated zero transition state denoted c standard state concentration whose value 1660 molecule results entropic freedom gained proton dissociates acid atomistic configurations qm mm calculations selected umbrella sampling trajectories order ensure uniform distribution along rc individual configurations sorted rc value 60 0.067 wide bins five configurations selected random bin giving total 300 configurations iteration qm mm performed cp2k using b3lyp double zeta basis set unrestricted dft used allow accurate calculation forces near dissociation barrier b3lyp chosen mp2 recent studies shown comparable accuracy reduced computational cost water solvated excess proton calculations run 256 intel sandy bridge cores average completed within 10 min the qm region included entire amino acid residue waters found ms rmd state search proximity classical point charges reduces accuracy forces calculated qm atoms additional 3 buffer layer qm water added around qm atoms together results qm region containing average 208 atoms one asp glu 61 waters total four iterations needed asp parameters converge glu parameters converged three iterations parameters new asp glu models presented table 1 these parameters fit qm mm reference forces using previously described iterative scheme ensure convergence it must noted asp glu models parametrized using method entirely independent data sets the fact final parameters model similar surprising however given molecular similarity small difference experimental pka values as next section discusses pka predicted model good estimate experimental value the fact models able capture subtle differences evidence methodology works well the potential mean force pmf deprotonation describes free energy process function rc obtain free energy change two points pmf one simply integrates pmf figure 4a shows pmf deprotonation asp figure 4b shows pmf glu black lines as depicted figure 5 rc gives distance center mass carboxylic moiety cec rc values around 1.3 correspond protonated amino acid values 2.1 5 correspond stable cip values 5.5 represent excess proton separated anionic acid bulk solvent pmfs cmax distributions final asp b glu models the colormap background gives cmax probability distribution normalized rc value this distribution describes extent charge delocalization extension solvation structure snapshots umbrella sampling trajectories illustrating types structures suggested cmax distributions 2d rdfs arrows indicate region pmf windows run distances box center harmonic restraint the position cec shown yellow sphere eigen structures the cec nearly aligned central water oxygen zundel structures the protonated forms asp glu much stable deprotonated forms consistent status weak acids evaluating integral eq 9 estimates pka values asp glu 3.82 0.17 4.56 0.18 respectively these good agreement experimental ranges 3.71 3.90 asp 4.15 4.31 glu the barrier prevents protonation due cost forming zundel like arrangement acid hydronium the depth extent cip varies system however existence predicted variety weak acid systems simulated different methods preparing simulation calculate pmf deprotonation pka care must taken ensure rc sampled far enough beyond cip ensure bulk like properties if done pmf pka calculated shifted resulting pka neither accurate reflect quality model fortunately sampling well beyond cip problem ms rmd models due efficiency however care needs taken running qm mm simulations ensure large enough qm box enough solvating waters used sample beyond cip also avoid boundary issues pmf hand one the ms rmd methodology conveniently provides measure structure solvated complex it shown square largest component ground state eigenvector cmax c eq 3 describes solvated structure a value 1 indicates limiting case entirely localized excess charge values less quantify degree charge delocalization eigen structures excess charge shared among central hydronium three h bound water molecules cmax value around 0.65 zundel structures share excess charge equally two water molecules cmax value closer 0.5 it emphasized always additional delocalization surrounding water molecules even limiting eigen- zundel like cations plotting cmax probability density function rc gain insight structural changes accompany deprotonation this probability density plotted colormap figure 4 low rc values both asp glu average cmax greater 0.9 indicates structure dynamics mostly resemble limiting case protonated acid bulk water little charge transfer surrounding water molecules this notably different protonated water molecule always involves significant amount charge delocalization as proton begins dissociate cmax decreases proton goes clear zundel like transition acid solvating water beyond transition state the system begins resemble eigen cation one solvating waters replaced acid anion however eigen structure seen cip distinctly different seen bulk water evidenced cmax 0.73 the close proximity anionic acid helps stabilize hydronium leading localized charge further evidence uniqueness cip well defined zundel transition around 4 linking cip bulk like structure longer distances eigen transitions bulk water around anionic amino acid structured evident distinct zundel like transition rc value around 4 figure 5 shows snapshots typical structures found different rc values characteristic significant regions pmf the bonding topology reflects h distances less equal 1.6 commonly considered length hydrogen bond it also interesting look structural changes occur directly around cec to two dimensional radial distribution functions 2d rdfs cec surrounding water oxygens ow water hydrogens hw shown figure 6 a slice along first dimension 2d rdfs gives traditional 1d rdf describes probability finding indicated pair given distance apart scanning second dimension shows solvation structure changes reaction progresses according rc combination cmax analysis the 2d rdfs show solvent well defined rearrangements proton dissociates asp travels bulk figure 6a shows 2d rdf asp cec ow distance once asp deprotonated first peak near 2.5 characteristic eigen structure when rc reaches 4 peak distance drops around 1.5 characteristic slightly asymmetric zundel cation cec resides close midpoint vector 2d rdf showing asp cec 2d rdfs cec ow b cec hw asp these plots show water structure changes around cec deprotonation occurs 2d rdfs cec ow b cec hw glu we presented procedure fitting parameters ms rmd model reproduce forces qm mm calculations due efficiency ms rmd able collect analyze data large time length scales reveal intricate behavior essential converged bulk phase thermodynamic properties new methodology used parametrize new models asp glu correctly predict correct experimental pka values this first time ms rmd model able reproduce experimental pka values without fitting experimental data multi nanosecond trajectories analyzed extract important information mechanism underlying deprotonation process it shown deprotonation process follows well defined series zundel eigen transitions excess proton travels asp bulk solution this work considered continued progress toward goal flexible systematic algorithms reliably make multiscale connection accurate electronic structure calculations efficient empirical models describe complex reactive processes accurate ab initio methodologies e.g. those explicitly accounting electronic correlation become computationally tractable qm mm condensed phase systems procedure presented herein related force matching algorithms invaluable tools mapping high level data efficient rmd models significantly extend time length scales reactive simulations explore complex phenomena while results presented herein important true test procedure apply biological systems pka individual residues shifted several pka units proton transport proteins sensitive underlying protonatable residue models therefore crucial procedure ensure models physically accurate furthermore biological systems orders magnitude larger much slower dynamics systems presented while conceivable qm mm md simulations could reach sort time scales solution simulations presented would prohibitively expensive run length time scales needed account slow dynamics commonly found biological processes the ms rmd methodology already shown scale well hundreds thousands atoms realistically reach tens nanosecond simulations large explicit biomembrane systems work already underway implement reactive models protein environments use presented methodology fine tune individual amino acid models behave properly specific protein environments	accurately calculating a weak acid s pka from simulations remains a challenging task . we report a multiscale theoretical approach to calculate the free energy profile for acid ionization , resulting in accurate absolute pka values in addition to insights into the underlying mechanism . importantly , our approach minimizes empiricism by mapping electronic structure data ( qm / mm forces ) into a reactive molecular dynamics model capable of extensive sampling . consequently , the bulk property of interest ( the absolute pka ) is the natural consequence of the model , not a parameter used to fit it . this approach is applied to create reactive models of aspartic and glutamic acids . we show that these models predict the correct pka values and provide ample statistics to probe the molecular mechanism of dissociation . this analysis shows changes in the solvation structure and zundel - dominated transitions between the protonated acid , contact ion pair , and bulk solvated excess proton .
worldwide 2015 second common newly diagnosed cancer fourth common cause cancer death men united states incidence mortality prostate cancer ranked first second respectively men past years incidence prostate cancer increased steadily slowly increased mortality 13 current treatments prostate cancer include surgical medically induced castration androgen deprivation therapy adt using androgen receptor ar antagonists despite treatments castrate resistant prostate cancer crpc defined disease progression despite adt may present spectrum disease ranging rising prostate specific antigen psa levels progression preexisting disease appearance new metastases 68 docetaxel approved us food drug administration fda 2004 taxane drug induces polymerization microtubules phosphorylation bcl-2 protein three weeks combined docetaxel prednisone currently considered standard first line chemotherapy men crpc the second line chemotherapy cabazitaxel shown increased survival time patients crpc however severe adverse events reported treatments 10 11 advances understanding disease pathophysiology new treatments crpc emerge recent years aim improve survival quality life patients these treatments include cancer immunotherapy sipuleucel ar directed therapies abiraterone acetate aa enzalutamide enz radium-223 prostvac 1318 phase iii clinical trials conducted sipuleucel aa enz fda approved use patients crpc 2123 these new treatments hold great potential first line treatments patients crpc finding optimal regimen major clinical challenge this meta analysis aimed investigate compare efficacy safety two treatments provide scientific evidence management crpc aa steroidal antiandrogen exerts effect inhibiting cyp17a also acts antagonist ar 24 25 it strong binding affinity ar addition prevents binding ar deoxyribonucleic acid ar coactivator proteins the antigen presenting cells apcs harvested individual patient peripheral blood later incubated recombinant fusion protein antigen contains prostatic acid phosphatase granulocyte macrophage colony stimulating factor 27 28 this process activates apcs critical priming cytotoxic lymphocyte mediated immune response these activated apcs reinfused individual patient 2010 sipuleucel became first immune therapeutic agent approved fda patients crpc based consistent observed improvement overall survival this meta analysis aimed determine clinical efficacy safety two types treatments namely sipuleucel ar directed therapies aa enz management crpc survival disease progression assessed overall survival os time progression ttp respectively we systematically searched seven literature databases ovid springer pubmed web science sciencedirect medline cochrane library 1966 october 2015 relevant articles entering terms including castrate resistant prostate cancer sipuleucel enzalutamide abiraterone acetate key words title subject heading text word we also searched potentially missed articles reference list retrieved articles previous narrative reviews topic studies included met following criteria 1 randomized double blind place controlled clinical trials sipuleucel aa enz presenting original data 2 patients crpc 3 english articles published october 2015 case duplicated reports article presenting latest comprehensive data largest cohorts selected studies excluded 1 duplicated reports poor quality lacking original data presented incomplete data 2 review articles conference abstracts commentary two authors renliang yi baoxin chen conducted literature search study selection independently results compared discrepancies resolved discussion another author peng duan quality included articles assessed using newcastle ottawa scale nos study judged three broad perspectives selection study groups adequate definition cases representativeness cases selection controls definition controls comparability groups compatibility cases controls ascertainment outcome interest ascertainment exposure ascertainment cases controls nonresponse rate results compared discrepancies resolved discussion another author weilin ou the following outcomes extracted study os ttp reduction psa level 50% adverse events grade 3 results compared discrepancies resolved discussion corresponding author zhiheng zhou review manager 5.1 software used data synthesis analysis hazard ratio hr 95% confidence interval ci ) heterogeneity analysis performed using q test p 0.1 50% suggesting homogeneity among studies data without significant heterogeneity fixed effect models used pooled analyses case significant heterogeneity sensitivity analysis performed excluding study highest variance case definite cause found heterogeneity random effect model used pooled analyses the significance pooled data tested p 0.05 considered statistically significant enough studies included funnel plot delineated publication bias evaluated a total 302 articles excluded reviewing titles abstracts 80 articles excluded due duplicated reports exclusion reasons included review articles commentary correspondence nonrandomized placebo controlled trials lack complete study outcomes seven articles included meta analysis three articles sipuleucel two aa two enz respectively all seven studies randomized double blind placebo controlled clinical trials results quality assessment using nos seven studies showed table 1 regimens used studies follows 1 sipuleucel patients randomly assigned 2 1 ratio receive either sipuleucel placebo every two weeks total three infusions 2 aa intervention group received combined aa 1000 mg prednisone 10 mg daily placebo group received prednisone 10 mg daily plus placebo 3 enz intervention group received enz 60 mg daily placebo group received placebo all seven studies provided data survival follow period 36 months 29 3136 analyses os performed 5,936 patients 737 patients sipuleucel intervention group versus placebo group 488 versus 249 patients 5,199 patients ar directed therapies intervention group versus placebo group 3,015 versus 2,184 patients results showed compared placebo sipuleucel ar directed therapies significantly improved survival patient crpc pooled hr os 0.73 sipuleucel 95% ci 0.610.88 z 3.31 p 0.001 0.72 ar directed therapies 95% ci 0.660.78 z 7.94 p 0.00001 tests heterogeneity showed insignificant results indicating homogeneity among studies p 0.1 50% six studies total 5,936 patients reported ttp 29 3135 including 737 patients sipuleucel intervention group versus placebo group 488 versus 249 patients 5,199 patients ar directed therapies intervention group versus placebo group 3,015 versus 2,184 patients compared placebo sipuleucel showed significant favorable effect ttp pooled hr 0.88 95% ci 0.741.06 z 1.35 p 0.18 test heterogeneity significant p 0.35 4% in contrast ar directed therapies showed significant improvement ttp pooled hr 0.59 95% ci 0.400.88 z 2.59 p 0.009 seven studies total 5,936 patients reported reduction psa level 50% study outcome 29 3136 including 689 patients sipuleucel intervention group versus placebo group 458 versus 231 patients 4,975 patients ar directed therapies intervention group versus placebo group 2,928 versus 2,047 patients pooled rr showed sipuleucel significant effect reducing psa level 50% rr 2.51 95% ci 0.659.73 z 1.33 p 0.18 test heterogeneity significant p 0.5 0% in contrast ar direct therapies showed significant effect reducing psa level 50% rr 9.82 95% ci 1.9948.46 z 2.89 p 0.004 figure 4 investigate safety treatments compared occurrence adverse events grade 3 including fatigue headache back pain arthralgia constipation diarrhea placebo pooled rr revealed compared placebo risk adverse event significantly increased sipuleucel ar directed therapies p 0.05 table 3 figure 5 figure 6 shows symmetry funnel plot indicating significant evidence publication bias researches novel treatments crpc gained increasing interest past years especially sipuleucel ar directed therapies this meta analysis investigated efficacy safety sipuleucel ar directed therapies providing valuable information might useful clinical evidence treatments crpc we found sipuleucel ar directed therapies could significantly improve os patients crpc favorable safety ar directed therapies appear superior effects improving ttp reduction psa level however still debates efficacy optimal regimen new treatment methods it known traditional chemotherapeutic drugs lacked selectivity target tumor cells may cause different damage normal cells even serious effects patients indicated adverse effects docetaxel including edema neurotoxicity hair loss limit application zhou et al also showed 2.7% crpc patients died docetaxel plus prednisone therapy 58.56% neutropenia 19.82% leukopenia unlike traditional ones sipuleucel ar directed therapies target tumor cells thus causing little toxic effects normal cells due high selectivity for instance aa enz antagonize androgen receptors inhibit activity tumor cells similarly sipuleucel could elicit immune response targeting antigen prostatic acid phosphatase pap highly expressed prostate cancer cells 39 40 many results showed sipuleucel ar directed therapies improved overall survival 29 3136 exerting different effects ttp psa level aes although surgery radiotherapy chemotherapy stopped period time new drugs clinical trials given still hard rule possibility influence former treatments therefore clinical validation needed beyond paid attention sequela applicable scopes contraindications treatments all trials strict selection patients eligible case sipuleucel trial histological confirmation castrate resistant prostate cancer serum testosterone level 50 ng dl considerable somatic function expected survival required patients accepted aa trial two previous chemotherapies least one previous docetaxel therapy mild symptoms symptoms radiographic progression soft tissue bone without psa progression psa 50 ng dl ecog performance status 2 less patients sipuleucel trials scheduled undergo leukapheresis procedures every 2 week total three times second day leukapheresis procedure patients treated infusion sipuleucel placebo patients aa trials received abiraterone acetate 1000 mg daily plus prednisone 5 mg twice daily oral placebo plus prednisone enz trials patients received enzalutamide 160 mg orally daily matched placebo we found aa trials patients lower score ecog age 65 years psa level median higher hr contrary enzalutamide trials patients age 65 years higher score ecog psa level median higher hr sipuleucel trials patients age median psa median higher score ecog higher hr drake 2012 indicated subgroup patients aged less 65 years favor sipuleucel another observation potential harm impact study interventions extent sipuleucel broke immune balance challenges remain finding optimal regimen sipuleucel ar directed therapies combined sipuleucel aa prednisone formula proposed novel treatment diagram crpc research shown concurrent administration aa prednisone blunt immunologic effects alter immune parameters correlate sipuleucel clinical benefits cumulative apc activation cumulative apc number total nucleated cell counts immune responses sipuleucel affected coadministration aa prednisone combination treatments well tolerated new risk marker emerging sipuleucel recommended first line treatment patients crpc national comprehensive cancer network recommended early use asymptomatic crpc patients mild symptoms this possibly result mutation ar induced prednisone subsequently impact effect enz ar therefore appears limited clinical benefit combination sequential use enz aa 4548	new treatments , such as sipuleucel - t and androgen receptor- ( ar- ) directed therapies ( enzalutamide ( enz ) and abiraterone acetate ( aa ) ) , have emerged and been approved for the management of castration - resistant prostate cancer ( crpc ) . there are still debates over their efficacy and clinical benefits . this meta - analysis aimed to investigate the efficacy and safety of sipuleucel - t and ar - directed therapies in patients with crpc . revman 5.1 was used for pooled analysis and analysis of publication bias . seven studies were included in the meta - analysis , with three studies in sipuleucel - t ( totally 737 patients , 488 patients in treatment group , and 249 patients in placebo group ) and four in ar - directed therapies ( totally 5,199 patients , 3,015 patients in treatment group , and 2,184 patients in placebo group ) . treatment with sipuleucel - t significantly improved overall survival in patients with crpc and was not associated with increased risk of adverse event of grade 3 ( p > 0.05 ) . however , treatment with sipuleucel - t did not improve time - to - progression and reduction of prostate - specific antigen ( psa ) level 50% was not significantly different from that with placebo . ar - directed therapies significantly improved overall survival in patients with crpc and improved time - to - progression and reduction of psa level 50% . ar - directed therapies did not increase risk of adverse event of grade 3 ( p > 0.05 ) .
national children food survey ncfs 20032004 national teens food survey ntfs 20052006 carried establish databases habitual food drink consumption representative samples irish children aged 512 years teenagers aged 1317 years a 7-d weighed food record used collect food intake data 594 children 293 boys 301 girls 7-d semi weighed food record used collect food intake data 441 teenagers 224 boys 217 girls participants parents guardians visited trained nutritionist four times including one training visit recording period participants aid parents guardians younger children requiring aid 100 asked record detailed information regarding amount types foods beverages supplements consumed 7-d period applicable cooking method used brand name food consumed packaging size type details recipes leftover a hierarchal method dietary data collection quantification used included weighing photographic food atlases manufacturers information household measurements analyses dietary intake data carried using wisp tinuviel software contains mccance widdowson composition foods 6th edition irish food composition database self reported health lifestyle questionnaires completed participants parents guardians concurrent collection food intake data this study conducted according guidelines laid declaration helsinki procedures involving human participants approved st james hospital federated dublin voluntary hospitals joint research ethics committee ncfs university college cork clinical research ethics committee cork teaching hospitals ntfs written informed consent given children teenagers parents guardians children selected twenty eight primary schools republic ireland database obtained department education science the database divided small medium large schools b boys girls mixed c disadvantage disadvantaged urban rural a random sample selected category final sample proportions children attending categories schools reflected proportions according database the principal selected schools given detailed instructions select children participation survey school roll teenagers recruited similar vein thirty two secondary schools divide secondary vocational comprehension schools place small medium large children the overall response rate 66 children 63 teenagers analysis demographic features samples shown representative samples irish children teenagers respect age sex social class socio economic group geographic location compared census data ded kj g calculated including food excluding beverages this included solid foods liquid like foods yoghurts soups excluded beverages energy containing non energy containing this method previously used authors water accounts much variability ded it thought inclusion beverages may disproportionately affect estimates high beverage consumption the intakes individual nutrients used indicators nutritional quality diet the intakes macronutrients expressed percentage total energy micronutrients adjusted 10 mj each 1945 foods ncfs 1761 foods ntfs consumed surveys aggregated thirty two food groups examine food intake patterns associated ded participants consumed nutritional supplement least recording days defined supplement users weight height measurements taken researchers participants homes weight measured duplicate using seca 770 digital personal weighing scale chasmores ltd nearest 01 kg height measured nearest 01 cm using leicester portable height measure chasmores ltd participant head positioned frankfurt plane minimum energy intake cut points calculated multiples bmr used identify reporters energy accordingly 32 children 64 teenagers classified reporters results presented total population natural cut offs exist ded estimates vary significantly age sex within study populations split equally three categories low- ncfs 756 ntfs < 765 kj g medium- ncfs 756875 ntfs 766885 kj g high ded ncfs 875 ntfs 885 analyses differences low- medium- high ded groups carried using one way anova tukey honestly significant difference hsd idk post hoc test test differences means whitney u used assumptions anova met variables could normalised transformation natural log square root the mean weight food food beverages consumed decreased across tertile ded p 0001 mean daily intake energy change significantly table 1 table 1.daily intake energy macronutrients dietary fibre weight food consumed tertile energy density diets irish children n 594 teenagers n 441 mean values standard deviations)childrenteenagerslowmediumhighlowmediumhighmean dietary energy density kj g)677817985663825988tertile cut offs<756756875>875<765766885>885 n 198198198147147147mean sd mean sd mean sd pmean sd mean sd mean sd pweight food excluding beverages g d)845197702158603150000010554028642527312160000weight food beverages g d)16784141549371147336400002204791199561718525640000energy mj)69146915721600958125842485240116protein te)14622137181252100001582514724136230000fat te)32642345393474300003384935247378460000saturated fat te)13625145241472600001312613825149260000monounsaturated fat te)105171141711619000010921141912620000polyunsaturated fat te)46114812491501155316541659190006unsaturated fat saturated fat11402311302311502807121280291240261270280485carbohydrate te)524495134552250050498524925479490007total sugar te)239542364724357058420452025206490739added sugars te)1244914445170580000104431264714450000starch te)2754826742674801202864528143265440000dietary fibre g/10 mj)20241176361543800002176318744160330000%te total energy arrows denote direction association increasing dietary energy density determined anova daily intake energy macronutrients dietary fibre weight food consumed tertile energy density diets irish children n 594 teenagers n 441 mean values standard deviations mean values unlike superscript letters significantly different groups arrows denote direction association increasing dietary energy density determined anova percentage total energy te fat saturated fat monounsaturated fat added sugars increased p 0001 across tertile ded te protein dietary fibre g/10 mj decreased p 0001 populations teenagers alone seen ded increased te carbohydrate p 001 starch p 0001 decreased te poly unsaturated fats increased p 001 the te total sugars unsaturated fat saturated fat ratio change significantly either population ded increased table 1 children as ded increased significant decrease intakes energy adjusted vitamin vitamin vitamin b12 folate biotin thiamin riboflavin niacin equivalents vitamin b6 pantothenic acid vitamin c ca mg p k cu zn mn na p 0001 fe p 005 table 2 table 2.daily vitamin mineral intakes per 10 mj energy sources tertile energy density diets irish children n 594 teenagers n 441 mean values standard deviations)childrenteenagerslowmediumhighlowmediumhighmean dietary energy density kj g)677817985663825988tertile cut offs<756756875>875<765766885>885 n 198198198147147147mean sd mean sd mean sd p mean sd mean sd mean sd pvitaminsvitamin g/10 mj per d)13799131015586656392000013317088884596433830000vitamin g/10 mj per d)4343132242800004736262123170000thiamin mg/10 mj per d)25372107200600003561221320260000riboflavin mg/10 mj per d)2937260924080000386324142110000niacin equivalents mg/10 mj per d)43811340488378880000505139443102389920000vitamin b6 mg/10 mj per d)33382809260900004661311625090000vitamin b12 g/10 mj per d)694622556220000695592152230000folate g/10 mj per d)3631563131042828200004021893151042701060000biotin g/10 mj per d)4345283472730217500005246673121822922580000pantothenic acid mg/10 mj per d)8549742469230000927371286120000vitamin c mg/10 mj per d)16641291116371392153500001751593107811657555350000mineralsca mg/10 mj per d)12883231231314116532200001098298110229310133000011mg mg/10 mj per d)29843275362553800003115827840250340000p mg/10 mj per d)15452521472209135723300001538252144921913442200000fe mg/10 mj per d)13837134411304004817819215821120610000k mg/10 mj per d)34604543111370281939600003522537319239729124270000cu mg/10 mj per d)13061204100300001406120310040000zn mg/10 mj per d)101296248520000118441032391210000mn mg/10 mj per d)26092307200600003113260822080000na mg/10 mj per d)30535662997526285651700013150590305355829775550117 mean values unlike superscript letters significantly different groups as determined anova unless otherwise specified. determined kruskal wallis test daily vitamin mineral intakes per 10 mj energy sources tertile energy density diets irish children n 594 teenagers n 441 mean values standard deviations mean values unlike superscript letters significantly different groups arrows denote direction association increasing dietary energy density determined anova unless otherwise specified determined kruskal as ded increased significant decrease intakes energy adjusted vitamin folate biotin vitamin thiamin riboflavin niacin equivalents vitamin b6 vitamin b12 pantothenic acid vitamin c mg p fe k cu zn mn decreased ded increased p 0001 ca decreased p 005 there significant difference na intakes across tertile ded teenagers table 2 children teenagers however overall association micronutrient density diet change intake nutritional supplements excluded table 3 displays mean daily intake food groups g/10 mj fruit vegetable intakes inversely associated ded children teenagers p 0001 fruit vegetable juices intakes p 001 table 3.mean daily food group intakes g/10 mj tertile energy density diets irish children n 594 teenagers n 441 mean values standard deviations)childrenteenagerslowmediumhighlowmediumhighmean ded kj g)677817985663825988tertile cut offs<756756875>875<765766885>885 n 198198198147147147mean sd mean sd mean sd pmean sd mean sd mean sd p*fruit vegetablesfruit15501108992724624850000141617424925692934650000vegetables vegetable dishes102176861142734633200001114832711524484140000fruit vegetable juices167318111209140611481500003135617051085140680812430002cereal productswhite bread rolls8555029294899146601626824877885078554720005wholemeal brown bread rolls2524351623089821300003404672093461352740000grains rice pasta pizza cereals100480576460271865900001276109610878258377590000breakfast cereals5866134833755439102017228125385693423370000dairy productswhole milk329425193454243733825060797234123692401218224523580588reduced fat milks5341362328113628810820011515132657513339212260326cheeses1071331121321071640126141721311821311870424yoghurts7817616126243163940000396512483971322460000butter spreadsreduced fat spreads 40 2854255316470023327238222540862butter dairy spreads 40 84910087124113000089961031181331460098potatoes potato dishespotatoes boiled baked mashed)1083794703598506499000011369158726585605150000potato products55172902019020300537220979174871960577chipped fried roasted potatoes47540757745366447200006225968005579277010000beveragestea coffee435232144361298337725710188805963863604902596647960004carbonated beverages1203147716671558234623250000144517922012065322126190000diet carbonated beverages204561272671695530395218759347792859680019squashes cordials fruit juice drinks1039148992311471182125501024168944266854017280400meat fish eggsfresh meat meat dishes10237028885696215030000158479414357359985810000burgers sausages meat products53539757637458139202674683656084467445020000fish fish dishes204283109154771330000191299108264761370057eggs egg dishes1191861141819216201641031841061711031820552confectionery savoury snackssugars syrups preserves81998110795151086781126101167861310542chocolate confectionery19921322520629925400001902072201943232610000non chocolate confectionery1542072272924429200011151851652511281780392savoury snacks1431418714321218500001171461511662192140000biscuits cakes pastries3042284102533802900002572942752882853140494creams ice creams chilled desserts44513884153233420166273642623242443260772miscellaneoussoups sauces49958533140323429600007987784613983773830000nuts seeds herbs spices1237094811350395164614106290578ded dietary energy density arrows denote direction association increasing ded determined anova unless otherwise specified. determined kruskal mean daily food group intakes g/10 mj tertile energy density diets irish children n 594 teenagers n 441 mean values standard deviations ded dietary energy density arrows denote direction association increasing ded determined anova unless otherwise specified determined kruskal low ded associated higher intakes wholemeal brown bread grains rice pasta pizza cereals yoghurts potatoes fresh meat meat dishes fish soups sauces p 0001 reduced fat milks reduced fat spread p 005 lower intakes butter dairy spreads chipped fried roasted potatoes carbonated beverages chocolate non chocolate confectionery savoury snacks biscuits cakes p 0001 teenagers low ded associated higher intakes wholemeal brown bread grains rice pasta pizza cereals breakfast cereals yoghurts potatoes fresh meat meat dishes soups sauces p 0001 tea coffee p 001 lower intakes chips carbonated beverages burgers sausages chocolate savoury snacks p 0001 white bread p 001 diet carbonated beverages p 005 table 3 removal reporters analyses mean ded estimated children 826 139 kj g teenagers 835 163 kj g neither significantly different total population estimates 826 144 kj g children 826 151 kj g teenagers analyses associations repeated excluding children teenagers classified reporters variations associations ded nutritional quality diet minimal in two national detailed nutrition surveys irish children teenagers ded inversely associated multiple individual markers nutritional quality diet lower ded generally considered associated healthier diet proposed use possible proxy dietary quality this study adds evidence use ded marker better nutritional quality diet examining data children teenagers minimal evidence also using dietary intake data weighed semi weighed 7-d food diaries whereas previous evidence ffq 24-h recall dietary data irish children teenagers low ded associated generally better macronutrient profile higher energy adjusted intakes protein dietary fibre lower intakes total fat saturated fat monounsaturated fat added sugars irish teenagers children low ded also associated higher intakes carbohydrates starch lower intakes polyunsaturated fat similar results reported swedish children teenagers finding low ded associated higher energy adjusted intakes carbohydrates protein fibre lower intakes total fat saturated fat sucrose studies adults also reported low ded associated higher intakes protein carbohydrates dietary fibre lower intakes fat saturated fat examining broad range vitamins minerals this study showed lower ded associated higher micronutrient density diet children teenagers previous studies found children teenagers low ded higher intakes micronutrients examined high ded adults reported low ded higher energy adjusted intakes vitamins c b6 folate fe ca k high ded counterparts also higher intakes folate vitamin c carotenoids vitamin b6 ca fe lower ded higher compliance dietary recommendations micronutrient intakes associated lower ded study american men women low ded were reported higher prevalence multivitamin multimineral supplement use the association increased use nutritional supplements ded also examined current study found associated lower ded irish children teenagers this detract association increased micronutrient intake association lower ded increased micronutrient density diet found independent nutritional supplement usage this better nutritional quality associated lower ded may explained differences food intake patterns generally closer healthy eating guidelines children teenagers low ded compared high ded consumed fruit vegetables fruit vegetable juices wholemeal bread grains rice pasta pizza cereals breakfast cereals teenagers fresh meat potatoes mashed boiled baked yoghurts children fish low fat dairy products less chipped potatoes carbonated beverages confectionery butter children teenagers white bread processed meat similar results current analyses found swedish children teenagers lower ded likely consume fruit vegetables pasta rice potatoes cereals less likely consume sweets chocolate sweetened drinks generally followed nordic nutrition recommendations better high ded it also reported adults consuming diets low ded tend closer dietary recommendations established spanish society community nutrition high ded study spanish adults those low ded showed trend towards healthier lifestyle characterised leisure time physical activity lower prevalence smoking sedentary lifestyle alcohol consumption some exceptions association low ded better nutritional quality diet noted study firstly na intakes slightly higher lower ded children teenagers these intakes however estimated food consumption data take account discretionary salt added cooking table reflect total intakes secondly lower ded associated lower intakes monounsaturated fat poly unsaturated fat teenagers investigate association ded unsaturated fat saturated the lack association shown analysis suggests lower intakes unsaturated fats seen lower ded reflect association ded lower total fat similarly lower unsaturated fat intakes reported swedish children teenagers spanish adults lower ded decrease unsaturated fat saturated fat ratio increasing ded also reported spanish adults although differences associations ded food intakes noted children teenagers differences direction association macro- micronutrients ded shown keeping notion ded indicator overall dietary quality ded useful marker nutritional quality diet easy calculate applicable data used place multiple individual markers dietary quality cumulative scores one difficulty use determination cut points level ded begin reflect less healthy diet ? this study categorised individuals according tertile ded sample specific cut points represent healthy unhealthy ends spectrum rather less healthy within study group this undermine usefulness ded marker readily used continuous form the cross sectional nature data collection prevents determination direction associations the percentages reporters energy study populations high particularly teenagers however upon repeating analyses without inclusion associations better nutritional quality diet remained significant no well accepted method calculating ded exists limiting findings study method food only. food method calculating ded used water contributes weight diet energy intake thought inclusion beverages may disproportionate effect ded misclassify high beverage consumers also allowed comparisons publications strengths analyses include detailed level dietary intake data collected making use 7-d weighed semi weighed diaries collected trained nutritionists use sample nationally representative age sex social class socio economic group geographic location this study shows children teenagers ireland low ded associated multiple individual indicators better nutritional quality diet including higher intakes dietary fibre micronutrients generally better balance macronutrients low ded also associated food intake patterns generally closer healthy eating guidelines well supplement use taken together findings support conclusion low ded may useful indicator better nutritional quality diet	to examine the relationship between dietary energy density ( ded ) and the nutritional quality of the diet , using data from the irish national children 's food survey ( ncfs ) and the national teens ' food survey ( ntfs ) , two cross - sectional studies of food consumption were carried out between 2003 and 2006 . data from the ncfs and ntfs were used to examine the intakes of nutrients and foods among those with low- ( ncfs < 756 , ntfs < 765 kj / g ) , medium- ( ncfs 756875 , ntfs 766885 kj / g ) and high - energy - dense diets ( ncfs > 875 , ntfs > 885 kj / g ) . a 7-d food diary was used to collect food intake data from children ( n 594 ) and teenagers ( n 441 ) . ded ( kj / g ) was calculated including food alone and excluding beverages . participants with lower ded consumed more food ( weight ) but not more energy . they also consumed less fat and added sugars and more protein , carbohydrates , starch and dietary fibre and had higher intakes of micronutrients . participants with lower ded had food intake patterns that adhered more closely to food - based dietary guidelines . low ded was associated with multiple individual indicators of a better nutritional quality of the diet , including higher intakes of dietary fibre and micronutrients and a generally better balance of macronutrients , as well as being associated with food intake patterns that were closer to healthy eating guidelines . taken together , these findings support the conclusion that a low ded may be an indicator of a better nutritional quality of the diet .
period 8 months september 2012 april 2013 eighteen adult hemato oncological patients scheduled autologous sct maastricht university medical center included the number venous blood draws transfusion regime influenced observational study two patients excluded due missing data i.e. day platelet recovery recorded venous whole blood samples collected k2-edta vacutainer tubes bd diagnostics plymouth uk hemato oncological patients admitted ward routinely sampled daily around 8 samples drawn frequently a previous study showed ipf samples k2-edta stored 4c stays within precision limits 72 h 31 whole blood edta anticoagulated samples measured sysmex xe-5000 analyzer sysmex corporation kobe japan sysmex xn analyzer earlier sysmex hematology analyzers xe-5000 use ret channel measurement immature platelets optic platelet count plt the sysmex xn addition novel plt f channel measurement mature immature platelets this plt f channel introduced specifically gate platelets accurate platelet count plt ipf analyzers measurement immature platelets similar analyzers based principle hemocytometry after perforation platelet cellular membranes reagents nucleic acids stained fluorescent dyes polymethine oxazine xe-5000 oxadine xn 31,32 this algorithm contains side fluorescence reflection rna content side scattered light information intracellular structure forward scattered light information cell size prophylactic transfusion trigger defined platelet concentration 10 10/l case clinical complications surgical intervention use anticoagulants patients sct protocol received irradiated platelet products prepared buffy coats five different abo matched whole blood donors resuspended one unit plasma volume circa 350 ml containing least 250 10 platelets 33,34 some patients received pathogen inactivated platelets treated riboflavin uvb pathogen mirasol terumobct lakewood co usa see table2 transfusion reactions reported according standard protocol assess biological within person variation plt ipf and the absolute number immature platelets ipa measured eight healthy subjects four men four women age 2333 day time 5 duplicate sysmex xn xe analyzers twofold nested anova used estimate person cvbp biological within person cvwp analytical cva coefficients variation including 95% confidence intervals 35 rcv calculated based biological analytical coefficients variations found experiment rcv calculated using formula reflects minimal difference required define statistically significant increase decrease compared previous result person z number standard deviations appropriate desired probability 36,37 study platelet recovery defined first day platelet count increased without transfusion exceeding rcv statistical analyses performed spss statistics version 20 ibm corporation new york ny usa sensitivity specificity positive predictive value ppv calculated described emir et al 38 sensitivity specificity ppv patient population weighted averages weights used based number patient samples control recovery within 2 case recovery within 2 we analyzed sensitivity specificity ipa ipf day 8 sct day platelet recovery using data for period 8 months september 2012 april 2013 eighteen adult hemato oncological patients scheduled autologous sct maastricht university medical center included the number venous blood draws transfusion regime influenced observational study two patients excluded due missing data i.e. day platelet recovery recorded venous whole blood samples collected k2-edta vacutainer tubes bd diagnostics plymouth uk hemato oncological patients admitted ward routinely sampled daily around 8 samples drawn frequently a previous study showed ipf samples k2-edta stored 4c stays within precision limits 72 h 31 whole blood edta anticoagulated samples measured sysmex xe-5000 analyzer sysmex corporation kobe japan sysmex xn analyzer earlier sysmex hematology analyzers xe-5000 use ret channel measurement immature platelets optic platelet count plt the sysmex xn addition novel plt f channel measurement mature immature platelets this plt f channel introduced specifically gate platelets accurate platelet count plt ipf analyzers measurement immature platelets similar analyzers based principle hemocytometry after perforation platelet cellular membranes reagents nucleic acids stained fluorescent dyes polymethine oxazine xe-5000 oxadine xn 31,32 this algorithm contains side fluorescence reflection rna content side scattered light information intracellular structure forward scattered light information cell size prophylactic transfusion trigger defined platelet concentration 10 10/l case clinical complications surgical intervention use anticoagulants patients sct protocol received irradiated platelet products prepared buffy coats five different abo matched whole blood donors resuspended one unit plasma volume circa 350 ml containing least 250 10 platelets 33,34 some patients received pathogen inactivated platelets treated riboflavin uvb pathogen mirasol terumobct lakewood co usa see table2 to assess biological within person variation plt ipf absolute number immature platelets ipa measured eight healthy subjects four men four women age 2333 day time 5 duplicate sysmex xn xe analyzers twofold nested anova used estimate person cvbp biological within person cvwp analytical cva coefficients variation including 95% confidence intervals 35 rcv calculated based biological analytical coefficients variations found experiment rcv calculated using formula reflects minimal difference required define statistically significant increase decrease compared previous result person z number standard deviations appropriate desired probability 36,37 study platelet recovery defined first day platelet count increased without transfusion exceeding rcv statistical analyses performed spss statistics version 20 ibm corporation new york ny usa sensitivity specificity positive predictive value ppv calculated described emir et al 38 sensitivity specificity ppv patient population weighted averages weights used based number patient samples control recovery within 2 case recovery within 2 we analyzed sensitivity specificity ipa ipf day 8 sct day platelet recovery using data figure1 shows mean concentrations absolute ranges plt ipa ipf eight healthy individuals measured described methods section using data calculated analytical within person person coefficients variation plt ipa ipf coefficients variation rcv reference change values rcv analytical coefficient variation cva 95% confidence interval within person coefficient variation cvwp 95% confidence interval person coefficient variation cvbp 95% confidence interval platelet count plt immature platelet fraction ipf absolute number immature platelets ipa based biological variation study mean concentrations dots absolute range horizontal lines platelet count plt panel immature platelet fraction ipf panel b absolute number immature platelets ipa panel c measured healthy individuals n 8) 5 duplicate patient characteristics aitl angioimmunoblastic cell lymphoma beam bcnu cytarabine etoposide melphalan dlbcl diffuse large b cell lymphoma hdm high dose melphalan mm multiple myeloma pbsct peripheral blood stem cell transplantation platelet recovery increase platelets greater rcv due platelet transfusion observed median 13 patients autologous sct platelet recovery observed increase ipa exceeding rcv 33.63% patients this increase ipa measured xn analyzer preceded platelet recovery median 3 range 16 increase ipf exceeding rcv 23.44% also observed patients prior platelet recovery this increase ipf measured xn analyzer seen median 4 range 27 platelet recovery figure2 shows course plt ipa ipf patient autologous sct representative example course platelet count plt absolute number immature platelets ipa immature platelet fraction ipf patient stem cell transplantation sct recovery panel shows course plt black ipa gray panel b shows course plt black ipf gray stars indicate increase plt ipa ipf exceeding reference change value rcv due platelet transfusion ipa ipf well xn xe data analyzed separately roc curve ipf day 8 till moment platelet recovery autologous sct measured xn analyzer showed area curve auc 0.86 roc curves ipa based data sysmex xe-5000 lower aucs aucs roc curves based estimated sensitivity specificity ipf absolute number immature platelets ipa measured symex xe-5000 xn analyzer roc curves aucs immature platelet fraction ipf measured sysmex xe-5000 xn analyzer autologous stem cell transplantation sct roc curve ipf autologous sct measured sysmex xn showed optimal auc we determined cutoff value 5.3% sensitivity 0.47 95% ci 0.290.65 specificity 0.98 95% ci 0.851.10 ppv 0.93 95% ci 0.810.1.06 predict platelet recovery within 2 measured sysmex xn figure1 shows mean concentrations absolute ranges plt ipa ipf eight healthy individuals measured described methods section using data calculated analytical within person person coefficients variation plt ipa ipf coefficients variation rcv reference change values rcv analytical coefficient variation cva 95% confidence interval within person coefficient variation cvwp 95% confidence interval person coefficient variation cvbp 95% confidence interval platelet count plt immature platelet fraction ipf absolute number immature platelets ipa based biological variation study mean concentrations dots absolute range horizontal lines platelet count plt panel immature platelet fraction ipf panel b absolute number immature platelets ipa panel c measured healthy individuals n 8) 5 duplicate patient characteristics aitl angioimmunoblastic cell lymphoma beam bcnu cytarabine etoposide melphalan dlbcl diffuse large b cell lymphoma hdm high dose melphalan mm multiple myeloma pbsct peripheral blood stem cell transplantation platelet recovery increase platelets greater rcv due platelet transfusion observed median 13 patients autologous sct platelet recovery observed increase ipa exceeding rcv 33.63% patients this increase ipa measured xn analyzer preceded platelet recovery median 3 range 16 increase ipf exceeding rcv 23.44% also observed patients prior platelet recovery this increase ipf measured xn analyzer seen median 4 range 27 platelet recovery figure2 shows course plt ipa ipf patient autologous sct representative example course platelet count plt absolute number immature platelets ipa immature platelet fraction ipf patient stem cell transplantation sct recovery panel shows course plt black ipa gray panel b shows course plt black ipf gray stars indicate increase plt ipa ipf exceeding reference change value rcv due platelet transfusion ipa ipf well xn xe data analyzed separately roc curve ipf day 8 till moment platelet recovery autologous sct measured xn analyzer showed area curve auc 0.86 roc curves ipa based data sysmex xe-5000 lower aucs aucs roc curves based estimated sensitivity specificity ipf absolute number immature platelets ipa measured symex xe-5000 xn analyzer roc curves aucs immature platelet fraction ipf measured sysmex xe-5000 xn analyzer autologous stem cell transplantation sct roc curve ipf autologous sct measured sysmex xn showed optimal auc we determined cutoff value 5.3% sensitivity 0.47 95% ci 0.290.65 specificity 0.98 95% ci 0.851.10 ppv 0.93 95% ci 0.810.1.06 predict platelet recovery within 2 measured sysmex xn in patients awaiting thrombopoietic recovery sct strategy prophylactic platelet transfusion considered best practice despite questions debates dose lowest acceptable platelet counts 21,22,39 platelet transfusions although generally accepted safe may cause various transfusion reactions considered scarce also costly resource 23 search sensitive predictors thrombopoietic recovery the feasibility immature platelets measured sysmex xn hematocytometer studied tool detect early platelet recruitment an important step toward determination cutoff value immature platelets objectively define platelet recovery we used validated statistical approach based biological analytical variation objectify platelet recovery based rcv 36,37 a possible limitation may assumed biological within subject variation healthy subjects patients sct however assumption appears valid previous study showed majority parameters biological within subject variation order health disease 40 nevertheless fraser 41 showed ratio 0.50 analytical variation within subject variation effect 12% rcv within subject variation much larger analytical variation study previous studies used different definitions platelet recovery example platelet count 30 10/l three consecutive days seven consecutive days platelet count 20 10/l without platelet transfusions spontaneous increase plt count without platelet transfusions 1315,18,28 despite fact used rcv define platelet recovery the interval increase immature platelets platelet recovery found appears similar approximately 2 15,16,18,28 estimate sensitivity specificity ppv used approach proposed emir et al this may limitation led different number controls per patient controls recovery time longer turn led higher specificity day 8 chosen observed earliest platelet recovery 2 later day 10 roc curves based estimated sensitivity specificity showed differences aucs ipf ipa measurements sysmex xe-5000 sysmex xn roc curve ipf measured sysmex xn larger auc compared xe-5000 this reflects ipf measured xn better precision measured xe-5000 we estimated cutoff value ipf 5.3% patients autologous sct predict thrombopoietic recovery within 2 ppv 0.93 based large subject variations 32.9% 45.9% ipa ipf respectively found biological variation study would reasonable define cutoff value indicating difference two measurements delta ) however roc curves based absolute delta values ipa ipf acceptable aucs method therefore investigated data shown one study cutoff ipf predicting platelet recovery autologous sct estimated 18 study containing 31 patients ipf greater 7.0% day 8 sct predicted platelet recovery within 4 ppv 79% sensitivity 76% immature platelets assessed using flow cytometry the cutoff value ipf 5.3% high ppv specificity based observational data theoretically cutoff may used decide whether give platelet transfusion platelet transfusion may omitted platelet count likely recover within 2 d. strategy may reduce number platelet transfusions associated risks costs the hemostatic capacity immature platelets point interest current prophylactic strategy intended prevent serious bleeding incidents previous studies suggest thrombocytopenic patients high concentrations immature platelets 4050% itp patients smaller bleeding tendency compared thrombocytopenic patients low concentrations immature platelets chemotherapy treated patients 42 clearly clinical interventional studies needed address issue proving evidence value high ipf platelet transfusions strategies another argument include marker thrombopoiesis transfusion strategy observation thrombopoiesis may suppressed transfused platelets 7,15,27,43 however previous studies reported decrease ipf platelet transfusion 7,15 observe unequivocal effect platelet transfusions population 44 showed platelet transfusions lead decrease ipf alter ipa suggesting dilution increase circulating mature platelets our finding immature platelets sometimes increased sometimes decreased platelet transfusion the dilution effect platelet transfusion immature platelets e.g. increase decrease depends immature platelet count transfusion immature platelet content platelet concentrate 17,45 in summary demonstrated increase immature platelets measured sysmex xn analyzer preceding platelet recovery we showed ipf cutoff 5.3% promising predictor platelet recovery patients autologous sct however small number patients included final data analysis due observational design study interventional clinical trials multicenter setting required validate cutoff value presented study establish role ipf based transfusion policies	objectivesa period of thrombocytopenia is common after stem cell transplantation ( sct ) . to prevent serious bleeding complications , prophylactic platelet transfusions are administered . previous studies have shown that a rise in immature platelets precedes recovery of platelet count . our aim was to define a cutoff value for immature platelets predicting thrombopoietic recovery within 2 d.methodshematological parameters were measured on the sysmex xn hemocytometer . we calculated reference change values ( rcv ) for platelets in eight healthy individuals as marker for platelet recovery . to define a cutoff value , we performed roc analysis using data from 16 autologous sct patients.resultsrcv for platelet concentration was 14.1% . platelet recovery was observed 13 ( median ; range 931 ) days after sct . increase in immature platelet fraction ( ipf ) before platelet recovery was seen in all autologous sct patients . optimal cutoff ipf was found to be 5.3% for platelet recovery within 2 d ( specificity 0.98 , sensitivity 0.47 , positive predictive value 0.93).conclusionswe identified an optimal cutoff value for ipf 5.3% to predict platelet recovery after autologous sct within 2 d. implementing this cutoff value in transfusion strategy may reduce the number of prophylactic platelet transfusions .
interdisciplinary teamwork essential component holistic care since team members skills experience knowledge pooled together produce best outcomes each members intensive care unit icu team plays unique role according patients need physiotherapy accepted integral component management patients require intensive care physiotherapists play unique role part icu team physiotherapists elemental team representatives clinical healthcare team need understand practitioners roles communicate effectively provide high quality coordinated patient care nurse hand plays vital role critical care unit serves important communicator icu team nurses make large component healthcare sector essential interprofessional healthcare team hospital setting this perceived dominant role may influence power relationship nurses physiotherapists current demanding healthcare environment interprofessional team practice promoted comprehensive means providing cost effective healthcare literature suggests professional specialization led fragmentation professions likely result health care team members unable look problems patient whole team a small number studies highlighted part attitudes perceptions may underlie interprofessional relationships effect teamwork effectiveness management critical care communication identified particular interest complex sociotechnical tendency icu environment interpersonal factors reported main causes stress high dependency areas whereas poor communication reported cause errors a study exploring interprofessional perceptions physiotherapists midwives using nominal group technique follow questionnaires identified lack awareness discipline another study examined nurse occupational therapist interface established little similarity work nurses therapists produced conflicts patient handling there stands scarcity literature indian hospital setting incorporating interdisciplinary practice critical care setting role perception health care providers various professions further research collaboration communication physiotherapists nurses critical care unit serve base improve interprofessional relationships the objective study examine nurses perceptions role physiotherapists critical care team tertiary care teaching hospital india this study designed examine nurses perceptions experiences rather measure specific identified attitudes semi structured interview used appropriate method critical care nurses minimum experience 6 months recruited interview obtaining written informed consent this study approved institution ethics committee father muller charitable institutions purposive this sample size chosen allow depth exploration range perceptions as study exploratory aim secure strictly representative sample a written informed consent obtained participant commencement interview investigators personally contacted nursing supervisor unit identify total number nurses working critical care team also recognize ones fulfilling inclusion criteria once identified interviewer individually approached fixed specific time interview according convenience the interview questions developed based previous literature discussions various experienced icu team members the interview questions focused following general issues existence physiotherapist icu role played various techniques used therapists providing icu care questions interaction communication nurses therapists within icu also asked in addition questions related multidisciplinary practice necessity also included know perceptions although common interview guide used interviews precise manner questions raised varied response direction interview case however style interview informal unstandardized nonjudgmental stance taken participants reported perceptions experience the interview took place 1520 min silent room disturbance themes emerged interview transcripts categorized relationships resulting categories identified first coding subsample transcripts checked investigator trained qualitative research similar research interests relevant background knowledge process thirty three nurses 32 females 1 male interviewed critical care units these themes presented two main headings main issues key outcomes identified table 1 principle issues analysis issue emerged strongly relation physiotherapist role facilitating ambulation critical care patients n 20 all participants referred aspect physiotherapy frequently placed within functional context reference range functions ambulation assisting patient walk limb physiotherapy n 23 commonly perceived roles physiotherapists the nonphysical aspect physiotherapist role mentioned motivating patients n 1 this might represent actual role adopted physiotherapists critical care team might also reflect way aspects therapy probably less visible health care professionals a strong theme emerged data nurses perceived efficacy physiotherapy managing range patients a majority respondents admitted seen improvement outcomes n 29 physiotherapy described several nurses field practice facilitated quicker weaning accelerated discharge critical unit providing independence patients spite admitted critical care example asked whether seen improvement patients physiotherapy nurse reported yes many number times mostly case patients ventilated the patients actually stood ventilator surprising see.yes quite lot improvement especially patient walked so consider walking sign shift times yes the patients actually stood ventilator surprising see yes quite lot improvement especially patient walked feel look happy complaint less pain total number four nurses reported notice improvement following physiotherapy hand denied seen adverse events posttherapy enquired importance interprofessional communication nurses n 33 felt necessity strong communication skills patient minute details missed good communication exists the nature information exchanged professionals highly valued seen significant contribution good teamwork although appeared short duration however perceived problems information sharing nurses valued highly included lack time eg usually discuss busy work sometimes may discuss something like anything told physician side interprofessional communication related patient care found limited although strong felt need interprofessional communications all participants felt frequent exchange important information two professionals especially regarding feeding timings sedation adverse events occurred time physiotherapists around attempt explore underlying conflicts one questions aimed determine knowledge existing disagreements professionals when prompted nurses admitted minor conflicts patient care n 12 majority reported conflicts conflicts resolved simple face face discussion reported respondents whatever problem physiotherapist settled within day discussed issue never repeated this theorizes selfdom ego permitted critical care direct impact patient care certainly majority subjects admitted interaction nurses physiotherapists appropriate congruency patient care most nurses strongly felt necessity forming multidisciplinary team critical care setting n 31 this combined considerations save person time management completely patient centered confusions less statements suggest teamwork would thus accepted way providing holistic care since team members skills experience knowledge pooled together produce best outcome the issue emerged strongly relation physiotherapist role facilitating ambulation critical care patients n 20 all participants referred aspect physiotherapy frequently placed within functional context reference range functions ambulation assisting patient walk limb physiotherapy n 23 commonly perceived roles physiotherapists the nonphysical aspect physiotherapist role mentioned motivating patients n 1 this might represent actual role adopted physiotherapists critical care team might also reflect way aspects therapy probably less visible health care professionals a strong theme emerged data nurses perceived efficacy physiotherapy managing range patients a majority respondents admitted seen improvement outcomes n 29 physiotherapy described several nurses field practice facilitated quicker weaning accelerated discharge critical unit providing independence patients spite admitted critical care example asked whether seen improvement patients physiotherapy nurse reported yes many number times mostly case patients ventilated the patients actually stood ventilator surprising see.yes quite lot improvement especially patient walked so consider walking sign shift times yes the patients actually stood ventilator surprising see yes quite lot improvement especially patient walked total number four nurses reported notice improvement following physiotherapy hand denied seen adverse events posttherapy enquired importance interprofessional communication all nurses n 33 felt necessity strong communication skills patient minute details missed good communication exists the nature information exchanged professionals highly valued seen significant contribution good teamwork although appeared short duration however perceived problems information sharing nurses valued highly included lack time eg usually discuss busy work sometimes may discuss something like anything told physician side interprofessional communication related patient care found limited although strong felt need interprofessional communications all participants felt frequent exchange important information two professionals especially regarding feeding timings sedation adverse events occurred time physiotherapists around attempt explore underlying conflicts one questions aimed determine knowledge existing disagreements professionals when prompted nurses admitted minor conflicts patient care n 12 majority reported conflicts the conflicts resolved simple face face discussion reported respondents whatever problem physiotherapist and i settled within day discussed issue never repeated this theorizes selfdom ego permitted critical care direct impact patient care certainly majority subjects admitted interaction nurses physiotherapists appropriate congruency patient care most nurses strongly felt necessity forming multidisciplinary team critical care setting n 31 this combined considerations save person time management completely patient centered confusions less these statements suggest teamwork would thus accepted way providing holistic care since team members skills experience knowledge pooled together produce best outcome the issue emerged strongly relation physiotherapist role facilitating ambulation critical care patients n 20 all participants referred aspect physiotherapy frequently placed within functional context reference range functions ambulation assisting patient walk limb physiotherapy n 23 commonly perceived roles physiotherapists the nonphysical aspect physiotherapist role mentioned motivating patients n 1 this might represent actual role adopted physiotherapists critical care team might also reflect way aspects therapy probably less visible health care professionals a strong theme emerged data nurses perceived efficacy physiotherapy managing range patients a majority respondents admitted seen improvement outcomes n 29 physiotherapy described several nurses field practice facilitated quicker weaning accelerated discharge critical unit providing independence patients spite admitted critical care example asked whether seen improvement patients physiotherapy nurse reported yes many number times mostly case patients ventilated the patients actually stood ventilator surprising see.yes quite lot improvement especially patient walked so consider walking sign shift times yes the patients actually stood ventilator surprising see yes quite lot improvement especially patient walked total number four nurses reported notice improvement following physiotherapy hand denied seen adverse events posttherapy when enquired importance interprofessional communication nurses n 33 felt necessity strong communication skills patient minute details missed good communication exists the nature information exchanged professionals highly valued seen significant contribution good teamwork although appeared short duration however perceived problems information sharing nurses valued highly included lack time eg usually discuss busy work sometimes may discuss something like anything told physician side interprofessional communication related patient care found limited although strong felt need interprofessional communications all participants felt frequent exchange important information two professionals especially regarding feeding timings sedation adverse events occurred time physiotherapists around attempt explore underlying conflicts one questions aimed determine knowledge existing disagreements professionals when prompted nurses admitted minor conflicts patient care n 12 majority reported conflicts the conflicts resolved simple face face discussion reported respondents whatever problem physiotherapist settled within day discussed issue never repeated this theorizes selfdom ego permitted critical care direct impact patient care certainly majority subjects admitted interaction nurses physiotherapists appropriate congruency patient care most nurses strongly felt necessity forming multidisciplinary team critical care setting n 31 this combined considerations save person time management completely patient centered confusions less these statements suggest teamwork would thus accepted way providing holistic care since team members skills experience knowledge pooled together produce best outcome the major role physiotherapist perceived nurses facilitating early mobilization could attributed fact center study carried practices early mobilization protocol designed tested indigenously most respondents felt physiotherapist could help case ventilated patients thereby reducing chances ventilated associated infections improving patients condition promote quicker recovery all nurses commented need good communication critical care unit a study kind advocated communication would significant step assisting healthcare delivery clients families become flawless efficient effective hence need reflect core competency health professionals a majority nurses felt lack time major reason lack communication critical care practice disagreements another criterion requires pondered discussion critical care respondents felt disagreements bound take place setting two professions work congruency hence the major factor may influence interprofessional learning shown positive impact awareness understanding professional roles interprofessional issues valued others roles well support offer turn helped reduce barriers interprofessional conflicts perhaps understandably profession views issue perspective blame change adaptation liable shifted profession this suggests change effective bilateral blame change shared across two professions one way might occur would nurses physiotherapists working concurrently patient accomplishing goals nursing therapy activities for example change patient position side lying may simultaneously provide skin pressure care improve lung ventilation sputum clearance it would appear physiotherapists consider spending time sharing nurses sufficient skills provide continuity care patients physiotherapists one hand expect nurses provide continuity progression hand protective therapy skills area case physiotherapists unduly worried score brown greenwood suggest flexible cooperation might enhance core skills profession promoting working roles nurses also despite problems identified spoke good excellent relationships physiotherapists admitted lacked teamwork discuss patient goals often work together strategies achieve goals one major limitations study smaller sample size might able derive perception entire nurse population this preliminary exploratory study revealed nurses working critical care team positive perception physiotherapists participants study aware role physiotherapists critical care useful clinical decision making therapist	background : interprofessional relationship plays a major role in effective patient care . specialized units such as critical care require multidisciplinary care where perception about every members role may affect the delivery of patient care . the objective of this study was to find out nurses perceptions of the role of physiotherapists in the critical care team.methods:qualitative study by using semi - structured interview was conducted among the qualified nurses working in the intensive care unit of a tertiary care hospital . the interview consisted of 19 questions divided into 3 sections . interviews were audio recorded and transcribed . in - depth content analysis was carried out to identify major themes in relation to the research question.results:analysis identified five major issues which included role and image of a physiotherapist , effectiveness of treatment , communications , teamwork , and interprofessional relations . physiotherapists were perceived to be an important member of the critical team with the role of mobilizing the patients . the respondents admitted that there existed limitations in interprofessional relationship.conclusion:nurses perceived the role of physiotherapist in the critical care unit as an integral part and agreed on the need for inclusion of therapist multidisciplinary critical care team .
	these are peer - reviewed poster - platform submissions finalized by the scientific program committee . a total of 153 abstracts ( 14 platforms [ pp1 through pp14 ] & 139 posters [ 1 through 139 ] ) were selected from 161 submissions to be considered for presentation during november 4 8 , 2011 , at the hilton baltimore hotel , to pathologists , cytopathologists , cytotechnologists , residents , fellows , students , and other members of cytopathology - related medical and scientific fields .
cone beam computed tomography cbct found niche different fields dental practice recent years 15 nowadays use three dimensional radiographies increasing diagnosis treatment dentistry single slice ct multislice ct techniques first introduced regard 6 7 the case two systems exposed patients high radiation doses 810 thus cbct introduced promise low radiation doses together adequate image quality well fast image processing lower costs 11 12 consequently use technique dramatically increased implant dentistry maxillofacial surgery 1 13 orthodontics endodontics forth as different treatment approaches highly depend exact estimation distance anatomical landmarks bone thickness many clinicians tend use linear measurement capability cbct unfortunately unwanted measurement errors may lead catastrophic consequences like treatment failure 16 17 since cbct machines equipped cephalostat skull might eccentric position scanning procedure previous studies investigated accuracy linear measurements cbct images using newtom 3 g accuitomo cbct machines 17 1922 concluding linear measurement capability units reliable structures closely associated dentomaxillofacial imaging have evaluated effect patient head position linear measurement accuracy newtom 3 g cbct machine mischkowski et al evaluated geometric accuracy scans obtained galileous cbct device they declared liner measurements anatomical structures present soft tissue significantly accurate although newly introduced galileous cbct machine reported one cbct dental devices lowest effective dose linear measurement accuracy evaluated different positions since probable patient head deviate true vertical horizontal orientation scanning procedure might adversely affect measurement accuracy aim study determine accuracy linear measurements dry human skulls ideal position different deviated positions simulating clinical relevant distances using galileous cbct machine this experimental study human skulls conducted isfahan university medical sciences approved ethical committee isfahan dental school research center 5 regions selected jaw anterior premolar molar regions left right sides jaw order measure buccolingual mesiodistal distances height region four points determined using 1.5 mm rod shaped gutta percha size 40 opaque markers table 1 way first marker glued embrasure buccal alveolar crest studied region second marker embrasure lingual alveolar crest perpendicular first marker third marker apical region buccal alveolar crest direction first marker fourth marker adjacent tooth embrasure buccal alveolar crest next first marker the buccolingual mesiodistal distances heights region measured two times first observer one week interval second observer using digital caliper guanglu taizhou china the images taken using galileos comfort 3d imaging system sirona dental systems inc 5 different radiographs provided skull different positions ideal position positions 10-to-15-degree rotation 10-to-15-degree tilt 10-to-15-degree forward tilt flexion 10-to-15-degree backward tilt extension reconstruct temporomandibular joint space a 1.5 mm thick baseplate wax placed condylar process temporal fossa after guiding jaw centric occlusion jaws attached adhesive tape a polyvinyl pipe placed foramen magnum attached camera tripod zeiss universal tripod ft6302 oberkochen germany capability lateral forward backward tilt rotational adjustment via dial plate provide standard radiographs the skull held image field using machine occlusal bite block teeth way occlusal plane perfectly horizontal according manufacturer instructions ensure appropriate position skulls system light localizer displays midsagittal line then imaging performed 7 42 mas 85 kvp 14-second scan time 270 rotation each scan produced 200 projections 15 15 15 cm field view a charge coupled device detector 1024 1024 matrix 0.15 mm voxel size used detect images afterwards radiographic distances measured twice first observer two week interval second observer it added measured distance end one marker end another the physical radiographic distances measured region illustrated table 1 intraclass correlation coefficient icc used analyze intraobserver interobserver reliability measurements 0.05 wilcoxon test used compare physical radiographic values different measurements 0.05 less differences physical radiographic measurements accuracy radiographic measurements one sample test used compare differences acceptable 0.5 mm mean absolute error 0.05 univariate analysis variance used assess difference radiographic physical measurements considering confounding variables due severe bone resorption distances mandibular left premolar molar regions one skull also mandibular right premolar molar regions another skull separately measured reducing whole measurements 174 according icc values interobserver correlations radiographic measurement physical measurements 0.996 p value 0.001 the mean difference physical measurements radiographic measurements present study 0.05 0.45 there significant difference physical measurements radiographic measurements ideal rotation tilt extension positions accuracy measurements height significantly lower physical measurements positions p value 0.05 tukey hsd showed accuracy measurements skull number 5 significantly lower skulls number 2 3 4 6 p value 0.022 0.001 0.006 0.001 resp also accuracy measurements rotation flexion positions significantly lower ideal position p value 0.042 0.043 resp there significant difference among accuracy measurements molar premolar central regions p value 0.05 accuracy measurements left sides skulls significantly lower right side p value 0.01 there significant difference upper lower jaws terms accuracy measurements p value 0.115 table 5 compares absolute mean difference radiographic position 0.5 mm acceptable error this table shows accuracy measurements cases 0.5 mm it important determine whether accuracy measurements decreases remains unchanged patient head position changes the aim study determine accuracy linear measurements dry human skulls different positions skull simulating clinical relevant distances present study soft tissue simulated prevent probable confounding effect accuracy measurements main errors patient head position tilt extension flexion rotation evaluated lateral displacement assessed since position error less likely occurs due probable effect teeth situation type jaw mandible maxilla radiographic units able measure height mesiodistal length buccolingual length implant treatments distances included present study the rod shaped opaque markers would let observers easily accurately measure distance end one marker end another make sure measurements accurate two observers measured distances the intraobserver inter observer correlations 0.95 show accuracy acceptable the results study showed differences measurement normal deviated positions cases however since average difference less 0.5 mm considered clinically significant comparison accuracy radiographic measurements ideal deviated positions showed significant difference exists rotation flexion positions may suggest positions effective deviations measurement accuracy hassan et al assessment accuracy measurements dry human skulls found significant difference different positions skulls this contrast present study probably due lower number measurements longer distances study this contrast might due different distances measured studies well different study designs the high rates standard deviation differences physical radiographic measurements present study suggest factors affecting accuracy measurements there number reasons may justify differences accuracy measurements predominant artifacts cbct imaging including noise scatter extinction artifact beam hardening exponential edge gradient effect aliasing artifacts ring artifacts may cause difficulties detecting exact situation objects cbct output image leads inaccurate measurements moreover anatomical distortions function shape orientation structures cause distortions well results present study showed accuracy measurements affected skull type this suggests cbct units enhanced features like posterior position adjustment letting practitioner consider anatomical asymmetries differences however distortion caused anatomical asymmetry always distinguishable radiographic distortion hand although deviated skulls showed severe distortion panorama view galaxis software present study distances markers could still accurately measured cross sectional tangential axial views this partly due fact cbct software lets practitioner choose orientation reconstructed image layer also image plane cross sectional tangential axial views expected display however failure appropriate setting lead difficulties measuring distances for instance see acceptable cross sectional image planes one previously set image plane panorama view if practitioner fails cross sectional display appropriate measurements observation present study sometimes markers precisely placed buccal lingual embrasures tooth could displayed time cross sectional view software even changing image plane panorama orientation reconstructed image layer implies shortcoming unit software corrected the mean difference physical measurements radiographic measurements present study 0.05 0.45 mm ludlow et al used method selection points reported 0.29 0.20 mm mean difference marmulla et al however used computer algorithm localize measurement points pixel fractionalization these differences due part different study designs measurement techniques cbct units used moreover leung et al measured alveolar bone height reported accuracy 0.6 mm these contrary results explained fact determining anatomical landmarks difficult opaque markers the mean absolute error galileos cbct machine estimated 0.26 0.18 mm mischkowski et al the difference study present study probably due different investigated areas distances measured lund et al reported measurements cbct accurate absolute mean difference even less voxel size in fact lund et al used object consisting plexiglass plates present study performed human dry skulls present study evaluating effect different head position skulls it may reason significant difference left right side the manufacturer galileos cbct machine claims accuracy length measurements 0.15 mm however results present study showed accuracy depends numerous criteria always range we suggest study larger number skulls conducted criteria aspect measurement included univariate anova moreover recommended simulate soft tissue attenuation one separate group assess probable effect conclusion present study demonstrates accuracy measurements galileos cbct machine varies position skull deviates ideal however reduction accuracy could clinically considered insignificant	introduction . the aim of this study was to determine the accuracy of linear measurements in dry human skulls in ideal position and different deviated positions of the skull . methods . 6 dry human skulls were included in the study . opaque markers were attached to alveolar bone . buccolingual and mesiodistal distances and heights were measured in 5 different regions of either jaws using a digital caliper . radiographic distances were measured in ideal , rotation , tilt , flexion , and extension positions of the skulls . the physical and radiographic measurements were compared to estimate linear measurement accuracy . results . the mean difference between physical measurements and radiographic measurements was 0.05 0.45 . there was a significant difference between physical measurements and radiographic measurements in ideal , rotation , tilt , and extension positions ( p value < 0.05 ) . conclusions . the accuracy of measurements in galileous cbct machine varies when the position of the skull deviates from ideal ; however , the differences are not clinically significant .
pure red cell aplasia prca disorder first described 1922 characterized normocytic anemia associated absence erythroblasts bone marrow prca induced various causes.1 however cases prca associated hepatitis reported.2 6 korea several reports prca associated thymoma lymphoma sle hashimoto disease parvovirus adverse drug reactions however case prca caused acute hepatitis yet reported report describe case prca acute hepatitis review literature a 36-year old male admitted 3-day history fever jaundice vomiting his vital signs follows blood pressure 120/90 mmhg heart rate 88 beats min respiratory rate 18/min body temperature 37.1. obvious jaundice icteric sclera his hemoglobin concentration 17.1 g dl red cell count 5.7410/l white blood cell count 5,000/l platelet count 114,000/l blood chemistry analyses revealed total bilirubin level 3.8 mg dl direct bilirubin 2.39 mg dl ast 7736 iu l alt 3558 iu l ldh 14,407 iu l albumin 3.8 g dl prothrombin time 18.6 10.1 12.4 bun 50.9 mg dl cr 5.7 mg dl tests hepatitis b surface antigen igm anti hepatitis b core anti hepatitis c virus antibody negative tests human immunodeficiency virus antibody epstein barr virus vca igm antibody negative parvovirus undetectable polymerase chain reaction c3 86.6 mg dl c4 53 mg dl igg 746 mg dl iga 442 mg dl igm 469 mg dl the results chest x ray abdominal ultrasonography duodenoscopy unremarkable he received hemodialysis treatment owing acute renal failure three times week day 2 day 4 diagnosed hepatitis treated fluid therapy admission sign anemia hemoglobin level gradually decreased hemoglobin level dropped 4.8 g dl reticulocyte count significantly decreased 0.13% the bone marrow biopsy showed 50% cellularity myeloid erythroid ratio 16.1:1 a paucity erythroid precursors noted although granulopoiesis normal number maturation differential erythroid cell counts aspirates follows pronormoblast 1.4% basophilic normoblast 2.4% polychromatic normoblast 0.0% orthochromatic normoblast 0.0% result findings diagnosed pure red cell aplasia associated acute hepatitis a. began treatment intravenous methylprednisolone 1 mg kg day daily day 29 after steroid therapy hemoglobin level renal function began improve steadily hemodialysis stopped day 34 hemoglobin level increased 8.3 g dl discharge one month discharge prednisolone dose tapered 10 mg outpatient clinic day 48 discharge prednisolone treatment stopped hemoglobin level improved 13.9 g dl cr level decreased 1.3 mg dl fig prca results anemia associated severe reticulocytopenia absence marrow erythroid precursor cells.1 innate prca known blackfan diamond anemia usually diagnosed among infants less 1 year age adults prca usually occurs acquired disease mainly due thymoma connective tissue disease viral infection lymphoma adverse drug reactions.1 present case patient treated fluid therapy hemodialysis hepatitis acute renal failure hemoglobin level gradually decreased no signs gastrointestinal bleeding observed evidence thymoma apparent chest x ray results negative human immunodeficiency virus antibody epstein barr virus vca igm antibody viral hepatitis b antibody viral hepatitis c antibody anti nuclear antibody parvovirus pcr rheumatoid arthritis factor there suspicious findings lymphoma peripheral blood smear bone marrow bone marrow examination showed marked erythroid hypoplasia normal granulocytes megakaryocytes result diagnosed prca caused acute hepatitis a. globally cases acute hepatitis associated prca rare cases reported date transient severe anemia appeared acute phase hepatitis passed disappeared within short period blood transfusion corticosteroid therapy the clinical course prca hepatitis prognosis patients good.2 6 mechanism prca seen many cases viral hepatitis poorly understood bone marrow liver contain components reticuloendothelial system may therefore adversely affected similar agents previously known main mechanisms viral induced autoimmune response direct viral infection bone marrow progenitor cells.1 autoimmune response directly cause cytolytic reaction bone marrow progenitor cells cells natural killer cells complement binding antibody damage bone marrow stromal cells.1 idiopathic prca initially treated corticosteroids blood transfusion generally recovery period 1 month.7 study 27 prca patients using corticosteroids 2 5 weeks remission occurred within 4 weeks 40% cases cure rate 37% reported.8 case studies prca acute viral hepatitis rare cases treatment corticosteroids blood transfusion reported.2 6 corticosteroid resistant cases prca treated cyclosporin cyclophosphamide a study 43 patients treated cyclosporin showed overall response 65%.9 one study reported duration remission induced cyclophosphamide seemed prolonged compared induced corticosteroid.8 addition several studies reported antithymocyte globulin alemtuzumab rituximab useful treatment refractory prca.7 summary reported first case prca associated acute hepatitis korea the patient showed early response corticosteroids successfully achieved remission 2 months treatment	pure red cell aplasia is characterized as a normocytic anemia associated with reticulocytopenia and the absence of erythroblasts in the bone marrow . pure red cell aplasia can be induced by various causes such as thymoma , connective tissue disease , viral infection , lymphoma , and adverse drug reactions . there have been only a few reports of pure red cell aplasia associated with acute viral hepatitis a. in korea , no case of pure red cell aplasia caused by acute hepatitis a has yet been reported . we recently experienced a case of acute viral hepatitis a complicated by pure red cell aplasia . the patient was successfully treated with corticosteroids . here we report this case and review the literature .
age related macular degeneration amd complex disorder influenced genetic environmental factors heritability estimated account 45% 71% cases 1 2 several ~20 amd genetic susceptibility genes identified two loci complement factor h cfh 1q32 age related maculopathy susceptibility 2/htra serine peptidase 1 arms2/htra1 10q26 accounting 50% amd cases 3 4 the cfh locus harbors many independent risk protective haplotypes 5 6 arms2/htra1 single major risk haplotype associated amd multiple studies also demonstrated haplotype tagging single nucleotide polymorphisms snps cfh arms2 major determinants amd endophenotypes disease progression specifically cfh rs1061170 associated drusen early advanced amd arms2-rs10490924 strongly associated reticular pseudodrusen rapid progression late amd 5 79 nevertheless various estimates currently known genetic loci account 50%75% overall amd risk interest role retinal pigment epithelium rpe lipofuscin amd stems knowledge accumulates age 10 11 high central retina exhibits behaviors toxic rpe 1215 exhibits link drusen formation advances non invasive fundus imaging facilitated diagnosis differentiation retinal disease vivo imaging provides window within view natural course retinal disease of available imaging modalities fundus autofluorescence af proven especially valuable large part disease related processes alter distribution af signal the natural autofluorescence fundus excited sw light 488 nm excitation figure 1 exhibits spectral features age relationship indicates principle origin fluorescent pigments accumulate rpe cells lipofuscin unlike lipofuscin species accumulate non dividing cells pigments rpe lipofuscin produced membranes photoreceptor outer segments non enzymatic reactions vitamin aldehyde 1821 this fluorescent material transferred rpe cells within phagocytosed outer segment disks 22 23 becomes deposited lysosomal compartment cells healthy retina the age related increase levels age 70 perhaps loss photoreceptor rpe cells and/or changes fluorescence emission due extensive photooxidation photodegradation bisretinoid compounds discussed rpe lipofuscin consists complex mixture fluorophores identified chromatography mass spectrometry characterized structurally known bisretinoid lipofuscin pigments detected human eyes figure 2 ( a2-gpe a2e isomers a2e 2836 dimers trans retinal cyclohexadiene head group trans retinal dimer 33 37 associated protonated schiff base conjugate uncharged a2-dhp pe a2-dihydropyridine phosphatidylethanolamine higher molecular weight adducts also form aldehyde bearing cleavage products bisretinoid react intact bisretinoid molecules other molecular constituents rpe lipofuscin adducts cep 2-(-carboxyethyl)-pyrrole hne 4-hydroxynonenal mda malondialdehyde derived oxidative fragmentation lipid products lipid oxidation generally non fluorescent blue emitting fluorophores 42 43 case could generated photoreactivity lipofuscin fluorophores accumulation bisretinoids rpe cells unlikely depend inhibition lysosomal enzyme activity since fluorescent material amassed healthy eyes beginning early ages present central six carbon ring extend two polyene arms terminating ionone rings each arms derived molecule retinaldehyde constitutes separate light absorbing chromophore one arm absorbing ultraviolet range visible figure 2 the numbers alternating carbon carbon double single bonds form conjugation systems arms determine wavelength absorbance longer conjugation system molecule confers absorbance visible range absorbances visible spectrum significant since wavelengths reach retina since adducts retinaldehyde held together covalent bonds bisretinoids provide stores retinoid visual cycle suggested in clinical settings sw fundus af excited wavelengths ranging 488 nm excitation employed confocal scanning laser ophthalmoscope cslo 535580 nm range utilized modified fundus camera 568 nm light used fluorescence adaptive optics ophthalmoscopy 17 47 48 fundus autofluorescence measured vivo spectrophotometry broad excitation spectrum peaks 490510 nm the fluorescence emission also broad centered approximately 600 nm 11 17 rpe lipofuscin ex vivo exhibits excitation spectrum peaks 450490 nm fluorescence emission maximal ~600 nm figure 3 moreover fundus autofluorescence emission spectrum recorded whole lipofuscin exhibits red shifts excited progressively longer wavelengths figure 3 thus spectral characteristics fundus autofluorescence consistent rpe lipofuscin 43 5052 chiefly origin bisretinoid fluorescent pigments known constituents rpe lipofuscin the bisretinoids characterized absorbance maxima varying 440 nm 510 nm emit orange fluorescence peaks ~600 nm bisretinoid a2e emit fluorescence longer wavelength excitations 545 nm figure 3b while exists evidence bisretinoids rpe lipofuscin undergo lysosomal degradation loss material due photodegradation demonstrated thus studies rpe lipofuscin 5355 individual bisretinoid lipofuscin fluorophores a2-gpe trans retinal dimer a2e revealed compounds photoinducible generators reactive oxygen species singlet oxygen superoxide anion singlet oxygen turn reacts conjugated double bond systems comprising arms bisretinoid molecules 5661 leading fragmentation parent molecules release aldehyde bearing cleavage products methylgloxal glyoxal react inactivate proteins these small dicarbonyls also provoke formation advanced glycation end products age deposit extracellularly 16 62 ages incite inflammatory processes since detected drusen 63 64 reflect link rpe bisretinoid lipofuscin formation sub rpe deposits photooxidation a2e trans retinal dimer also shown incite complement activation 65 66 photooxidation clearly ongoing process eye since photooxidized forms a2e trans retinal dimer detected isolated human mouse rpe 25 57 these processes likely contribute bruch membrane thickening photoreceptor cell degeneration 68 69 abca4 mutant mice cause increased vulnerability albino abca4 mice retinal light damage the propensity bisretinoids undergo photooxidative photodegradative processes may underlie decline rpe lipofuscin fluorescence emission photobleaching observed non human primates vivo fluorescence imaging adaptive optics scanning laser ophthalmoscopy 48 71 cell culture models non cellular assays figure 4 lipofuscin photobleaching may also explain surgical repair cases retinal detachment hyperautofluorescent lines coursing parallel retinal blood vessels visible fundus af images 73 74 figure 5 the hyperautofluorescent imprint interpreted indicating change position vessel relative underlying retinal tissue visible contrasting levels af brightness given time the intensity fundus af likely difference fluorophore synthesis one hand lipofuscin photoxidation photodegradation rpe shadow blood vessel the formation bisretinoid retinaldehyde 11-cis converted trans retinal would likely continue unabated 20 30 7577 lipofuscin photooxidation photobleaching would substantially reduced result vessel imprint intense af would revealed upon retinal translocation when rpe lipofuscin assayed recording fluorescence histological sections human retina signal found increase central fovea perifovea peaking eccentricity ~8 decreases towards periphery 10 78 a similar pattern observed quantitative fundus autofluorescence qaf figure 6 eccentricity 10 qaf approximately 95% measured centrally reduced foveal fundus autofluorescence due large part absorption exciting light macular pigment higher optical density melanin central rpe fundus spectrophotometry qaf fluorescence photomicroscopy highest levels rpe lipofucin healthy eyes unexpectedly pattern replicated another study relying fluorescence measurements flat mounted human cadaver eyes based spatial distribution mass peaks detected matrix assisted laser desorption ionization imaging mass spectrometry maldi ms investigators reported a2e detectable central retina mice central human rpe instead highest a2e levels restricted small patch rpe found exclusively far periphery temporal retina this patch matched similar a2e signal periphery superior nasal inferior retina a2e well known fluorescent surprisingly patch almost devoid fluorescence since spectral features rpe lipofuscin fundus autofluorescence best accounted excitation emission spectra bisretinoid constituents fluorescence originating centrally situated rpe cells likely originates combination di retinal adducts interestingly maldi ms findings could indicate various species bisretinoid lipofuscin compounds exhibit spatial heterogeneity reduced levels a2e macula could also consequence greater lipofuscin photocleavage central rpe explanation could account greater susceptibility macula disease failure detect a2e centrally may even attributable limitations methodology maldi ms surface based technique depends extraction analyte matrix applied surface tissue factors could cause spatial differences extraction efficiency regional differences rpe height spatial differences compartmentalization lipofuscin instance rpe cells taller narrower human macula melanin uppermost lipofuscin greater depths cells after age 50 complex organelles containing melanin lipofuscin melanolipofuscin predominate cells macular rpe containing melanolipofuscin rpe equator periphery thus likely extraction central rpe less efficient depths lipofuscin cells and/or difficulty accessing lipofuscin complex melanolipofuscin organelles the healthy fundus also exhibits near infrared autofluorescence nir af 800 nm excited ~787 nm 84 85 figure 1 the intensity fundus nir af least 60 times less sw af several lines evidence indicate rpe choroidal melanin serve source nir af signal additionally high nir af signal fovea corresponds elevated optical density melanin area conversely nir af emanating full thickness macular hole similar brightness surrounding retina the frequent use sw af may due part introduction heidelberg spectralis optical coherence tomography oct capability hra oct subsequent decline popularity hra2 spectralis hra retinal clinics the oct module spectralis reduces nir af signal intensity thus compromising nir af image quality compared cslos without oct e.g. hra2 spectralis hra nevertheless nir af advantages sw af for instance image acquisition patients disturbed nir af light sw af exciting light in presence retinal disease amd patterns intensities fundus autofluorescence notably altered 8893 locations rpe photoreceptor cell demise ( atrophy sw af nir af signals become strikingly deficient absent 94 95 these areas atrophy take form discrete spots isolated patches large expanses geographic atrophy ga usa while ga presents areas darkness sw nir af figure 7 lesion size sometimes appear larger either sw af nir af modality 84 97 figure 7 nevertheless rate increase ga area whether measured sw- nir af images exudative amd the developing neovascular lesion discerned sw af images early focal hyperautofluorescence later sw af signal reduced within lesion 99 100 cases the edge neovascular lesion exhibits increased sw af signal zone retina immediately adjacent geographic atrophy often additional af changes these aberrant signals present intermittent foci continuous bands altered brightness sw af nir af images 101103 junctional zones areas increased sw af coincide increased nir af increased sw af overlap reduced nir af nir af signal enhanced sw af may appear normal 84 104 figure 7 interestingly loss photoreceptor function found associated increased decreased nir af 97 105 since sw af nir af considered originate rpe cells puzzling sw af increased positions nir af reduced absent this apparent incongruity attributed abnormal rpe cells lost melanin accumulating excessive levels lipofuscin due accelerated rates outer segment phagocytosis 84 105 the lipofuscin forms photoreceptor cells prior disc shedding phagocytosis evident studies rcs rat fluorophores lipofuscin form accumulate photoreceptor outer segment debris even absence phagocytosis 106108 other observations indicate photoreceptor cells likely degenerating junctional zones increased sw af in particular retinal sensitivity measured microperimetry commonly reduced positions presenting increased sw af compared normal sw af 105 109 in addition oct findings zone enhanced autofluorescence surrounding ga include thinning reflective band attributable rpe bruch membrane disruption reflectivity band corresponding ellipsoid zone photoreceptor inner segments 96 110 thus could positions diminished nir af rpe cells atrophied lost impaired photoreceptor cells become source accelerated lipofuscin formation thus enhanced sw af ? mechanistically mishandling retinaldehyde precursor lipofuscin known lead elevated bisretinoid formation photoreceptor cells compromised photoreceptor cells may able provide energy needed reduction retinaldehyde non reactive alcohol form similar mechanisms may explain rapid onset elevated fundus sw af co localizes scotomas associated acute macular neuroretinopathy amn 93 112 the observation nir af signals increase parallel increases sw af border ga may also fully understand hyperautofluorescence foci junctional zone ga least cases attributed abnormally superimposed rpe cells 113 114 but whether account extensive bands high nir af certain it suggested rpe lipofuscin may contribute nir af fundus however albino rats exhibit nir af despite presence lipofuscin shown figure 8 detected nir af signal synthesized samples a2e otherwise emit fluorescence excited 488 nm nir af emission bisretinoids unlikely given small structural differences amongst compounds figure 2 if melanogenesis basis increased nir af brightness border ga suggested 84 105 one might expect increased melanin concentrations would visible hyperpigmented spots bands color fundus photographs considering optical effect explanation increased nir af signal could rpe lipofuscin fluoresce nir range modify nir af emission melanin this could occur lipofuscin secondary lysosomes intercalate amongst apically situated melanosomes 78 116 thereby reducing nir af quenching associated secondary self absorbance fluorescence emission a mechanism might also explain hyperautofluorescent rings visible nir af fundus images retinitis pigmentosa exhibit spatial correspondence high intensity rings observed sw af images interest role rpe lipofuscin amd stems age related increase 10 11 accumulation pronounced central retina propensity adverse effects rpe photoreceptor cells 1215 68 70 links drusen formation 16 67 contributions amd susceptibility rpe lipofuscin would exist within context background genetic risk since products bisretinoid photodegradation damaging 16 60 worth considering whether lipofuscin lost photooxidation photodegradation significant lipofuscin remaining cells given time lipofuscin rpe recorded sw af may consist portion fluorescent material accumulated life time sw af emitted rpe bisretinoids commonly regarded way monitor health rpe areas high af indicating increased lipofuscin levels areas low af indicating rpe loss however discussed increasing evidence interpretations sw af signal complex for instance impaired photoreceptors may generate increased levels bisretinoid fluorophores thus amplifying sw af signal ultimately understanding patterns fundus af impact use images assess therapeutic outcomes while fundus autofluorescence provides en face spatial information spectral features fluorescence elucidated cellular origin fluorescence identified recently this approach shown enable differentiation similar phenotypes disparate genetic origins 44 118 the qaf approach may eventually help ascertain role lipofuscin various retinal disorders including amd limited gradations signal thus greater contrast diseased versus non diseased areas retina easier distinguish nir af images compared sw af images indeed recessive stargardt disease stgd1 sw af changes often obvious fundus locations abnormalities detectable nir af images in addition many cases low nir af signal corresponds spatially loss inner segment ellipsoid zone ez spectral domain sd oct images while origin nir af signal may completely understood nir af signal provide good estimate size geographic atrophy surrounding abnormalities all issues favor inclusion nir af management retinal diseases amd	genes that increase susceptibility to age - related macular degeneration ( amd ) have been identified ; however , since many individuals carrying these risk alleles do not develop disease , other contributors are involved . one additional factor , long implicated in the pathogenesis of amd , is the lipofuscin of retinal pigment epithelium ( rpe ) . the fluorophores that constitute rpe lipofuscin also serve as a source of autofluorescence ( af ) that can be imaged by confocal laser ophthalmoscopy . the af originating from lipofuscin is excited by the delivery of short wavelength ( sw ) light . a second autofluorescence is emitted from the melanin of rpe ( and choroid ) upon near - infrared ( nir - af ) excitation . sw - af imaging is currently used in the clinical management of retinal disorders and the advantages of nir - af are increasingly recognized . here we visit the damaging properties of rpe lipofuscin that could be significant when expressed on a background of genetic susceptibility . to advance interpretations of disease - related patterns of fundus af in amd , we also consider the photochemical and spectrophotometric features of the lipofuscin compounds responsible for generating the fluorescence emission .
head neck squamous cell carcinoma hnscc including oral squamous cell carcinoma oscc sixth prevalent type malignancy worldwide accounts approximately 8% 10% cancers southeast asia 1 2 hnscc related mortality mainly caused cervical lymph node metastasis occasionally distant organ metastasis the epithelial mesenchymal transition emt process epithelial cells lose polarity adopt mesenchymal phenotype this process thought critical step induction tumor metastasis malignancy mani et al demonstrated induction emt results cells stem cell properties generates cells properties similar breast cancer stem cells snail member zinc finger transcription factor family one master regulators promotes emt mediates invasiveness well metastasis many different types malignant tumors 7 8 the aldehyde dehydrogenase aldh family enzymes comprised cytosolic isoenzymes oxidize intracellular aldehydes contribute oxidation retinol retinoic acid early stem cell differentiation recently aldh reported unique marker head neck cancer stem cells csc 10 11 aldh1 also found co localize cscs related markers including mmp-9 cd44 ck14 invasive front tumor these hnscc aldh1 cells displayed radioresistance represented reservoir cells proliferative potential generate tumors these findings suggested snail expression may regulate tumorigenesis radiochemoresistance cancer stem cell properties malignant hnscc tumors however molecular mechanisms involved mediating metastasis tumor malignancy hnscc csc regulation snail remain unknown bmi-1 member polycomb pcg family transcriptional repressors mediate gene silencing regulating chromatin structure bmi-1 essential maintaining ability neural hematopoietic intestinal stem cells self renew 1517 bmi-1 identified proto oncogene cooperates myc promote generation lymphoma additionally bmi-1 verified predictor prognosis bladder cancer prostate cancer brain cancer 22 23 breast cancer pancreatic cancer lung cancer bmi-1 demonstrated play role tumorigenesis hnscc 27 28 bmi-1 also reported involved tumor metastasis 29 30 recently elegant study song et al showed bmi-1 directly promote emt malignancy nasopharyngeal carcinoma regulating snail the goal study clarify relationship bmi-1 snail aldh1 hnscc hnscc associated csc involved molecular mechanisms the study approved institutional ethics committee institutional review board taipei veterans general hospital the dissociated cells samples hnscc patients suspended 1 10 cells ml 37c dmem supplemented 2% fcs the identification aldehyde dehydrogenase 1 aldh1 positive hnscc cells carried using aldefluor assay stemcell technologies durham nc usa fluorescence activated cell sorting cells suspended aldefluor assay buffer containing aldh substrate baaa 1 mol l per 1 10 cells incubated 40 min 37c negative control sample cells aliquot treated 50 mmol l diethylaminobenzaldehyde deab specific aldh inhibitor the sorting gates established using cells stained pi negative control aldefluor stained cells treated deab staining secondary antibody alone test viability hnscc aldh1 cells cultured medium consisting serum free dmem f12 gibco brl gaithersburg md n2 supplement r systems inc minneapolis 10 ng ml bfgf r systems 10 ng ml egf r systems 13 32 briefly total rna 1 g sample reverse transcribed using 0.5 g oligo dt 200 u superscript ii rt invitrogen the primer sequences real time rt pcr listed table 2 the amplification carried total volume 20 l containing 0.5 moll primer 4 mmoll mgcl2 2 l lightcyclertm faststart dna master sybr green roche molecular systems alameda ca 2 l 1 10 diluted cdna pcr reactions prepared duplicate performed using following program 95c 10 min followed 40 cycles denaturation 95c 10 sec annealing 55c 5 sec extension 72c 20 sec standard curves cycle threshold values versus template concentration prepared target gene endogenous reference gene gapdh sample quantification unknown samples performed using lightcycler relative quantification software version 3.3 roche the oligonucleotide 5-aaaacctaatactttccagattgatttggat ccaaatcaatctggaaagtattagg-3 targeting human bmi-1 nm_005180 nt 10611081 synthesized cloned plvrnai generate lentiviral expression vector plvrnai sh bmi1 the lentiviral expression vector carrying bmi-1 full length cdna plv bmi-1 obtained biosettia inc pcmvr8.9 pmd.g expressing gag pol vesicular stomatitis virus envelope respectively provided consortium academia sinica taipei taiwan the lentiviruses generated cotransfecting 5 10 293 ft cells per 10 cm plate lentiviral vector packaging plasmids using lipofectamine 2000 lf2000 invitrogen subconfluent cells infected lentivirus multiplicity infection 5 presence 8 g ml polybrene sigma aldrich 13 33 total rna extracted cells using trizol reagent life technologies bethesda md usa qiagen rnaeasy qiagen valencia ca usa column purification affymetrix hg u133 plus 2.0 microarrays containing 54,675 probe sets 47,000 transcripts variants including 38,500 human genes typical probeset contains eleven 25-mer oligo nucleotide pairs perfect match mismatch control microarray analysis sample labeling hybridization staining the average linkage distance used assess similarity two groups gene expression profiles described the difference distance two groups sample expression profiles third assessed comparing corresponding average linkage distances mean pairwise distances linkages members two groups concerned the error comparison estimated combining standard errors standard deviation pairwise linkages divided square root number linkages average linkage distances involved classical multidimensional scaling mds performed using standard function r program provide visual impression various sample groups related all procedures involving animals accordance institutional animal welfare guidelines taipei veterans general hospital eight week old scid mice and/or nude mice balb c strain injected 105 cells orthotopically vivo gfp imaging was performed using illuminating device lt-9500 illumatool tls equipped excitation source 470 nm filter plate 515 nm tumor size measured calipers tumor volume calculated using formula length width2)/2 the integrated optical density green fluorescence intensity captured analyzed using image pro plus software 33 34 the statistical package social sciences software spss inc chicago il used statistical analysis an independent student test used compare continuous variables groups a log rank test used compare cumulative survival durations different patient groups initially parental isolated aldh1 aldh1 cells isolated tissue samples six hnscc patients using aldefluor assay fluorescence activated cell sorting facs analysis figure 1(a table 1 13 35 it reported cancer stem like cells cultured suspension generate floating spheroid like bodies sb serum free medium bfgf egf interestingly aldh1 increased higher tumor spheres forming capability aldh1 figure 1(b furthermore aldh1-derived spheres regular 10% serum cultivation increased epithelial attached cells differentiation marker ck18)(see figure 1(a supplementary material available online doi 10.1155/2011/609259).to evaluate enhancement tumorigenicity hnscc aldh1 cells soft agar colony formation assays matrigel transwell invasion examined compared parental aldh1 aldh1 derived hnscc patients no.1 2 showed colony forming ability higher invasion activity figures 1(c 1(d evaluate vivo tumor initiating capability aldh1 aldh1 injected 1000 3000 10 cells neck scid mice the results showed 104 aldh1 induce tumor formation 3,000 aldh1 hnscc tissues six patients xenotransplanted mice resulted generation visible tumors 6 weeks injection table 1).the results xenotransplanted analysis showed aldh1 demonstrated higher abilities induce tumor growth figure 1(e lastly serial xenotransplanted analysis suggested aldh1 vivo self renewal ability supplementary figure 1(b based findings aldh1-lineage cells isolated hnscc patients presented significant tumor initiating abilities especially aldh1 cells patients 1 no real time rt pcr data demonstrated stemness emt related genes especially bmi-1 snail significantly activated hnscc aldh1 table 2 data shown to investigate role bmi-1 maintaining biological properties hnscc aldh1 used loss function approach bmi-1 knocked small hairpin rna shrna hnscc aldh1 cells stable knockdown bmi-1 hnscc aldh1 cells achieved transduction lentivirus expressed shrna targeting bmi-1 sh bmi-1 lentivirus expressed shrna targeted luciferase sh luc used control western blot analysis confirmed shbmi-1 repressed bmi-1 protein expression hnscc aldh1 cells figure 2(a importantly silencing bmi-1 expression led downregulation snail aldh1 expression figure 2(a additionally results showed silencing bmi-1 hnscc aldh1 cells inhibited ability cells form colonies soft agar figure 2(b migrate invade figure 2(c evaluate whether overexpression bmi-1 could enhance tumorigenic properties hnscc aldh1 cells generated stable bmi-1-overexpressing bmi-1over hnsccs using lentiviral transduction figure 2(d total proteins hnscc aldh1 overexpressing bmi-1 exhibited elevated expression snail aldh1 figure 2(d in addition overexpression bmi-1 significantly increased soft agar colony formation figure 2(e migration invasion hnscc aldh cells figure 2(f taken together results suggest bmi-1 modulates vitro tumorigenic properties hnscc aldh1 aldh1 cells regulating snail explore molecules governing stemness tumorigenicity hnscc cd44aldh1 cells treated bmi1-overexpressing lentivirus examined transcriptome profile using gene expression microarray analysis figure 3(a principle component analysis pca showed transcriptome profile hnscc aldh1 cells overexpressing bmi-1 demonstrated higher expression levels embryonic stem cells escs transcriptomes table 3 figure 3(b multidimensional scaling analysis demonstrated hnscc aldh1 cells hnscc aldh1 cells overexpressing bmi-1 similar escs hnscc aldh1 cells p .05 figure 3(c validate microarray analysis results real time pcr performed confirm mrna expression levels embryonic genes oct-4 nanog sox2 klf4 lin28 emt related genes snail slug drug resistant related genes mdr-1 abcg2 bmi-1-overexpressing aldh1 cells significantly higher aldh1 cells p .05 table 2 figure 3(d we next sought determine bmi-1 expression could modulate vivo tumor initiating activity immunocompromised nude mice monitor vivo growth aldh1 aldh1 bmi-1-overexpressing aldh1 cells cells transfected using lentivector combined green fluorescent protein gene gfp followed vivo gfp imaging system firstly results showed 1 10aldh1 cells induce tumor formation nude mice 1000 aldh1 cells generated visible tumors 6 weeks injection table 1 in contrast aldh1 cells one three 33.3% nude mice detected tumor formation 6-week transplantation 3000 bmi-1-overexpressing aldh1 cells furthermore tumor volumes hnscc aldh1 transplanted mice significantly decreased mice treated sh bmi-1 table 1 figure 4(a overexpression bmi-1 enhanced vivo tumor growth hnscc aldh1 table 1 figure 4(a furthermore investigated role bmi-1 radio sensitivity hnscc aldh1 hnscc aldh1 treated sh bmi-1 bmi-1 overexpressing an ionizing radiation ir dose 0 10 gy applied cells hnscc aldh1 cells showed greater radioresistance aldh1 cells p .05 figure 4(b knockdown bmi-1 aldh1 cells results significant inhibition radioresistance overexpression bmi-1 aldh- cells promotes radioresistant properties p .05 figure 4(b moreover confirm bmi-1 crucial metastasis vivo mice injected different numbers aldh1 aldh1/sh bmi-1 aldh1/bmi-1over control gfp expressing aldh1 cells 5x105 bmi-1-overexpressing aldh1 cells significantly increased local invasion distant metastasis lungs tumor size compared control aldh1 cells figures 5(a 5(b in addition silencing bmi-1 aldh1 cells effectively reduced number lung metastases tumor size vivo figures 5(a 5(b taken together results reveal crucial role bmi-1 signaling maintenance vivo tumorigenicity metastasis hnscc aldh1 -aldh1 cells elevated snail protein expression hnscc correlated development metastasis poor survival elevated expression aldh1 also correlates poor prognosis hnscc patients investigate whether positive correlation bmi-1 snail aldh1 head neck cancers studied expression bmi-1 snail aldh1 immunohistochemical ihc staining panel specimens array 93 hnscc patients the ihc results showed elevated expression bmi-1 snail aldh1 positively associated high grade poorly differentiated hnscc figure 6(a our results also showed significant positive correlation aldh-1 bmi-1 figure 6(b aldh-1 snail figure 6(c bmi-1 snail figure 6(d hnscc tissues this consistent previous studies reported hnscc aldh1 cells elevated bmi-1 snail expression 13 38 determine prognostic significance bmi-1 snail aldh1 coexpression patients hnscc patients triple positive bmi-1 snail aldh1 predicted worst survival rate compared head neck cancer patients figure 6(e bmi-1/snail aldh1 versus groups overall data indicate expression bmi-1 snail aldh1 hnscc patients could critical factor predicting disease progression clinical outcomes a recent study demonstrated bmi-1 mrna protein overexpressed subpopulation tumor initiating cells cd44 hnscc possessed self renewal tumor formation ability zhang et al also reported side populations oral squamous cell carcinomas express high levels abcg2 abcb1 cd44 oct-4 bmi-1 nspc1 ck19 our previous work showed hnscc aldh1 cells high levels bmi-1 ability self renew radiochemoresistance confirmed aldh1 -lineage cells underwent epithelial mesenchymal transition emt endogenously co expressed snail current study data demonstrated hnscc aldh1 cells high levels bmi-1 mrna protein levels figure 2 using lentiviral vector expressing shrna targeting bmi-1 observed level aldh1 expression tumorigenic properties hnscc aldh1 could regulated knockdown bmi-1 figure 2 importantly overexpression bmi-1 could turn hnscc aldh1 cancer stem cell like hnscc aldh1 cells figure 3 consistent findings immunohistochemical survey 93 hnscc patient tissues showed positive correlation expression bmi-1 snail aldh1 tumor stage figure 6 kaplan meier analysis demonstrated patients expressing bmi-1 snail aldh1 predicted worst survival prognosis hnscc patients figure 6(e however recent study showed significant correlation negative bmi-1 protein expression recurrence tongue cancer tongue cancer patients especially female tongue cancer patients usually habits the close relationship tongue cancer human papillomavirus explored many researchers 4245 the prognosis hnscc patients distant metastases lung liver bone poor 3 46 study found bmi-1 regulate snail aldh1 change emt related genotypes aldh1 cells modulate distant lung metastases figure 5 distant metastases reported associated bmi-1 expression breast cancer 4749 melanoma gastric cancer colon cancer microarray analysis revealed eleven gene signatures correlated bmi-1-driven pathway closely related distant lung metastases bmi-1 target gene sall4 human hematopoietic well leukemic cells regulated sall4 knocked sirna hl-60 leukemia cell line 52 53 recently researchers employed microrna profiling gain insight role bmi-1 regulating emt overexpression mir-200c decreased bmi-1 expression breast cancer stem cells bcscs inhibited formation mammary ducts well tumors normal mammary stem cells bcscs found mir-15a mir-16 directly targeted bmi-1 3 untranslated region correlated bmi-1 protein levels ovarian cancer patients cell lines together research shows bmi-1 signaling pathways play major role maintenance stemness metastatic ability hnscc csc regulating snail expression additionally demonstrate coexpression bmi-1 snail aldh1 hnscc patients	recent studies suggest that aldh1 is a putative marker for hnscc - derived cancer stem cells . however , the regulation mechanisms that maintain the stemness and metastatic capability of hnscc - aldh1 + cells remain unclear . initially , hnscc - aldh1 + cells from hnscc patient showed cancer stemness properties , and high expression of bmi1 and snail . functionally , tumorigenic properties of hnscc - aldh1 + cells could be downregulated by knockdown of bmi-1 . overexpression of bmi-1 altered in expression property aldh1 cells to that of aldh1 + cells . furthermore , knockdown of bmi-1 enhanced the radiosensitivity of radiation - treated hnscc - aldh1 + cells . moreover , overexpression of bmi-1 in hnscc - aldh1 cells increased tumor volume and number of pulmonary metastatic lesions by xenotransplant assay . importantly , knock - down of bmi1 in hnscc - aldh1 + cells significantly decreased distant metastases in the lungs . clinically , coexpression of bmi-1/snail / aldh1 predicted the worst prognosis in hnscc patients . collectively , our data suggested that bmi-1 plays a key role in regulating snail expression and cancer stemness properties of hnscc - aldh1 + cells .
neuroleptic malignant syndrome nms rare life threatening complication antipsychotic agents it initially reported 1960s since many cases recognized worldwide nms associated significant mortality rate requires early recognition prompt treatment early diagnosis nms clinical challenge family physicians treat patients medical psychiatric conditions increasing use antipsychotic agents primary secondary care setting nms missed suspected patients antipsychotics presenting general practice hyperthermia muscle rigidity we report case nms diagnosed patient poorly controlled diabetes urban health center vellore tamil nadu india a 34-year old male history type 2 diabetes mellitus oral hypoglycemic agents hospitalized twice symptoms ketosis poor drug compliance poor motivation regarding diabetes care psychomotor agitation noted hospitalization one week starting antipsychotics presented extrapyramidal symptoms dystonia parkinsonian gait fine tremors high spiking fever altered sensorium muscle rigidity blood counts urine microscopy renal function normal except low sodium table 1 creatine phosphokinase cpk ordered view muscle rigidity high 1543 a diagnosis nms made according diagnostic statistical manual mental disorders dsm iv criteria laboratory abnormalities patient risperidone stopped immediately treated lorazepam trihexyphenidyl paracetamol intravenous fluids consultation psychiatrist within 48 h hospitalization family informed diagnosis need close monitoring glycemic control nms rare condition reported two studies done neurology psychiatric units teaching hospitals india incidence 1.401.41/1000 cases treated antipsychotics among risk factors some studies report older age high risk due associated medical morbidities nutritional deficiencies dehydration electrolyte abnormalities male gender genetic predisposition other studies report cases age group 2050 years associated high antipsychotic dosage seen patient the antidopaminergic activity antipsychotic drugs associated symptoms muscle rigidity hyperthermia autonomic dysfunction mental status change these symptoms recognized diagnostic according american psychiatric associations dsm iv the signs symptoms develop 2472 h period following administration antipsychotic drug however develop later seen patient newer antipsychotic agents risperidone block serotonin receptors dopamine receptors however nms reported use case study anti emetics metoclopramide droperidol linked nms dopaminergic blocking activity laboratory abnormalities may include leukocytosis electrolyte disturbances elevated cpk secondary muscle damage diagnostic tests fever may include urine analysis chest radiography lumbar puncture imaging studies brain diagnostic nms however may rule causes altered mental status possible complications include dehydration poor oral intake renal failure secondary rhabdomyolysis coagulation abnormalities mortality nms decreased 76% 10% 20% however complete recovery noted patients mortality caused complications respiratory failure cardiovascular collapse renal failure arrhythmias thromboembolism patients hemodynamically unstable transferred higher centers intensive monitoring mild cases managed secondary care setting consultation psychiatrist supportive therapy involves discontinuation antipsychotic agents correction electrolyte imbalances nutritional deficiencies monitoring airway breathing circulation our patient managed urban health center team family physicians specific dopaminergic agents bromocriptine dantrolene electroconvulsive therapy option considered severe cases psychiatrists symptoms may last month patients depot preparations restarting antipsychotics patients history nms needed done consultation psychiatrist depot preparations generally recommended however 2 weeks interval considered recovery restarting antipsychotic agents early detection management side effects caused neuroleptic agents particular consideration family physicians attend early symptoms decreasing risk factors aggravate rigidity include avoiding dehydration minimal use restraints intramuscular injections adequate nutrition screening history nms patient family members	neuroleptic malignant syndrome ( nms ) is a life - threatening emergency that is often seen as a complication of antipsychotic agents . it is characterized by a tetrad of motor , behavioral , autonomic , and laboratory abnormalities . we report a case of a 34-year - old man with a history of newly diagnosed type 2 diabetes mellitus , mental retardation , and behavioral abnormalities who developed nms after starting on antipsychotic agents . he presented with high temperature , muscle rigidity , tachycardia , and elevated blood pressure . after a week of hospital treatment in the general ward of a secondary care unit , he was discharged in a hemodynamically and mentally stable state .
chronic myelogenous leukemia cml chronic myelo proliferative disorder initially chronic course lasting 35 years cml one first diseases specific chromosomal abnormality identified t(9;22)(q34;q11 philadelphia ph chromosome avascular necrosis femoral head avnfh occurs complicated traumatic nontraumatic disorder most cases avnfh nontraumatic occur secondary excessive corticosteroid use alcohol abuse.1 causes include coagulopathies hemoglobinopathies eg sickle cell disease chronic liver disease gout idiopathic hyperlipidemia metabolic bone disorders pregnancy radiation chemotherapy smoking systemic lupus erythematosus vasculitis syndromes intravascular coagulation appears central event associated nontraumatic avnfh.2 coagulation may occur secondary extravascular compression eg marrow fat enlargement vessel wall injury eg chemotherapy radiation thromboembolic event eg fat emboli in addition ischemic insult femoral head may result subchondral bone infarction in situation weakened unrepaired necrotic bony trabeculae fail compressive load leading subchondral collapse eg crescent sign ultimately articular collapse.3 traumatic causes femoral head avascular necrosis avn include femoral neck fractures hip dislocation slipped capital femoral epiphysis.4 avnfh presenting manifestation patient cml we literature review came number cases reporting avnfh initial presentation cml illustrated table 1 avnfh reported initial presentation cases cml many authors table 1 a 34-year old sudanese female diagnosis cml started imatinib first line therapy failed first line therapy per european leukemianet guidelines 2010 she referred hematology service national center cancer care research ncccr evaluation her clinical examination unremarkable work repeated including complete blood count cytogenetics bcr abl pcr plain radiograph treatment available reported normal her work revealed chronic phase cml failing first line therapy she started dasatinib 100 mg po daily second line therapy achieved chr ccyr mmr 18 months after 18 months therapy dasatinib presented severe pain left groin limping her peripheral smear reported normal disease revaluated molecular level showed major molecular response radiological evaluation including pelvic radiography see fig 1a b magnetic resonance imaging mri showed grade 34 avnfh see fig this limited number reports absence prospective studies evaluating issue situation in addition whether disease and/or treatment encourage development avnfh known post contrast material enhanced mri inherent high spatial resolution capabilities considered excellent diagnostic tool detecting staging femoral head avn it considered preferred method diagnosis occult avn since sensitive bone scan plain films owing high incidence bilateral avn mri may pick avn opposite asymptomatic hip an avn lesion typically well demarcated epiphyseal area altered variable signal intensity figs 1 2 ) early stages t2-weighted images stir short tau inversion recovery help detection necrotic tissue unusual avn lesions mostly showed ill delimited edema like marrow changes.11,12 mri 90100% sensitivity symptomatic disease cases contrast enhanced mris may increase diagnostic confidence showing homogeneous hypervascularization bone marrow edema lesions depicting hypovascular marrow areas avn lesions also mri discriminate avn transient marrow edema.11,13 sequential follow mri considered valuable assessment equivocal femoral head lesions especially early stages findings usually trivial.12,13 treatment historically passed two eras the era interferon limited data interferon alfa 2a cause avnfh there reports literature avnfh therapeutic uses interferon alfa therefore occurrence avnfh patients cml interferon treatment may result interaction cml interferon alfa therapy interferon alfa inhibit angiogenesis may cause avn stress weight bearing may make femoral head particularly vulnerable.14 second era cml treatment started using tyrosine kinase inhibitor tki table 3 few cases avnfh reported disease presentation cml well use first generation tkis imatinib glivec though mechanism dasatinib cause avn clear postulated micro circulatory obstruction femoral head the mentioned review literature states six patients cml presented avnfh initial presentation prior therapy five era interferon two era tkis one imatinib dasatinib treatment there two issues considered either condition rare underreporting side effect observational studies proper reporting required accurately measure incidence complication could significantly affect patients safety quality life	chronic myeloid leukemia ( cml ) is a myeloproliferative neoplasm characterized by the presence of the philadelphia ( ph ) chromosome resulting from the reciprocal translocation t(9;22)(q34;q11 ) . the molecular consequence of this translocation is the generation of the bcr abl fusion gene , which encodes a constitutively active protein tyrosine kinase . the oncogenic protein tyrosine kinase , which is located in the cytoplasm , is responsible for the leukemia phenotype through the constitutive activation of multiple signaling pathways involved in the cell cycle and in adhesion and apoptosis . avascular necrosis of the femoral head ( avnfh ) is not a specific disease . it occurs as a complication or secondary to various causes . these conditions probably lead to impaired blood supply to the femoral head . the diagnosis of avnfh is based on clinical findings and is supported by specific radiological manifestations . we reported a case of a 34-year - old sudanese female with cml who developed avnfh after receiving dasatinib as a second - line therapy . though the mechanism by which dasatinib can cause avascular necrosis ( avn ) is not clear , it can be postulated because of microcirculatory obstruction of the femoral head . to the best of our knowledge and after extensive literature search , this is the first reported case of avnfh induced by dasatinib in a patient with cml .
colorectal cancer crc one common forms cancer western society every year 9,500 patients netherlands diagnosed disease almost half die dutch cancer registry 2002 it estimated around 20% patients colorectal tumour genetic factors play role aetiology 15% patients crc are thought hereditary non polyposis colorectal cancer hnpcc lynch syndrome dominant hereditary disease caused defect one dna mismatch repair mmr genes important clinical characteristics crc associated hnpcc relatively young age patients diagnosed disease average 45 years old proximal localisation tumour colon besides increased risk developing tumour colon increased risk developing tumour elsewhere body especially endometrium lifetime risk 50% small intestines ovaries brain urinary tract biliary tract development keratoacanthoma carcinoma sebaceous glands skin the identification patients hereditary colorectal carcinoma great importance patient treatment follow tumour differ non hereditary colorectal carcinoma furthermore identification patients important offers efficient manners prevention colorectal carcinoma forms cancer patient well family it shown colonoscopy every three years lead decline mortality least 65% genetic defect hnpcc another method select families mutation analysis mmr genes analysis errors repetitive dna sequences i.e. micro satellite instability msi msi found around 15% non selected crc 95% colorectal tumours associated hnpcc 1996 these called bethesda guidelines describe practically situations suspicion hnpcc table 1guidelines performance msi analysis colorectal tumour revised bethesda guidelinesa person colorectal carcinoma diagnosed age 50a person colorectal carcinoma msi associated pathology<60 yearsa person colorectal carcinoma hnpcc associated tumoura person colorectal carcinoma first degree relative colorectal hnpcc associated tumour least one tumours diagnosed age 50three relatives diagnosed colorectal carcinoma hnpcc associated tumour diagnosed age one patient needs first degree relative twothe presence tumor infiltrating lymphocytes called crohn like lymfocyte reaction mucinous signet ring cell carcinoma differentiation medullary growth patterncarcinoma endometrial tissue stomach small intestines pancreatic gland biliary tract urinary tract ovaries brain keratoacanthoma carcinoma sebaceous glands guidelines performance msi analysis colorectal tumour presence tumor infiltrating lymphocytes called crohn like lymfocyte reaction mucinous signet ring cell carcinoma differentiation medullary growth pattern carcinoma endometrial tissue stomach small intestines pancreatic gland biliary tract urinary tract ovaries brain keratoacanthoma carcinoma sebaceous glands discovery mmr genes common approach diagnostic work hnpcc use amsterdam criteria. criteria met within one family three individuals colorectal another hnpcc associated kind tumour one person first degree family member two least one carcinoma diagnosed age fifty evaluate amsterdam criteria patients crc complete history cancer patient family obtained until known whether adequate family history taken patients colorectal carcinoma we also know extent medical specialists use mentioned clinical bethesda guidelines tumours patients match criteria tested msi the objective present study answer questions using data cancer registry comprehensive cancer centre west cccw leiden netherlands we selected patients diagnosed primary invasive colorectal tumour period 19992001 cancer registry cr comprehensive cancer centre west cccw netherlands the patients satisfy one following two bethesda guidelines patient one tumour i.e. one colorectal carcinoma second one colorectal cancer another hnpcc associated kind tumour patient fifty years younger diagnosis the selected patients considered indication performance msi analysis and/or referral clinical genetic centre cgc patients carcinoma situ carcinod appendix included analysis 1999 2001 434 patients complied mentioned criteria diagnosed crc one twelve hospitals cccw region seven hospitals gave permission collection information concerning family history msi analysis referral cgc the family history considered complete medical records reported cancer family information age time diagnosis type cancer occurrence cancer within first degree second degree family members 120 patients multiple tumours 109 patients fifty years younger time diagnosis 15 patients characteristics comparisons patients multiple tumours patients young diagnosis characteristics allocated multivariate logistic regression analysis used study whether presence complete family history referral cgc could explained age sex inclusion criterion multiple tumours young age diagnosis hospital type medical specialist the study group consisted 244 persons complied one bethesda guidelines therefore considered referred msi analysis and/or genetic counselling the male female ratio 49:51 differ groups selected basis multiple tumours age 50 years diagnosis a complete family history recorded medical records 38 16% 244 patients 136 patients 55% limited information family history available 70 29% patients information family history of 38 patients complete family history 20 53% referred cgc this percentage higher patients incomplete family history 13% patients without information family history 4% p 0.0001 table 2 msi analysis performed often patients complete family history 34% patients complete family history compared 6% patients incomplete family history 1% patients without family history p 0.0001 table 2 presence complete family history performance msi analysis associated age sex inclusion criterion multiple tumours young age diagnosis hospital type medical specialist multivariate logistic regression analysis data shown table 2diagnostic work hnpcc 244 patients colorectal cancer completeness family history reported medical recordsdiagnostic workupfamily history complete n 38)family history incomplete n 136)family history absent n 70)referred cgc20 53%)17 13%)3 4%)msi analysis performed13 34%)8 6%)1 1%)results msi analysis3 msi 10 stable7 stable 1 unknown1 stablediagnosis hnpcc6 ( 16%)3 2%)1 1% diagnostic work hnpcc 244 patients colorectal cancer completeness family history reported medical records we used bethesda guidelines select group patients suspicion hnpcc these patients diagnosed colorectal cancer 1999 2001 period msi analysis bethesda guidelines already available therefore expected patients physicians would examined reported patients family history msi analysis would performed study group however family history patients diagnosed colorectal carcinoma sufficiently examined reported medical records for reason believe bethesda guidelines sufficiently applied physicians consequence msi analysis performed small proportion tumours more patients complete family history medical records referred physicians cgc patients without family history we expect low risk population i.e. patients colorectal cancer meet bethesda guidelines results would even dramatic one hand we collected data using medical records various medical specialties treating physician overview practice hand possible physician examined family history none family members diagnosed cancer report medical records case family history considered absent although fact examined nevertheless expect msi analysis performed patient referred cgc would certainly reported we found attention hnpcc diagnostic workup crc differed widely for seven participating hospitals proportion patients reported family history cancer ranged 38% 91% for reasons generalise results whole cccw region nevertheless conclude family history appears neglected majority patients colorectal cancer study period msi analysis performed small proportion patients meet guidelines analysis possibly attention identification patients hnpcc increased recent years our findings underscore importance implementation family history bethesda guidelines physician education	in the diagnostic work - up of hereditary non - polyposis colorectal cancer ( hnpcc , lynch syndrome ) , high - risk patients can be identified using information from the family history on cancer ( amsterdam criteria and bethesda guidelines ) . to investigate to what extent the medical specialists apply these criteria to patients with colorectal carcinoma and a suspicion of hnpcc , we collected information on diagnostic work - up of 224 patients of seven hospitals in the region of the comprehensive cancer centre west in leiden , the netherlands . these patients were diagnosed with colorectal cancer between 1999 and 2001 and satisfied at least one of the bethesda guidelines . a complete family history was recorded for 38 of the 244 patients ( 16% ) . patients with a complete family history were more likely to be referred to the clinical genetic centre than those with an incomplete or absent family history ( 53% vs. 13% and 4% , respectively ; p < 0.0001 ) , and more likely to be analyzed for microsatellite instability ( msi ) , which is a characteristic of hnpcc ( 34% vs. 6% and 1% , respectively ; p < 0.0001 ) . we conclude that the family history is neglected in the majority of patients with colorectal cancer and msi - analysis is only performed in a small proportion of the patients that meet the guidelines for this analysis .
great progress made neonatal care last decades reflected improving survival rates clinical outcomes preterm infants despite advances 45 years first description bronchopulmonary dysplasia bpd remains major complication premature birth causing ongoing morbidity mortality common neonatal chronic lung disease affecting around 25% 35% vlbw neonates ( low birth weight 1500 g associated increased risk rehospitalization 3 4 cognitive delay neurosensory deficits initially described northway et al 1967 old bpd mainly affected modestly premature newborns suffering respiratory distress therefore mechanically ventilated high levels supplemental oxygen introduction surfactant treatment prenatal maternal use glucocorticoids improved nutrition ventilator strategies clinical course pathology bpd changed considerably unlike original description today new bpd mainly regarded disruption distal lung growth 6 7 thus influenced genetic susceptibility 8 9 environmental factors immature lung pathophysiology characterized inflammation abnormal microvascularization impaired alveolarization alveolar formation primitive saccules complex process epithelial morphogenesis capillary growth coordinated extracellular matrix ecm remodelling fibroblast growth factor fgf signalling matrix metalloproteinase mmp activity play eminent roles some mmps upregulated inflammatory environment yet involved pulmonary host defense there evidence mmp isoforms important determinants alveolarization especially mmp-2 -9 -16 mmp-2 deficient mice showed fewer larger alveoli thinner interstitial tissue hadchouel et al demonstrated increase mmp-16 activity alveolar stage moreover found two snps within mmp-16 gene associated lower tracheal mmp-2 -16 activity protect bpd prospecting potential biomarkers bpd also mmp-9 shows promise example harijith et al highlighted mmp-9-dependent lung injury pathway ifn-mediated animal model bpd mice partial mmp-9 deficiency showed reversal ifn-induced lung injury hyperoxia mmps particularly mmp-2 -9 activate fibroblast growth factors fgfs cleavage ecm especially angiogenesis turn activated fgfs upregulate mmp expression fgfs secreted glycoproteins involved interactions epithelium mesenchyme regulating cell migration proliferation embryonic development especially fetal pulmogenesis 16 17 their signalling depends membrane located receptors fgfrs tyrosine kinase domain encoded four different genes fgfr 14 1820 they translated developing lungs suggested play major roles modifying distal lung patterns alveolarization example fgfr-3-fgfr-4 double knockout mice show alveolarization assumed heritable determinants contribute significantly bpd 8 23 rds account interested identifying genetic risk factors caucasian population premature newborn bpd rds we genotyped 27 polymorphisms within fourteen candidate genes bpd mmp-1 -2 -9 -12 -16 fgf receptors 2 4 fgf-2 -3 -4 -7 -18 signal regulatory protein sirpa thyroid transcription factor-1 ttf-1 we also included sirpa known effect surfactant proteins inhibition macrophages well ttf-1 due effect lung differentiation we recruited preterm neonates 28 weeks gestation born january 1996 september 2010 centre pediatrics adolescent medicine university hospital freiburg germany twins siblings excluded study children chromosomal aberrations congenital heart defects major congenital malformations dna collected buccal swabs routine blood sampling 2 weeks 2 years age this included gestational week number days supplemental oxygen need mechanical ventilation positive airway pressure need surfactant therapy as described previously subdivision bpd study population based analysis lavoie et al heritability bpd according consensus defined national institute health bpd population included infants moderate severe bpd supplemental oxygen least 28 days plus need oxygen and/or positive pressure 36 weeks gestation whereas control population consisted preterm neonates mild bpd recruiting neonates rds population targeted severe cases respiratory distress including newborns depending surfactant within first 24 hours birth see supplementary material available online http://dx.doi.org/10.1155/2013/932356 neonatal intensive care unit nicu following approach applied regarding treatment surfactant avoiding intubation independent gestational week therefore even premature infants intubated show failure ventilation and/or need supplemental oxygen 40% once required intubation immediate postnatal period receive surfactant within 2 hours we included minority polymorphisms already tested pathologies rs1799750 mmp1 rs2276109 rs652438 mmp12 pcr reactions genomic dna was initially denatured 94c 5 minutes underwent 3540 cycles denaturation 94c 30 seconds annealing 1 minute corresponding temperatures displayed table 2 extension reaction 72c 1 minute final extension step 72c 8 minutes table 2 some primers contain intended single nucleotide mismatches mutagenic primers create sites restriction enzymes accuracy rflp confirmed sequencing via dideoxy chain termination method respectively three controls homozygous wildtype heterozygous homozygous mutation polymorphism using big dye terminator cycle sequencing kit abi 310 sequencer applied biosystems genotyping data case control populations analysed using armitage trend test att possible association bpd rds specified previously moreover att used calculate hardy weinberg equilibrium hwe polymorphism collection blood buccal swabs experimental procedures approved ethical committee university freiburg parents given written verbal information study statement informed consent signed parents enrolled children the results 27 studied polymorphisms table 1 association bronchopulmonary dysplasia neonatal respiratory distress specified table 3 bpd table 4 rds among 11 genotyped polymorphisms different mmp genes see table 1 bpd associated polymorphism table 3 two polymorphisms associated p 0.05 rds rs20544 mmp-9 p 0.033 rs652438 mmp-12 p 0.047 see table 4 both snps show significant deviation hardy weinberg equilibrium neither control case population analysis rs20544 c identifies allele protective respiratory distress genotyping results amino acid substitution rs652438 ( a g asn357ser complete absence g g homozygous genotype respiratory distress case population must taken account the mmp snps showed association inclusively rs2664352 mmp16 associated protection bpd the fgfr-4 snp rs1966265 located exon region causing amino acid substitution isoleucine ile valine val associated bpd p 0.023 rds p 0.003 here the genotype ile could identified protective allele variant studied lung diseases association results significant differences allele frequencies bpd rds analysis g allele frequent disease populations see tables 3 4 the snps fgfr genes showed association neither bpd respiratory distress whereas association could detected eight fgf snps bpd rs10796856 fgf-3 rs4316697 fgf-7 showed associations rds correspondent p values p 0.036 rs10796856 p 0.044 rs4316697 deviations hardy weinberg equilibrium detected see table 4 the four snps sirpa ttf-1 showed association neither bpd rds analysis ttf-1 rs999460 unfolds deviation hardy weinberg equilibrium case one control populations caucasian population see tables 3 4 the aim study identify genetic risk factors ethnically homogenous caucasian population genetic contribution bpd is suggested basis twin studies demonstrating least half susceptibility hereditary 8 9 23 additionally lavoie et al could differentiate study mild bpd according national institute child health human development consensus definition mainly attributable shared environmental factors whereas moderate severe bpd attributable genetic influence following findings defined control population neonates bpd mild bpd whereas bpd population included neonates moderate severe bpd furthermore recruited preterm neonates 28 weeks gestational age bpd population avoid false associations based fact bpd hardly develops newborn older 30 weeks gestational age in contrast bpd results twin studies rds susceptibility showed mostly contradictory results 24 3235 twin study levit et al 332 twin pairs heterogeneous population has first one include assess influence several independent covariates revealing 50% variance rds susceptibility hereditary given lines evidence genetic contribution chosen candidate gene approach association study based hypothesis genes fundamental lung organogenesis alveolar remodelling mmp fgf determine susceptibility bpd rds known genetic risk factors rds mostly allelic polymorphisms genes encoding surfactant proteins sp a1 sp a2 sp b anyhow determinants components surfactant system might also affect liability rds genes encoding growth factors enzymes account alveolarization proper secondary septation extracellular remodeling might affect gas exchange therefore aggravate respiratory distress birth supposed genetic risk factors bpd mostly genes encoding components innate immunity antigen presentation cytokines antioxidant defences angiogenic growth factors mannose binding lectin mbl2 tumor necrosis factor alpha tnf- 28 38 human leucocyte antigen hla)-a -b -c alleles glutathione transferase p1 vascular endothelial growth factor vegf years ago two mmp-16 gene polymorphisms demonstrated protect bpd moreover associated lower tracheal mmp-2 -16 levels matrix metalloproteinases family zinc dependent endopeptidases degrade extracellular components play crucial role lung development especially alveolarization particularly mmp-2 -9 called gelatinases b seem relevant extracellular remodeling even pulmonary host defense they degrade type iv collagen fibronectin elastin denatured collagen gelatin mmp-2 deficient mice show abnormal saccular development larger simplified alveoles line finding newborns developing bpd showed low mmp-2 tracheal levels birth 41 42 recently mmp-9 could identified pathogenic key mediator murine model bpd hand increased tracheal levels mmp-9 early birth associated resolving rds suggesting increase mmp-9-activity physiologic repair response demonstrated increased mmp-9 activity neonatal lungs early birth correlated resolving respiratory distress syndrome demonstrating likely role mmp-9 pulmonary host defense study we identified snp rs20544 mmp-9 gene associated p 0.033 rds bpd respiratory distress syndrome defined need surfactant see supplementary material on one hand ethnically homogenous populations like caucasian population favourable detect possible pathogenetic determinants one must bear mind size rds population limited total numbers neonates studied polymorphism vary slightly according recruiting time point furthermore association studies rds prone confounding factors pulmonary conditions transient tachypnea provoked wet lung syndrome pulmonary infection might mimic respiratory distress syndrome caused surfactant deficiency thereby hamper results study in study included mmp-16 polymorphisms associated bpd french population rs2664352 population rs2664352 up role fgf3 mainly studied cancer diseases lung cancer exact role pulmogenesis remains elusive there evidence fgf-3 upregulation associated alveolar type 2 cell hyperplasia downregulation associated excessive recruitment free alveolar macrophages might lead symptoms respiratory distress furthermore shown fgf-3 stimulates secretion mmp-2 -9 propeptides vitro fgfr-4 polymorphism rs1966265 showed association respiratory distress p 0.003 bronchopulmonary dysplasia p 0.023 the genotype encoding isoleucin instead valine protective association study the exact test showed deviation hardy weinberg equilibrium snp case control populations suggesting association result population admixture genotyping errors fgfr-1 fgfr-4 expressed lung fgfr-3 -4 signalling particular appears fundamental alveolar formation weinstein et al demonstrated mice deficient fgfr-3 -4 show completely blocked alveolarization fail show formation secondary septae whereas solely fgfr-4(/ animals exhibit significant abnormalities revealing cooperative effect fgfr-3 -4 lung development hyperoxia exposed fio2 0.85 mice show bpd like lung pattern enlarged airspaces furthermore reduced expression fgfr-3 -4 suggesting pathogenic role arrested lung development replicated results fgfr-3 -4 deficient mice demonstrated addition fgfr-3/-4 signaling contributes excessive elastin production alveolar accumulation another typical feature bpd but abnormalities due fibroblast defects due increased expression paracrine factors alveolar type 2 cell at2 if reduction fgfr-3 -4 expression affects distal lung development functionally significant polymorphism within correspondent gene possibly alters susceptibility alveolar disease bpd rds showed peak fgfr-4 expression day birth respiratory distress syndrome occurs false positive results excluded replications study populations conclusion describe five snps mmp-9 mmp-12 fgfr-4 fgf-3 fgf-7 associated p 0.05 caucasian population respiratory distress syndrome newborn defined surfactant application within first 24 hours birth among polymorphisms one polymorphism fgfr-4 rs1966265 additionally associated bronchopulmonary dysplasia demonstrating possible role pathogenesis newborn lung diseases grounds pulmonal immaturity	background . bronchopulmonary dysplasia ( bpd ) is the most common chronic lung disease of premature birth , characterized by impaired alveolar development and inflammation . pathomechanisms contributing to bpd are poorly understood . however , it is assumed that genetic factors predispose to bpd and other pulmonary diseases of preterm neonates , such as neonatal respiratory distress syndrome ( rds ) . for association studies , genes upregulated during alveolarization are major candidates for genetic analysis , for example , matrix metalloproteinases ( mmps ) and fibroblast growth factors ( fgfs ) and their receptors ( fgfr ) . objective . determining genetic risk variants in a caucasian population of premature neonates with bpd and rds . methods . we genotyped 27 polymorphisms within 14 candidate genes via restriction fragment length polymorphism ( rflp ) : mmp-1 , -2 , -9 , and -12 , -16 , fgf receptors 2 and 4 , fgf-2 , -3 , -4 , -7 , and -18 , signal - regulatory protein ( sirpa ) and thyroid transcription factor-1 ( ttf-1 ) . results . five single nucleotide polymorphisms ( snps ) in mmp-9 , mmp-12 , fgfr-4 , fgf-3 , and fgf-7 are associated ( p < 0.05 ) with rds , defined as surfactant application within the first 24 hours after birth . one of them , in fgfr-4 ( rs1966265 ) , is associated with both rds ( p = 0.003 ) and bpd ( p = 0.023 ) . conclusion . rs1966265 in fgf receptor 4 is a possible genetic key variant in alveolar diseases of preterm newborns .
raised intracranial pressure icp usually associated increased morbidity mortality poor neurological outcomes the etiology could varied viz stroke liver failure meningitis meningoencephalitis metabolic encephalopathy postresuscitation syndrome it associated complications infection bleeding expensive regular assessment comparison computed tomography ct)/magnetic resonance imaging mri critically ill patients the optic nerve part central nervous system surrounded subarachnoid space experiences pressure change intracranial compartment the intraorbital part sheath particularly retrobulbar segment distend icp elevated the use bedside ocular ultrasonography usg measuring optic nerve sheath diameter onsd useful method detecting raised icp it advantage noninvasive portable easily performed bedside minimum time it repeated evaluation without risk radiation keeping view conducted bedside study noninvasive measurement onsd predictor detecting raised icp we conducted prospective observational study 101 adult individuals institutional review board permission period may 2013 august 2013 they divided two groups b. group 41 healthy controls 20 female 21 male a total 60 patients admitted period symptoms fever headache vomiting altered sensorium possibility elevated icp included group b. 17 female 43 male all patients examined supine position using 10 mhz phased linear array probe closed eyelids figure 1 the structures eye visualized align optic nerve directly opposite probe onsd width perpendicular vertical axis scanning plane a single onsd measured 3.00 mm behind globe figure 2 eyes the onsd measurements obtained averaging three readings eye create binocular onsd measurement occular sonography high frequency 10 mhz linear array probe placed gel closed eyelid optic nerve sheath diameter onsd measurement optic nerve appears homogeneous low internal reflectivity compared high reflectivity nerve sheath onsd measured 3 mm behind globe using electronic caliper angle perpendicular eye ball individuals control group 18 40 years controls a mean binocular onsd 4.6 mm 4.8 mm females males respectively the measurements 4.6 mm 4.8 mm females males considered increased icp imaging head ct mri done per requirement group b patients the finding ct mri reported site radiologist correlated bedside onsd measurement the patient imaging result considered positive raised icp radiologist impression described findings suggestive elevated icp significant cerebral edema midline shift mass effect effacement sulci collapse ventricles compression cisterns onsd 5.0 mm t2 mri the waiver individual consent requested intervention completely harmless nonchargeable patient patient identification used patients history optic neuritis arachnoid cyst optic nerve high myopic optic nerve trauma anterior orbital cavernous sinus mass excluded study the variables used age sex diagnosis heart rate blood pressure respiratory rate oxygen saturation temperature glasgow coma scale gcs onsd signs raised icp imaging serum osmolarity serum creatinine mannitol management statistically assessed observed differences among various onsd groups distribution categorical variables pearson fisher exact test association used statistics test baseline differences study group controls performed mann whitney u test statistically assessed observed differences among various onsd groups distribution categorical variables pearson fisher exact test association used statistics test baseline differences study group controls performed mann whitney u test statistically assessed observed differences among various onsd groups distribution categorical variables pearson fisher exact test association used statistics test baseline differences study group controls performed mann whitney u test a 41 females 20 males 21 control group the mean onsd control study group female 4.627 0.09 mm 5.103 0.62 mm male 4.8 0.10 mm 5.081 0.58 mm respectively the mean age control study group 27.44 3.31 56.15 18.86 years respectively demographic profile study patient 60 patients admitted 35 cases showed raised icp imaging onsd 5.43 0.53 mm the 25 patients show raised icp imaging onsd 4.61 0.19 mm it showed significant difference two sets patients p 0.001 however 10 25 showed rise onsd female 4.735 mm 4.6 mm male 4.907 mm 4.8 mm required reduction icp the mean gcs raised icp normal icp imaging 10.5 0.12 12.04 2.11 respectively mean temperature 99.31 0.75f 98.89 0.55f respectively raised icp normal icp it showed statistically significant p value gcs temperature 0.04 0.05 0.02 0.05 respectively other variables also analyzed show statistically significant difference shown table 2 association icp clinical profile receiver operator characteristic roc curve area curve auc mean onsd 4.716 mm 98.6% 95% ci 96.5 100% sensitivity 77.8% specificity 100% female roc curve auc onsd > 4.6 mm 100% 95% ci 100% sensitivity 84.6% specificity 100% whereas male roc curve auc onsd 4.8 mm 97.4% 95% ci 93.5 100% sensitivity 75.0% specificity 100% shown figures 3 4 receiving operating characteristic curve detecting raised intracranial pressure ultrasonography optic nerve sheath diameter female receiving operating characteristic curve detecting raised intracranial pressure ultrasonography optic nerve sheath diameter male patients received treatment mannitol antiepileptics antiplatelet antibiotics antiviral depending cerebrospinal fluid csf analysis the trend onsd patients raised icp recorded day 1 day 4 in the female population onsd day 1 5.405 0.5729 mm day 4 decreased 4.868 0.4417 mm similarly male onsd day1 5.442 0.5233 mm day 4 decreased 5.065 0.3730 mm 10 cases show raised icp imaging increased onsd day 1 female 4.735 0.064 mm male 4.907 0.054 mm reduction icp noted 2 day onsd decreased 4.630 0.071 mm female 4.823 0.038 mm male trend onsd treatment trend onsd treatment 35 patients raised icp imaging onsd 5.430 0.5311 mm 21 cases diagnosed infective meningitis meningoencephalities 12 cases cerebrovascular accident stroke intracranial hemorrhage 2 cases metabolic encephalopathy whereas 25 cases show raised icp radiologically 2 cases infective meningitis meningoencephalities 18 cases cerebrovascular accident stroke intracranial hemorrhage 5 cases metabolic encephalopathy 10 cases show raised icp radiologically mean onsd two female 4.735 mm eight male 4.907 mm they 8 cerebrovascular accident 1 metabolic encephalopathy 1 infective study group 60 patients 28 patients high onsd signs raised icp imaging received mannitol definitive treatment however three patients showed high onsd show raised icp imaging also received mannitol showed decrease onsd supportive therapy totally 26 patients required intubation controlled mechanical ventilation sedation study group 21 patients high onsd signs raised icp imaging five patients high onsd show signs raised icp imaging total 5 cases expired 2 icp increased 3 without icp find statistical significant raised icp usually associated conditions stroke liver failure meningitis meningoencephalitis metabolic encephalopathy postresuscitation syndrome the cranium vertebral canal along relatively inelastic dura form rigid container increase contents brain blood csf tend increase icp the monro kelliy doctrine relationship states small increases brain volume lead immediate increase icp due ability csf displaced spinal canal well slight ability stretch falx cerebri hemispheres tentorium hemispheres cerebellum however icp reaches around 20 25 mmhg small increase brain volume lead marked elevations icp due failure intracranial compliance stage 1 minimal increase icp stage 2 drastic increase icp change volume 100 200 ml stage 3 characterized sustained increased icp dramatic changes icp small changes volume as icp approaches mean arterial pressure becomes difficult squeeze blood intracranial space leading widespread reduction cerebral flow perfusion eventually leading ischemia brain infarction because hypoxia hyper apnea patients present decreased level consciousness loc cheyne stokes respiration hyperventilation sluggish dilated pupils widened pulse pressure generally rise icp common symptoms signs include headache vomiting without nausea altered loc headache worse coughing sneezing bending progressively worsens time the optic nerve sheath ons anatomically continuous dura mater trabeculated arachnoid space csf slowly percolates ultrasound examination optic nerve appears homogeneous low internal reflectivity compared high reflectivity nerve sheath utilized ossoinig performed first ultrasound measurement optic nerve using scan technique subsequently described standardized scanning using echography techniques several groups investigated relation onsd measured scan icp cennamo et al each demonstrated positive linear relation two variables neurosurgical patients particular immediate change onsd change icp a position 3 mm behind globe chosen ultrasound contrast greatest results reproducible anatomically anterior nerve distensible hansen et al presented data using transorbital b scan approach measurement onsd approach allowed select distance behind globe consistently measure nerve something difficult attain scan techniques helmke hansen demonstrated cadaver studies onsd increased 60% distance 3 mm behind globe compared 35% 10 mm thus confirming liu kahn observations furthermore went show optimal experimental scanning position longitudinal axial least interobserver variability found although significant difference measurement lateral axial transverse projection study average onsd control group aged 18 40 years 4.6 mm 4.8 mm female male respectively it proved dubourg et al systematic review meta analysis ultrasonographic onsd detection raised icp onsd adult 5 mm pediatrics 1 15 years ) they also concluded onsd 5.00 5.70 mm raised icp 20 mm diagnostic odds ratio 51 sensitivity 90% 95% ci 80 95% specificity 85% 95% ci 73 93% study conducted dubost et al detect the incidence raised icp preeclampatic patients concluded onsd 5.4 mm preeclampatic patients compared healthy pregnant women 4.5 mm similar study conducted rajajee et al concluded bedside measurement onsd accurate noninvasive method identify icp 20 mmhg heterogeneous group patients acute brain injury onsd 4.8 mm greatest accuracy in 60 admitted patients 35 cases raised icp radiological findings onsd female 5.405 mm male 5.442 mm 10 40% individuals raised icp imaging onsd found control female 4.735 0.064 mm male 4.907 0.054 mm we found mean onsd 4.716 mm sensitivity detecting raised icp 77.8% 95% ci 83 100% specificity 100% female sensitivity raised icp is 84.6% specificity 100% male sensitivity raised icp 75.0% specificity 100% beare et al evaluated ons ultrasound noninvasive method detecting raised icp african children they concluded sensitivity specificity detecting raised icp ct onsd 4.2 mm 100% 86% respectively conducted prospective blinded observational study adult head injury patients emergency department it proved dubourg et al systemic review meta analysis ultrasonographic measurement ons diameter detection raised icp onsd > 5.00 mm raised icp 20 mm pooled sensitivity 90% 95% ci 80 95% specificity 85% 95% ci 73 93% the patients raised icp 51 times likely positive onsd it also noted papilledema found acute situation takes hours days develop acute rise icp difficult diagnose symptoms nonspecific direct measurement icp attendant risks intracranial hemorrhage infection analysis 35 patients raised icp ct mri temperature gcs significant difference table 2 about 35 cases raised icp imaging high onsd 1 day admission starting appropriate treatment onsd measured subsequently days 2 3 4 we found significant reduction onsd female male 72 h treatment table 3a about 25 cases increased icp imaging however 10 cases 25 onsd higher cutoff value female 4.735 0.064 mm male 4.907 0.054 mm table 3b after supportive treatment onsd day 2 female male almost returned normal value the early detection raised icp difficult invasive devices available clinical signs raised icp headache vomiting drowsiness specific often difficult interpret sedated patients clinical signs raised icp bedside measurement onsd useful test identify raised icp noninvasive repeated multiple times devoid ionizing radiation applied broad range settings	background and aims : the aim was to evaluate efficacy of optic nerve sheath diameter ( onsd ) by ultrasound as a noninvasive method for detecting raised intracranial pressure ( icp ) in intensive care unit , to compare with computed tomography / magnetic resonance imaging ( mri ) findings of raised icp and to prognosticate onsd value with treatment.materials and methods : we conducted a prospective , observational study on 101 adults by including 41 healthy individuals in group a as control and 60 patients in group b admitted with fever , headache , vomiting , and altered sensorium . we examined them in supine position using 10 mhz linear array probe on closed eyelid . onsd was measured 3 mm behind the globe in each eye . a mean binocular onsd > 4.6 mm in female and 4.8 mm in male was considered abnormal . midline shift , edema , effacement or onsd > 5.0 mm on t2 mri suggestive of elevated icp was used to evaluate onsd accuracy.results:group a mean onsd was 4.6 mm in females and 4.8 mm in males . group b mean onsd for 17 females was 5.103 0.6221 mm ( p = 0.002 ) and for 43 males 5.081 0.5799 mm ( p = 0.032 ) . radiological sign of raised icp was confirmed in 35 patients ( females = 11 and males = 24 ) with high onsd value . sensitivity of detecting raised icp by onsd was 84.6% in females and 75% in males while specificity was 100% in both genders . out of 25 patients without radiological signs of raised icp 10 patients showed high onsd ( females = 4.735 mm and males = 4.907 mm ) . onsd was well prognosticated with treatment modalities.conclusion:bedside ocular ultrasonography for measuring onsd can be used an early test for diagnosing raised icp as it is a noninvasive , cost effective bedside test , which can be repeated for re - evaluation .
reports organogold complexes undergoing redox processes typically limited slow oxidative additions reductive eliminations however organogold complexes necessarily unreactive recently showed diaryl au(iii complexes undergo remarkably fast aryl aryl reductive elimination temperatures low 50 c these recent findings group well established vicente hashmi lloyd jones suggest barrier challenging reductive eliminations might substantially diminished au(iii cf3 bond reductive elimination typically slow process requiring elevated temperatures long reaction times due ground state stabilization afforded exceptionally strong bonding transition metals cf3 ligands instance ( dppbz)pd(2-me c6h4)(cf3 dppbz 1,2-bis(diphenylphosphino)benzene stable 130 c 3 days dppp)pd(ph)(cf3 dppp 1,3-diphenylphosphinopropane dppe)pd(ph)(cf3 dppe 1,2-diphenylphosphinoethane yield 10% phcf3 3 days 145 c reductive eliminations temperatures 50 80 c achieved pd(ii employing bulky ligands xantphos brettphos notably aryl cf3 reductive eliminations pd(iv often require similarly high temperatures sanford shown occur temperatures low 23 c 1 h. despite advances catalytic trifluoromethylation caryl cf3 reductive elimination still remains challenging step given importance trifluoromethylated arenes pharmaceuticals agrochemicals prompted investigate potentially low barrier caryl cf3 bond reductive elimination au(iii access complexes type r3pau(aryl)(cf3)i drawn puddephatt report oxidative addition cf3i me3paume afford cis trans mixtures me3paume2(cf3 me3paui one case me3pau(me)(cf3)i obtained exclusively preparation could reproduced authors reaction times varied 5 min 1 day rates dramatically slowed presence galvinoxyl authors concluded free radical chain mechanism operative cf3 propagating species prior investigations group revealed oxidation ph3pau(4-f c6h4 rapidly generates 4,4-difluorobiphenyl mechanism involving aryl group transfer however use bulkier pcy3 prevents transfer arene ligand instead resulting clean rapid oxidation cy3pau(4-f c6h4 1a isolable au(iii complex cis-(cy3p)au(4-f c6h4)cl2 2 eq 1).1 therefore began investigations au(i oxidation cf3i using 1a fluorinated arene ligand also providing convenient f nmr handle treatment 1a cd2cl2 cf3i 25 equiv afforded product formal cf3i oxidative addition 3a 1 h good yield eq 2 table 1 cf3 pcy3 ligands doublet 24.5 quartet 25.6 f p nmr spectra respectively provide diagnostic nmr signals table 2 substantial coupling jp f 63 hz fluorine phosphorus characteristic trans relationship cf3 phosphine ligands x ray analysis crystals 3a confirmed stereochemical relationship around square planar au(iii figure 1a homoleptic anion au(cf3)4 complex 3a contains rare example crystallographically characterized au(iii)cf3 bond complex 3a stable air water purified column chromatography well.2 f thermal ellipsoid representations 3a3d 12a 12b 50% probability level atoms color coded gray carbon yellow fluorine gold gold purple iodine orange phosphorus the reaction 1a cf3i represents rare oxidation au(i au(iii directly installs potentially reactive au(iii)carbon bonds attempts monitor oxidative addition f nmr found reaction occurred reaction mixture placed inside dark nmr spectrometer however reaction mixture exposed ambient fluorescent light 5 min formation 3a detected 20% given reliance numerous methods cf3i trifluoromethyl source investigated photochemical reactivity actinometry experiments carried determine overall quantum yield using norrish ii fragmentation valerophenone standard the oxidative addition cf3i 1a complete 20 irradiation hg vapor lamp 2 mm aq k2cro4 optical filter transmittance max 313 nm fragmentation valerophenone 1 took place 24 h identical conditions this rate difference addition ability ambient light bring reaction full conversion variable reaction times 15 min 1 h supports radical chain reaction mechanism au(i oxidation cf3i the reaction excess cf3i 1a also fast thf conversion never greater 65% 52% yield 3a even irradiated hg vapor lamp 1 h vida infra notably excess fluoroform hcf3 generated thf regardless light source dcf3 formed thf d8 used gc ms analysis reaction mixtures reveals several products thf oxidation likely formed h abstraction cf3 several control experiments using hcf3 production relative standard probe detect cf3 generation support involvement au(i initiation chain reaction uv absorption cf3i centered 270 nm tails beyond 350 nm irradiated 313 nm cf3i undergoes fast reversible c however absence 1a negligible amounts hcf3 observed thf solutions cf3i irradiated 30 min indicating carbon iodine radical recombination substantially faster h abstraction thf similarly insignificant quantities hcf3 observed 20 equiv relative cf3i h donors 1,4-cyclohexadiene 9,10-dihydroanthracene triphenylmethane added figure 2a additionally cy3pau(2-(ch2ch ch2)c6h4 4 containing pendent olefin either capture putative au(ii intermediate and/or cf3 fully consumed upon irradiation presence excess cf3i figure 2b this oxidation affords multiple au(iii products indiscriminate cf3 addition terminal olefin gold atom hcf3 thf used solvent see si 2-allylbromobenzene 5 react cf3i irradiated similar conditions hcf3 observed 5 min less 2% 30 min ) conclude au(i aryl complex necessary chain initiation these results also consistent initiation mechanism involving cf3i generates iodide cf3 following c bond homolysis control experiments assess involvement au(i initiation radical chain mechanism irradiation cf3i solutions containing h donors detect cf3h absence gold ( b radical trapping using olefin without pendant gold center we envisioned two possible initiation mechanisms generating cf3 propagating species cf3i chain reaction 1 initial photoexcitation 6 followed electron transfer cf3i 2 initial photoexcitation cf3i followed electron transfer 6 scheme 1 au(i aryl complexes well known chromophores photophysical properties investigated previously 1a absorbs weakly 310 nm cutoff many laboratory fluorescent lamps excitation 320 nm 37 cm results weak broad luminescence 340 460 nm classified fluorescence based lifetime excited species 1a 10 ns quantum yield fluorescence 0.03 despite short lifetime 1a cf3i effectively quenches fluorescence stern volmer quenching constant ksv 30 figure 3 although energy transfer could conceivably generate cf3 initiate chain reaction mechanism 1 scheme 1 cf3i removed fluorimetry samples vacuum fluorescence restored intensity prior introduction gas indicating consumption au(i occurred volmer plots fluorescence quenching 1a different concentrations cf3i blue boxes au(iii complex 3a blue triangles ch2cl2 concentrations au(iii mol l cf3i concentrations mmol l surprisingly fluorescence quenching au(iii complex 3a 2 orders magnitude effective ksv 4270 quenching cf3i figure 3 if propagating species terminate frequently critical concentration au(iii product exists may impede productive energy transfer excited species halting reinitiation chain reaction light puddephatt s report au(i alkyl complexes me3paume clearly react cf3i however mention dependence light process although reaction photoinitiated mechanism 1 would seem especially unlikely given absence chromophoric aryl ligand puddephatt examples test hypothesis irradiated cy3paume 9 presence cf3i scheme 2 9 absorb 300 nm see si reaction quantitative cd2cl2 irradiated ambient light proceed dark the oxidized product unobservable eliminating ch3i generate cy3paucf3 room temperature thf the reaction generates excess hcf thf3 presumably also solvent h abstraction cf3 if initiation mechanism 2 operative cf3 could generated irradiating cf3i solutions containing electron donors au(i phosphines scheme 3 indeed irradiation pme3 pcy3 presence cf3i results formation me3p cf3]i 10a jp consistent quenching cf3i au(iii oxidation pcy3 thf stalls roughly 45% conversion p nmr presence 25 mol au(iii complex 3a pph3 react cf3i eq 3 presumably due lower oxidation potential relative pme3 pcy3 pcy3 pph3 irradiated together cf3i pcy3 consumed suggesting pph3 neither initiates chain reacts cf3 propagation contrary initial hypothesis bulky phosphine ligands prevent aryl group transfer upon au(i oxidation found ph3pau(4-f c6h4 11a undergoes quantitative photoinitiated reaction cf3i cd2cl2 generate 12a eq 4 since pph3 unreactive toward cf3i oxidation 11a initiated small amounts dissociated pph3 disprove analogous mechanism pcy3-supported complex 1a complex 12a characterized x ray crystallography shown isostructural 3a figure 1b).3 basis results propose photoexcited cf3i undergoes rapid c i bond homolysis recombination also oxidizes au(i aryl alkyl complexes accepting electrons low lying somo generate radical anion cf3i mechanism 2 scheme 1 homolysis c bond cf3i generates iodide cf3 oxidizes r3p)aur 6 au(ii intermediate 7 iodine atom abstraction cf3i 7 affords au(iii complex 8 regenerates cf3 thf oxidation 6 cf3 competitive solvent h abstraction make hcf3 terminate radical chain sufficiently high concentrations au(iii product 8) quenches cf3i reinitiate radical chain reaction promisingly photoinitiated oxidative addition cf3i general electronically diverse complexes type cy3pau(aryl tables 1 2 the resulting au(iii products see figure 1 crystallographic analyses purified chromatography silica complex 1b aryl 3,5-f2-c6h3 electron deficient 1a aryl 4-f c6h4 reacts smoothly cf3i afford 3b complexes electron rich ligands 1c aryl c6h5 1d aryl 4-me c6h4 also react cf3i afford 3c 3d respectively electron rich complex 1e aryl 4-meo c6h4 decomposes au nano particles several cf3-containing au(iii complexes solution solid state products caryl au(iii product 3e detectable however decomposition slowed substantially addition mecn upon concentration reaction allowing solution state characterization the mechanism decomposition yet identified although speculate electron rich arene may encourage pcy3 dissociation room temperature subsequent aryl group transfer the complex 1f aryl 2-me c6h4 react cf3i suggesting cf3i oxidative addition sensitive sterics aryl ligand relaxation cf3i faster oxidation metal center initiate radical chain unsurprisingly hcf3 observed 1f irradiated thf 20 min cf3 reductive eliminations au(iii surprise 12a undergoes quantitative caryl reductive elimination toluene d8 110 c afford 4-fluoroiodobenzene ph3paucf3 20 min scheme 4 this process highly sensitive free phosphine stalling completely presence pph3 0.1 1.0 equiv 110 c 12 h. treatment 12a pph3-d15 room temperature results immediate formation 12a d15 presumably via associative process more electron rich aryl ligands 4-methylphenyl 12b significantly affect relative rates caryl caryl cf3 reductive elimination scheme 4 110 c complex 12b undergoes mostly caryl reductive elimination within 10 min afford 4-methyliodobenzene both caryl caryl cf3 reductive eliminations also completely inhibited presence pph3 0.1 1.0 equiv pph3-d15 reacts immediately room temperature afford 12b d15 also via associative ligand exchange these observations consistent mechanism involving highly reversible pph3 dissociation 12a 12b followed slow caryl , behaviors 12a 12b similar au(iii)alkyl complexes studied kochi reductively eliminate calkyl calkyl bonds 70 100 c via dissociative mechanism also undergo associative ligand exchange ambient temperature excess phosphine unsurprisingly analogous pcy3-stabilized complexes 3a 3d stable 110 c least 12 h presumably due greater -donating ability pcy3 relative pph3 phosphine exchange excess p(n bu)3 pbn3 pcy3 occur even temperatures precluding lower barrier associative exchange mechanism observed pph3-supported systems attributed larger cone angle pcy3 relative pph3 also pcy3 dissociation form three coordinate complex caryl reductive elimination significantly faster caryl cf3 reductive elimination cycle gold catalyzed trifluoromethylation must necessarily involve iodide abstraction au(iii product cf3i oxidative addition despite apparent kinetic stabilities au(iii complexes 3a3e 12a 12b undergo quantitative caryl cf3 reductive elimination less 1 min upon treatment agsbf6at room temperature to consider effects phosphine ligand silver mediated caryl cf3 reductive elimination au(iii used variable temperature nmr follow reductive elimination 3a 12a presence agsbf6 pcy3-substituted complex 3a undergoes fast quantitative conversion less 1 min caryl cf3 reductive elimination 10 c analogous pph3-stabilized 12a reacts similarly fast room temperature eq 5 lower temperatures several bridging species likely dimers observed f nmr upon halide abstraction cases if caryl cf3 bond reductive elimination occur monomeric three coordinate intermediate 12a might expected undergo slower reductive elimination due slower dimer dissociation and/or dimer monomer equilibrium favors dimer based smaller cone angle weaker -donation pph3 relative pcy3.5 these results reported herein support oxidative addition cf3i au(i via photoinitiated chain reaction reactions fast room temperature au(i aryl alkyl complexes aryl cf3 reductive elimination typically high barrier process occurs seconds room temperature au(iii cation the au(i)aryl species may regenerated via one numerous transmetalation strategies available involving carbon nucleophiles for instance excess 4-f c6h4)snme3 10 equiv undergoes fast quantitative transmetalation cy3pau]sbf6 room temperature afford 1a thereby closing hypothetical catalytic cycle based three elementary steps shown scheme 5 silver free halide abstraction au(iii complexes could conceivably enable practical mild cycle gold catalyzed trifluoromethylation aryl nucleophiles although deleterious reactions starting material metalloradical intermediates cf3 must mitigated well competitive aryl aryl homocoupling initially set probe caryl cf3 reductive elimination au(iii also explored oxidative addition cf3i au(i process potential implications beyond gold chemistry possibility photoinitiated oxidation transition metals main group elements cf3i discounted methods employing reagent trifluoromethyl source particularly since ambient fluorescent laboratory lighting sufficient initiate chain presence suitable reductant the results presented also suggest substrate photoexcitation may provide low barrier avenue kinetically challenging oxidative additions au(i providing access potentially reactive au(iii complexes	herein we report the mechanism of oxidative addition of cf3i to au(i ) , and remarkably fast caryl cf3 bond reductive elimination from au(iii ) cations . cf3i undergoes a fast , formal oxidative addition to r3paur ( r = cy , r = 3,5-f2-c6h4 , 4-f - c6h4 , c6h5 , 4-me - c6h4 , 4-meo - c6h4 , me ; r = ph , r = 4-f - c6h4 , 4-me - c6h4 ) . when r = aryl , complexes of the type r3pau(aryl)(cf3)i can be isolated and characterized . mechanistic studies suggest that near - ultraviolet light ( max = 313 nm ) photoinitiates a radical chain reaction by exciting cf3i . complexes supported by pph3 undergo reversible phosphine dissociation at 110 c to generate a three - coordinate intermediate that undergoes slow reductive elimination . these processes are quantitative and heavily favor caryl i reductive elimination over caryl cf3 reductive elimination . silver - mediated halide abstraction from all complexes of the type r3pau(aryl)(cf3)i results in quantitative formation of ar cf3 in less than 1 min at temperatures as low as 10 c .
despite technical advancement various imaging modalities still impossible differentiate benign malignant pancreatic lesions images tissue acquisition differentiate pancreatic lesions endoscopic ultrasound guided fine needle aspiration eus fna procedure choice high accuracy low complication rate pooled sensitivity specificity eus fna diagnosis etiology solid pancreatic mass 86.8% 95.8% respectively meta analysis.1 although eus fna shows high diagnostic accuracy patients suspected pancreatic carcinoma rate acquiring indeterminate cytologic findings still 10.9%.2 endosonographer face difficulties cytology result eus fna inconclusive malignancy highly suspicious clinical presentation although eus minimally invasive safe accurate technique tissue diagnosis sometimes endosonographers get nondiagnostic eus fna results obtaining specimen eus fna cytopathologist reads sample classifies inadequate benign reactive atypical suspicious and/or malignant problems eus fna inconclusive results diagnostic errors including false positive false negative the reasons problems stem various situations failed puncture successful puncture obtained inadequate sample material successful puncture obtained adequate sample material cytology negative malignancy there several options first place clinical observation follow serial imaging one study showed 30% patients negative nondiagnostic eus fna result finally able diagnosed pancreatic cancer later.3 situation visible predictors malignancy eus vascular invasion lymphadenopathy.3 pancreatic cancer clinically suspected careful short term follow eus imaging modalities risky next surgical exploration blind pancreatic resection chemoradiation therapy without definitive tissue diagnosis may option when endosonographers get negative nondiagnostic eus fna result pancreatic cancer highly suspicious clinically beneficial next step patient sought alternative diagnostic tools would chosen get tissue diagnosis bile duct brushing endoscopic retrograde cholangiopancreatography ercp computed tomography ct)-guided biopsy however ercp brushing associated postprocedural complications pancreatitis ct guided biopsy bears risk intraperitoneal spread one study compared alternative methods utilized tissue sampling pancreatic cancer suspicious.4 ercp brushing showed low sensitivity surgical biopsy showed high complication rate ct abdominal ultrasound guided percutaneous approach showed high rate failure compared eus fna considering options concerns and/or risks retrial eus fna also reasonable option if change one components eus fna anticipate different results repeated eus fna factors influence result eus fna related lesion location characteristics size location pancreatic head uncinate even difficult area.5 though change location lesion sometimes approach pancreatic head stomach rather duodenum get better result characteristics lesion also important factor background pancreatitis extensive necrosis mass difficult get good result eus fna.6 may try target different area lesion get better result accuracy eus fna increases size pancreatic mass increases.7 however one interesting study suggests repeated eus fna improve diagnostic yield even small pancreatic masses.8 evaluated role repeated eus fna small pancreatic mass previous indeterminate negative cytology january 2004 october 2006 47 eus fna done pancreatic mass less 3 cm size initial eus fna results 17 malignancies 21 benign nine indeterminate repeated eus fna nine indeterminate cases resulted six malignancies one benign two indeterminate again eus fna done two indeterminate cases one malignancy proved consequence initial diagnostic accuracy eus fna 83% increased 96% repeated eus fna regarding equipment ultrasound processor better resolution give us better view targeting lesion study comparing efficiency ultrasound processor eus fna there suggestion newly developed forward viewing echoendoscope may helpful puncture difficult lesions uncinate process head pancreas.9 articles eus fna needles issue clinical endoscopy eus fna technically demanding procedure steep learning curve.10 means result eus fna may operator dependent according guidelines credentialing granting privileges eus american society gastrointestinal endoscopy minimum 150 supervised cases recommended competency eus perform eus fna at least 25 supervised eus fna recommended.11 study showed rate positive yield eus fna increasing 20 30 40 eus fna procedures.12 looking learning curve 300 consecutive eus fna procedures study suggested even 45 eus fnas fellowship procedures needed gain proficiency efficiency eus fna these studies teach us yield eus fna depends experience endosonographer.13 well trained cytopathologist essential element successful eus fna procedure presence site pathologist endoscopy suite rapid site cytopathological examination helpful get adequate specimen hand interesting study revealed cytopathologists expertise could impact diagnostic accuracy eus fna result study local cytopathologists mailed eus fna slides difficult cases expert cytopathologists diagnostic sensitivity accuracy 72% 75% local cytopathologists respectively 89% 88% expert cystopathologists respectively.14 eus repeated similar clinical indication tertiary referral center significant clinical impact observed 63% patients.15 repeated eus center various indications also resulted change management plan 72% patients.16 results might expect repeated eus fna expert another center endosonographer different setting give successful result cases colonoscopy ercp maybe successfully performed previously failed procedure a study reported overall accuracy second eus fna 84%.6 twenty four repeat eus fna done study center second eus fna proved malignancy 46% cases eight 10 atypical suspicious cases initial eus fna confirmed malignancy surprisingly two 10 benign initial eus fna cases changed diagnosis malignancy two malignancy cases confirmed benign another researcher performed repeat eus fna 3 weeks later initial eus fna result indeterminate solid pancreatic lesion the result proved 78% 7/9 patients indeterminate cytology results malignancy.8 eus fna performed 62 cases repeated eus 82% patients 47/62 among inconclusive cytology previous eus fna 73% cases 45/62 prevented undergoing diagnostic work up.16 retrospective study evaluated repeated eus fna performed 15 cases including eight pancreatic mass seven unknown intra abdominal lymphadenopathy second eus fna proved malignancy 60% cases overall accuracy second eus fna 92.9%.17 mean study low diagnostic yield repeat eus fna twenty eight repeat eus fna done pancreatic cancer suspected prior eus fna results non diagnostic repeating eus fna reasonable choice repeated eus fna may impose substantial clinical impact low risk clinical practice repeated eus fna useful initial eus fna result suspected tumor nondiagnostic repeat eus fna considered especially predictors malignancy vascular invasion lymphadenopathy visible eus	for tissue diagnosis of suspected pancreatic cancer , endoscopic ultrasound - guided fine needle aspiration ( eus - fna ) is the procedure of choice with high safety and accuracy profiles . however , about 10% of cytologic findings of eus - fna are inconclusive . in that situation , careful observation , surgical exploration , or alternative diagnostic tools such as bile duct brushing with endoscopic retrograde cholangiopancreatography or computed tomography - guided biopsy can be considered . however , some concerns and/or risks of these options render repeat eus - fna a reasonable choice . repeated eus - fna may impose substantial clinical impact with low risk .
	this study examined the changes in cellular glucose uptake induced by 2,3,7,8 tetrachlorodibenzo - p - dioxin ( tcdd ) as measured by quantification of intracellular radioactivity in the nih 3t3 l1 preadipocyte cell line after a 30-minute incubation with the non - metabolizable radioactive analogue of glucose , 3-o - methyl - d-[1 - 3h ] glucose . treatment of differentiated nih 3t3 l1 cells with tcdd produced a time- and dose - dependent decrease in the cellular uptake of glucose . treatment of cells for 3 hr with 10(-8 ) m tcdd significantly reduced glucose uptake to about 10% of control values ( p < /= 0.05 ) . furthermore , cytochalasin b , a specific inhibitor of facilitative glucose transporter proteins totally abolished the portion of glucose transport activity that is sensitive to tcdd . the role of the ah receptor in tcdd - mediated reduction in glucose uptake was investigated . pretreatment of 3t3 l1 cells with the ah receptor blocker 4,7-phenanthroline antagonized the effect of tcdd on glucose uptake . structure - activity relationship studies with tcdd and two polychlorinated biphenyl ( pcb ) congeners revealed a rank order for their potency in the inhibition of glucose transport as follows : tcdd < < 3,3',4,4 ' tetrachlorobiphenyl < 2,2',5,5 ' tetrachlorobiphenyl ( tcb ) . such a rank order correlates both with previously determined biological activity of tcdd and the more active 3,3',4,4'- and less active 2,2',5,5'-tcb and with affinity for binding to the ah receptor . the thyroid hormone t4 , like tcdd , reduced glucose uptake and blocked the action of tcdd to further reduce glucose uptake . experimental evidence is consistent with a proposed mechanism for tcdd to reduce the titer of functional glucose transporter proteins through its interaction with the ah receptor.imagesp454-afigure 1.figure 2 .
technique known colony overlay procedure peptidases copp assay previously developed first test enumerate total vibrionaceae shellfish seawater well water 1 2 this assay recommended use monitoring molluscan shellfish potentially regulating harvest based levels total vibrionaceae this total vibrionaceae approach similar concept traditional sanitary surveys shellfish harvesting areas based total number fecal coliforms e. coli present either shellfish surrounding waters 3 4 original copp assay substrate l lysyl-7-amino-4-trifluoromethylcoumarin l lys afc is bound cellulose acetate membrane membrane overlaid 10 minutes onto overnight culture grown nonselective agar media a lysyl aminopeptidase present vibrionaceae family members tested date cleaves substrate produce fluorescent foci membrane viewed longwave uv present study extended overlay concept produce similar assays total fecal e. coli these assays based presence -glucuronidase gud activity found non o157:h7 e. coli results cleavage substrate 4-methyl--d glucuronide mug fluorescent 4-methylumbelliferone mug based fluorescence assays e. coli previously developed food water 612 mug based assays foods particularly molluscan shellfish often involve probable number mpn procedure labor intensive relatively costly requires three days results obtained consequently simpler rapid less expensive direct enumerative procedures needed monitor total fecal e. coli particularly perishable foods like shellfish study report simple membrane overlay methods separately enumerate total e. coli capable growing 37c fecal e. coli capable growing 44.5c total vibrionaceae capable growing 37c fourth multiplex method enumerate total e. coli total vibrionaceae simultaneously these methods applicable use monitoring presence organisms shellfish foods water environmental samples stock cultures consisted 37 strains non o157:h7 e. coli described table 1 22 enterobacteriaceae within genera citrobacter klebsiella pseudomonas salmonella shigella serratia yersinia table 2 human pathogenic vibrios consisted v. cholerae o1 v. vulnificus vv1003 previously described v. parahaemolyticus o3:k6 pandemic strain obtained e. fidelma boyd university delaware newark delaware eastern oysters crassostrea virginica obtained commercial source rhode island tidal river university delaware marine laboratory lewes delaware the oysters naturally contaminated low levels e. coli moderate levels vibrionaceae they collected principally warm summer months vibrionaceae present water column seawater also obtained university delaware marine laboratory summer the mpn procedure using mug ec broth tubes performed dilutions pure cultures seawater oyster homogenates according protocol published u.s the mug membrane overlay procedure developed specificity determined using e. coli serotypes enterobacteriaceae listed tables 1 2 the bacteria grown tryptic soy broth becton dickinson co. sparks maryland supplemented additional 0.5% nacl 1% total nacl streaked onto 100 mm plates tryptic soy agar becton dickinson co. containing total 1% nacl tsa n using flamed cooled metal triangle plates incubated overnight ~18 hours 37c culture incubation cellulose chromatography papers whatman international maidstone uk whatman 1 4 54 cellulose filter paper discs referred cellulose membranes ) were cut desired size petri dish colonies overlaid soaked 20 mm tris buffer ph 8.0 containing 50 mg l mug 10 seconds excess buffer allowed drip membranes 5 seconds membranes overlaid onto colonies growing surface tsa n plates unused substrate retained 4c future use shelf life several weeks membranes removed forceps placed empty petri dishes examined fluorescent foci using either hand held uv lamp wavelength 364 nm uv light box wavelength alternatively membranes could viewed hand held uv lamp still overlaying colonies the copp assay performed cellulose acetate membranes previously described 1 2 cellulose chromatography paper whatman international in essence substrate l lysyl-7-amino-4-trifluoromethylcoumarin l lys afc cat afc-008 mp biomedicals salon oh dissolved dimethylsulfoxide dmso 20 mm 2140 l dmso 25 mg l lys afc stock stored 20c needed a 250 substrate working solution prepared combining 25 l thawed substrate 2 ml 20 mm tris ph 9.0 substrate stock solution may refrozen thawed multiple times without appreciable deterioration substrate a cellulose acetate membrane plain cellulose membrane chromatography paper cut desired size placed working solution 1015 seconds the membrane lifted forceps allowed drip excess fluid 5 seconds overlaid onto overnight bacterial colonies grown 37c tsa n plates each membrane removed plate placed clean petri dish immediately viewed longwave 364 nm uv fluorescent foci counted alternatively foci could visualized hand held uv lamp membrane still covering colonies the appearance bright white pale blue fluorescence cellulose acetate membranes green fluorescence cellulose chromatography paper signifies presence lysyl aminopeptidase cleaves substrate positive controls consisted v. cholerae v. parahaemolyticus v. vulnificus propagated 37c the overlay enterobacteriaceae also performed 37c 10 minutes determine species contained lysyl aminopeptidase activity similar found vibrionaceae method simultaneously detect total vibrionaceae total e. coli evaluated using cellulose chromatography paper soaked 20 mm tris ph 8.0 containing 250 l lys afc 50 mg l mug oysters either 1 10 homogenates dilutions homogenates prepared 0.1% peptone buffer plates prepared using 100 l homogenate dilutions homogenates spread tsa n plates flamed cooled metal triangle after overnight incubation 37c membranes containing substrates overlaid onto culture plate vibrionaceae enumerated situ 10 minutes followed enumeration mug positive gud positive colonies additional 20 minutes 30 minutes total it anticipated total e. coli could easily distinguished total vibrionaceae based color fluorescent foci forty three principally food borne outbreak strains e. coli o157:h7 screened gud activity mpn mug assay mug overlay colonies grown tsa n incubated 37c 2 hours followed 44.5c overnight plates overlaid 30 minutes membranes viewed uv light box oysters seawater screened membrane overlay assay total e. coli total vibrionaceae multiplex assays spread plating 100 l 1 10 1 100 oyster homogenate prepared 0.1% peptone buffer 100 l undiluted seawater onto tsa n plates the plates allowed incubate either 37c total e. coli total vibrionaceae overlays 37c 2 hours followed 44.5c overnight e. coli overlays using cellulose membranes containing mug copp separately combined samples occasionally plated duplicate one plate incubated 37c multiplex assay total vibrionaceae total e. coli plate incubated 37c 2 hours 44.5c overnight fecal e. coli enumeration initial tests showed overnight colonies e. coli growing tsa n plates could overlaid cellulose membranes chromatography paper whatman 1 4 54 filter paper discs soaked mug produce strong blue fluorescent foci membranes corresponding site contact colony membrane comparable results obtained regardless type membrane used consequently selected chromatography paper perform mug overlays throughout study an evaluation substrate concentrations showed strong fluorescence intensity achieved membranes saturated 50 mg l mug membranes incubated 1560 minutes viewed fluorescent foci situ hand held uv lamp membrane could removed petri dish viewed hand held uv lamp placed uv light box viewing optimal results obtained 3060-minute overlay 30 minutes selected remainder study in contrast colonies screened total vibrionaceae copp assay saturated 250 l lys afc overlaid 10 minutes preclude weak enzyme activity present enterobacteriaceae non vibrionaceae producing false positive fluorescent foci figures 1(a)1(d show mug copp fluorescence cellulose membranes overlaying colonies three serotypes non o157 h7 e. coli top row panel three vibrionaceae bottom row panel edges foci distinct sharp somewhat fuzzy enzyme activity via diffusion enzymes within membranes examples representative mug fluorescence membranes shown total e. coli incubated 37c overnight overlaid 30 minutes mug containing membranes figure 1(a fecal e. coli grown 37c 2 hours incubated overnight 44.5c overlaid 30 minutes mug membrane figure 1(b these vibrios strongly copp positive overnight incubation 37c overlay 10 minutes l lys afc producing green fluorescence cellulose membranes depicted figure 1(c very weak copp fluorescence occasionally observed e. coli arrow figure 1(c foci counted vibrionaceae weak signal this fluorescence may minimized enumerating foci immediately 10-minute overlay results multiplex assay cultures incubated 37c overnight followed 30-minute overlay mug l lys afc combined shown figure 1(d blue fluorescence e. coli top row green fluorescence vibrios bottom row the arrow figure 1(d indicates blockage uv light opaque colony v. parahaemolyticus inadvertently transferred membrane blocked passage uv light light box membrane such transfer opaque colonies membranes occasionally occurs appears function stickiness colony cases foci may readily observed holding hand held uv lamp opposite side membrane side without opaque material the mug overlay mpn mug assays compared 37 strains e. coli non o157:h7 twenty four 65% 37 strains positive mug overlay 23 62% positive mpn mug assay however four colonies mug negative overlay positive weakly positive mpn mug method specifically strains o14:nm o42:h2 o103:h2 o111:nm table 1 likewise five isolates mug negative according mpn mug method positive overlay method specifically one o4:nm o26:h11 strains o78:h11 o91:h o91:h14 table 1 mpn mug often gave weak fluorescence signal listed table 1 repeat assays isolates showed variability perceived fluorescence intensities cultured mpn mug media no variability seen overlays consistently produced bright blue foci copp overlays cultures performed 10 minutes readings taken immediately overlay weakly positive results obtained four isolates table 1 differentiation shigella spp possible using individual mug copp assays one sh boydii mug copp positive sh flexneri mug copp negative sh dysenteriae mug negative copp positive sh sonnei mug positive copp negative cultures propagated 37c table 2 shigella boydii sh dysenteriae y. enterocolitica copp positive indicating enzyme analogous lysyl aminopeptidase found vibrionaceae family members this first time detected strong copp positive colonies associated bacteria unrelated vibrionaceae forty three e. coli o157:h7 strains tested triplicate mug negative overlay mpn mug assays data shown it well known o157:h7 strains lack gud activity therefore mug negative exceptions membranes simultaneously soaked mug l lys afc used multiplex format detect total e. coli total vibrionaceae plates grown overnight 37c figures 1(e 1(f multiplex assay oyster homogenates green dark blue foci obtained vibrionaceae total e. coli respectively incubated 37c figures 1(e 1(f accurate enumeration fluorescent foci must counted stages membranes incubated 10 minutes plates viewed hand held uv green fluorescent foci representing vibrionaceae colonies counted immediately avoid low levels enzymes non vibrionaceae leading false positive results the plate incubated additional 20 minutes longer 37c blue fluorescence development indicative colonies total e. coli illustration purposes only membranes shown figures 1(e 1(f illuminated uv light box photographed 30-minute overlay sufficient give bright blue fluorescence gud positive colonies longer recommended accurate vibrionaceae enumeration simultaneous detection practical countable levels total e. coli total vibrionaceae present dilution plate although figures 1(e 1(f demonstrate ease total e. coli colonies may identified even crowded plates multiplex assays appropriate cultures incubated 44.5c since many vibrionaceae may grow elevated temperatures one exception v. cholerae o1 produced typical copp fluorescence grown 44.5c if total vibrionaceae total fecal e. coli enumeration desired sample duplicate plating allows one plate incubated 37c total vibrionaceae total e. coli plate incubated 37c 2 hours 44.5c overnight fecal e. coli enumeration the 2 hours incubation 37c constitutes resuscitation step oysters may contain stressed bacteria need resuscitated higher e. coli counts obtained assays resuscitation step employed safety standpoint the mug assay offers additional protection pathogens detecting strains salmonella shigella mug positive could grow 44.5c specifically s. montevideo sh seawater produced bacterial colonies gave fluorescence signal comparable found oyster homogenates total fecal e. coli total vibrionaceae however levels bacteria generally 10- 100-fold less filter feeding molluscan shellfish bioconcentrate bacteria seawater within edible tissues by definition fecal coliforms including fecal e. coli gram negative bacteria ferment lactose production acid gas 44.545.5c such organisms indicative human gut bacteria used indicators possible presence human fecal pathogens foods water the mpn procedure capitalizes use lactose containing media collection gas growth 44.545.5c positive isolates meet classical definition fecal coliforms mpn mug procedures use mug indicator presence e. coli since e. coli primary producers gud elevated temperatures therefore positive mpn results presence mug considered confirmatory presence e. coli current mpn assays total fecal coliforms e. coli tedious costly time consuming the incorporation mug ec broth mpn detection e. coli hastened analysis previous mpn methods still complex produces false positives compromise results according u.s food drug administration bacteriological analytical manual mpn mug assay requires use new borosilicate glass tubes well new gas collection durham tubes tubes must prescreened fluorescence tubes exhibit autofluorescence hands autofluorescence problem may contributed weakly positive mpn mug results e. coli o14:nm o42:h2 o103:h2 o111:nm consistently negative mug overlay procedure table 1 in united states oysters growing waters monitored fecal coliforms e. coli using 5-tube mpn approach means 1530 new tubes may required single analysis depending number dilutions required number presumptive positive tubes need transferred lauryl sulfate tryptose broth ec broth thus making procedure costly impractical routine use since one major obstacles monitoring environmental contamination food safety lack practical cost effective assays goal produce simple rapid inexpensive procedures enhance monitoring efforts this paper provides new tools monitor total fecal e. coli total vibrionaceae levels study developed simple plate cultivation mug membrane overlay technique detect bacteria likely fecal e. coli based gud production ability grow 44.5c for overlay procedure total e. coli recognize occasional pathogens e. coli may gud positive like salmonella shigella strains table 2 streptococci however detection occasional pathogens simply enhances benefits using test potential regulatory tool endogenous levels gud high fish shellfish 8 17 problem plate based membrane overlays since overnight incubation plates either 37c 44.5c degrades endogenous tissue specific enzymes well plate overlaid membrane containing fluorogenic substrate consequently many assays performed oysters saw background fluorescence even though oyster tissues known contain gud in addition complexities performing traditional mpn based assays analyses vibrionaceae seawater shellfish usually complex generally limited picking isolates plate complex biochemical molecular biological testing specific pathogenic strains monitoring shellfish seawater pathogenic vibrios failed stop outbreaks v. parahaemolyticus routine monitoring programs v. vulnificus nonexistent spite fact v. vulnificus oysters causes occasional illness death acceptable baseline threshold levels vibrionaceae total fecal e. coli determined implementation regulations harvesting distribution shellfish threshold levels currently exist coliforms harvesting area waters shellfish meats 3 4 based mpn approaches no methods established date regulation shellfish harvesting distribution based total vibrionaceae levels e. coli levels using simple overlay methods screening 37 strains non o157:h7 e. coli associated major foodborne outbreaks illness 24 65% positive mug overlay 23 62% positive mpn mug assay in contrast studies showed recovery gud 95.5% 96.5% 91% isolates examined potential reasons differences gud distribution among isolates suggested chang et al conclusive studies explaining variability in addition subset non o157:h7 isolates mug negative 43 isolates e. coli o157:h7 derived wide variety food borne outbreaks mug negative failure detect o157:h7 strains limitation mpn mug mug overlay methods this finding lessen importance mug membrane overlay procedure since o157:h7 strains constitute minority e. coli environmental isolates mug based cultural assays like u.s food drug administration recommended mpn mug assay e. coli also fail detect o157:h7 serotype escherichia coli o157:h7 strains contain enzymatically active gud although strains contain gusa uida gene encodes gud two regulatory regions there appear regulatory repression restrict gud formation since antibody gud detects enzyme however gud inactive form lacking hydrolytic activity the cause inactive protein presence guanosine guanosine insertion causing frameshift resulting introduction premature termination codon gusa gene strains e. coli o157:h7 tested serotypes this mutation accounts presence incomplete protein lacking gud activity therefore mug based assays appropriate detection o157:h7 isolates advantages overlays far simpler less expensive directly quantitative unlike mpns give statistical probabilities counts culturing bacteria nonselective tsa n also advantage selective media like mcconkey agar without mug since selective media often inhibitory environmentally stressed bacteria with multiplex overlays consolidated assays simplify monitoring order drive costs screening promote frequent testing total e. coli vibrionaceae mug overlay copp assays relatively fast results derived within 24 hours mpn assays require 3 days completion 2448 hours incubation lst broth followed 24 hours ec broth additional time e. coli confirmation via biochemical testing desired together mug copp overlay methods provide new options quantifying total fecal e. coli vibrionaceae seawater shellfish food environmental matrices unlike original copp assay used cellulose acetate membranes could prepared advance dried storage soaked buffer overlay 1 2 cellulose membranes used copp mug assays paper prepared advance dried this copp substrate covalently bonds cellulose acetate membranes plain cellulose membranes mug bind either membrane although used cellulose acetate plain cellulose membranes screen stock cultures lysyl aminopeptidase activity used cellulose membranes exclusively multiplex assay total coliforms total vibrionaceae this copp assays cellulose acetate membranes produced bright light blue fluorescence mug produced stronger blue fluorescence thus differentiation two colors difficult times it became clear green blue fluorescence obtained plain cellulose membranes easier discriminate blue light blue fluorescence cellulose acetate membranes multiplex overlays simultaneous detection total e. coli total vibrionaceae may performed groups bacteria relatively proportion enumerated dilution plate methods monitor molluscan shellfish harvesting distribution much like methods foods water environmental samples often outdated touch today needs it necessary shift analytical regulatory paradigms simpler practical cost effective measures monitor relative levels contamination given development simple membrane overlay assays propose establishment membrane overlay based monitoring total fecal e. coli total vibrionaceae for routine monitoring purposes may time shift search specific vibrio pathogens enumeration total vibrionaceae environmental factors responsible increases human pathogenic vibrios within shellfish growing waters likely cause increase levels many vibrionaceae family members including pathogenic strains therefore copp assay could prove useful regulating shellfish harvesting based total vibrionaceae counts european standards shellfish harvesting coliform levels currently used regulate shellfish harvesting distribution 3 4 aquaculture setting simple copp assay may serve index fish health disease spikes vibrionaceae levels normal customary would suggest need refined assays specific pathogens corrective actions implemented within aquaculture hatchery setting membrane overlays simple practical routine monitoring could enhance food safety allowing increased numbers samples tested reduced cost providing simple alternative procedures rigorous routine use	three assays were developed to enumerate total and fecal escherichia coli and total vibrionaceae in shellfish , seawater , and other foods and environmental samples . assays involve membrane overlays of overnight colonies on nonselective agar plates to detect -glucuronidase and lysyl aminopeptidase activities for e. coli and vibrionaceae , respectively . cellulose membranes containing the substrates 4-methylumbeferyl--d - glucuronide ( mug ) produced a bright blue fluorescence when overlaid onto e. coli , while l - lysyl-7-amino-4-trifluoromethylcoumarin produced green fluorescent foci when overlaid onto vibrionaceae family members . a multiplex assay was also developed for simultaneously enumerating total e. coli and total vibrionaceae in oysters and seawater . overall , 65% of overlaid e. coli ( non - o157:h7 ) were mug - positive , compared with 62% as determined by the most - probable - number - mug assay . the overlays are rapid , simple , and cost effective for quantification purposes . this research provides practical alternatives for monitoring bacterial indicators and potential pathogens in complex samples , including molluscan shellfish .
73-year old female patient 150 cm tall weighing 50 kg visited hospital presenting complaints lower back pain radiating pain right lower extremity at first mild lower back pain occurred time time severe pain visual analogue score vas 8 higher started occur three months prior visit the patient particular medical history except osteoporosis diagnosed late fifties she felt pain body collapsing sinking accompanied pulling pain hip groin the pain became severe standing moving relieved lying rest the physical examination showed tenderness first lumbar l1 spinous process region the plain radiograph showed severe osteoporosis vertebral bodies severe compression fracture l1 vertebral body anterior compression rate 70% higher intravertebral vacuum cleft vertebral body fig 1 magnetic resonance imaging showed low signal area l1 t1 weighted image high signal t2 weighted image fig 2 despite conservative treatment four weeks including continuous epidural pain control the patient pain decrease rejecting surgical procedures spinal fusion although case general indication percutaneous vertebroplasty kyphoplasty due severe collapse vertebral body decided transpedicular kyphoplasty using method block cement outflow slowly injecting highly viscous bone cement procedure we patient take prone position supporting abdomen pillow order reduce abdominal lordosis check patient state procedure monitored blood pressure heart rate oxygen saturation supplement oxygen nasal cannula for sake sedation analgesia procedure needed injected fentanyl intravenously total 100 g using c arm image verified pedicle l1 determined working cannula implantation position angle local infiltration anesthesia performed 1% lidocaine expected cannula implantation pathway fluoroscopic c arm guidance implanted cannula fractured vertebral body vertebral pedicle moment left cannula inserted vertebral body air flowed vertebral body popping sound level vertebral body recovered spontaneously fig the cannula also inserted right side balloons inflated pressure 50 100 psi recover level vertebral body then 4.5 ml bone cement slowly injected side cannulas l1 vertebral body fig 4 injecting bone cement cement leakage vertebral body after procedure vas patient 2 indicating preoperative pain almost disappeared currently patient follow visits received particular treatments except medication osteoporosis kummell disease delayed disorder characterized avascular necrosis collapse vertebral body the avascular necrosis accumulates gas liquid inside vertebral body characteristically found intravertebral vacuum cleft computed tomography plain radiograph intravertebral vacuum cleft space formed necrotic bones fusion fractured bones difficult pseudoarthrosis could moved patient posture respiration forms previous reports literature mainly advocated conservative treatments bed rest wearing aids treatment kummell disease however effect conservative treatment often limited vertebral body necrosis continuously progresses natural healing hardly occurs disease case neurological damage however spinal fusion general anesthesia also quite limited patients old accompanied severe osteoporosis bone cement injected treatments appropriately agglutinates fractures resolves instability due pseudoarthrosis filling vacuum cleft particular kyphoplasty considered safe effective procedure percutaneous vertebroplasty treating kummell disease recover vertebral body reduce cement outflow toward space outside vertebral body although known absolute contraindication procedures treatment vertebral compression fractures however severely collapsed vertebral body vertebra planar generally considered contraindication procedures due difficulties procedure risk cement outflow case performed kyphoplasty without alternatives although patient severe osteonecrotic vertebral compression fracture vertebral compression rate higher 70% difficulties including difficulties procedure well risk cement outflow anticipated unexpectedly experienced procedure spontaneous recovery vertebral body level air suddenly flowed vacuum cleft vertebral body this rare even us similar cases found literature the possibility air embolism concerned us since air suddenly flowed vacuum cleft vertebral body however complications including air embolism occurred due flow air vertebral body recovery process vertebral body we assumed spontaneous recovery vertebral body level took place vacuum cleft filled air immediately cannula inserted negative pressure existed vacuum cleft intravertebral pseudoarthrosis formed although risk bone cement outflow since vertebral body could damaged due sudden recovery kyphoplasty successfully performed slowly meticulously injecting bone cement consistency viscous normal bone cement the patient achieved drastic analgesia recovery mobility procedure conclusion a kyphoplasty worthy considering good treatment modality may provide analgesia recovery mobility without complications patients kummell disease accompanied severe vertebral body compression fracture cases vacuum cleft negative pressure exists formed spontaneous recovery vertebral body level could occur	kummell 's disease is a spinal disorder characterized by delayed post - traumatic collapse of a vertebral body with avascular necrosis . although definitive treatment for kummell 's disease has not been established , it has been reported that percutaneous vertebroplasty or kyphoplasty has shown good results . however , these procedures are not recommended for severely collapsed vertebral bodies because of the risk of cement leakage or technical difficulties . authors report a rare case of spontaneous reduction in vertebral height by the insertion of a working cannula into the vertebral body in kummell 's disease .
inflammation mammary gland mastitis caused invading pathogens common among lactating dairy cows leads considerable economic loss reduced milk yield impaired milk quality increased veterinary costs globally mastitis one costly bovine diseases dairy industry estimated cost approximately 1.8 billion annually united states the differences types mastitis based invading pathogen(s resolution infection clinical mastitis stronger acute subclinical mastitis caused mainly gram negative bacteria escherichia coli the subclinical mastitis elicits milder inflammation persists life span infected cows gram positive bacteria like staphylococcus aureus involved subclinical mastitis infection endotoxin lipopolysaccharide lps lipoteichoic acid lta considered main virulence factor e. coli s. aureus respectively 3 4 moreover proinflammatory cytokine tumor necrosis factor- tnf- elicits local systemic inflammatory reactions triggers inflammatory cascade acute phase response inflammation participated acute phase coliform mastitis 5 6 suppress proliferation invading pathogenic mastitis causing bacteria modern dairy practice employs several strategies including teat disinfection antibiotic therapy culling persistently infected cows despite the great effectiveness antibiotics use coming increasing public scrutiny due possible development resistant pathogens like methicillin resistant s. aureus mrsa food safety concerns like antibiotic residues milk considering risks associated antibiotic therapies bovine mastitis development alternative treatment strategies management clinical subclinical mastitis propolis resinous substance collected honeybees apis mellifera l. various polyphenol rich plants it used widely folk medicine since ancient times attracted much attention recent years various biological properties recent studies determined propolis potent anti inflammatory effects macrophages boosted cellular antioxidant defence systems 11 12 previous literature shown propolis could inhibit growth several different bacterial strains known cause mastitis well antibiotic resistant s. aureus strains 1315 nevertheless little known effects propolis mastitis responses bovine mammary epithelial cells bmecs present study studied impact effect propolis bovine mammary epithelial cells challenged heat killed mastitis causing bacterial cells well selected agents also associated tissue response mastitis lps escherichia coli 0111:b4 lta staphylococcus aureus caffeic acid caffeic acid phenethyl ester cape chrysin ferulic acid galangin kaempferol pinocembrin quercetin purchased sigma st louis mo usa high performance liquid chromatography- hplc- grade methanol obtained merck darmstadt germany recombinant human tnf- purchased peprotech rocky hill nj usa culture plates obtained coring life science lowell ca usa the pi rnase staining buffer kit fitc conjugated annexin v binding buffer obtained bd biosciences san diego ca usa other chemicals analytical grade purchased sangon biotechnology shanghai china chinese propolis cp obtained colonies honeybees a. mellifera l. shandong province summer 2010 main plant origin poplar populus spp briefly raw propolis 100 g extracted 95% v v ethanol 1 l sonicated 40c 3 h. supernatant collected filtered remove residues raw propolis extracted three times supernatants collected evaporated rotary evaporator reduced pressure 50c evaporate ethanol dried ppe stored 20c use vitro studies cp redissolved directly ethanol concentration 20 mg ml sterilized using 0.22 syringe filter pall port washington ny usa the final concentration ethanol cell culture less 0.5% v v bovine mec line mac cells generously provided professor fengqi zhao university vermont burlington usa cultured high glucose dulbecco modified eagle medium dmem hyclone fremont ca usa supplemented 100 u ml penicillin 100 g ml streptomycin 10% v v heat inactivated fetal bovine serum fbs gibco carlsbad ca usa 37c 5% co2 humidified incubator we challenged cells heat inactivated bacteria particles mastitis causing pathogens e. coli strain 1303 s. aureus newbould 305 details regarding culture e. coli s. aureus pathogens usages heat inactivated bacteria particles challenge bmecs described previously e. coli s. aureus strains grown 37c lysogeny broth lb medium logarithmic phase culture growth heat inactivation performed 80c water bath 1 h kill live cells verified control plating subsequently cells spun washed twice pbs later resuspended dmem density 5 10 cells ml aliquots stored frozen 20c used cell viability assay performed using cck-8 kit dojido kumamoto japan according manufacture instruction briefly 10 10/ml mac cells seeded 96-well culture plates after 24 h incubation cells well specific treatment incubated 10 l cck-8 37c 2 h measuring od 450 nm microplate reader spectramax m5 molecular devices sunnvale ca usa cells stained annexin v fitc pi evaluated apoptosis flow cytometry according manufacturer protocol bd biosciences san diego ca usa briefly 10 cells washed twice pbs stained 5 l annexin v 5 l pi 50 g ml washing buffer kits 15 min room temperature dark apoptotic cells counted lower right quadrant corresponding early apoptotic cells annexin v positive upper right quadrant corresponded late apoptotic cells annexin v- pi positive total rna extracted rna pure kit aidlab biotechnologies co. ltd reverse transcription done using primescript rt reagent kit takara dalian china 1 g total rna quantitative real time pcr carried sybr premix ex taq takara following manufacturer instructions 1 10 diluted cdna template using standard two step reaction primers target genes covered introns designed primer5 software premier biosoft international palo alto ca listed table 1 after overnight incubation 30 ng firefly luciferase reporter plasmid pgl4.2-nf-b luc pgl4.37-luc2p hygro vector promega madison wi usa transfected drive transcription nf-b respectively using lipofectamine 2000 invitrogen carlsbad ca usa sea pansy luciferase reporter plasmid prl tk 5 ng transfected normalize transfection efficiency the pcdna3.1 empty vector used compensate total expression plasmids 500 ng well luciferase activities measured 24 h specific treatments using dual glo luciferase assay system promega data expressed means sd least three independently performed experiments one way analysis variance anova followed student newman keuls snk multiple comparison test used determine statistical significance multiple comparisons student test used comparisons two groups we analyzed major polyphenolic compounds chinese propolis using previously developed hplc method the major polyphenolic components chrysin pinocembrin pinobanksin galangin cape as shown figure 1(a stimuli caused cell viability decreases mac cells lps heat killed e. coli s. aureus tnf- lta stimulation lead significant cell viability losses 15% 52% p 0.0009 0.0041 0.001 lps e. coli s. aureus resp heat killed bacterial strains caused serious cell viability losses lps test effects cp protecting cell viability decreases caused mastitis pathogens various concentrations cp also shown figure 1(a tested concentrations cp 5 10 15 g ml pretreatment safe mac cells cp pretreatment 10 15 g ml significantly mitigated cell viability loss lps p 0.05 heat killed e. coli p 0.05 s. aureus induced cell viability losses inhibited 15 g ml cp pretreatment p 0.05 cell apoptosis analysis flow cytometry showed 10 particles ml heat killed mastitis strains caused substantially increased percentage apoptotic cells none stimuli tnf- lps lta cause changes apoptotic cell numbers figure 1(b nevertheless pretreatment 15 g ml cp mac cells showed significantly lower number apoptotic cells p 0.05 compared heat killed e. coli- s. aureus treated cells consistent result obtained cck-8 cell viability assay as shown figure 2 mastitis pathogens except lta lead significant increases il-6 il-8 p 0.05 lta heat killed s. aureus stimulation also failed induce expression tnf- compared uninfected cells p 0.05 contrary heat killed e. cp pretreated mac cells much slighter changes il-6 tnf- mrna compared corresponding stimuli controls surprisingly cp lead ~8-fold changes il-8 significantly higher tnf- lps heat killed e. coli stimuli p 0.05 shown figure 3(c gclm expression affected several mastitis pathogens tnf- two heat killed mastitis strain particles we noticed cp treatment mac cells leads substantial increases ho-1 txnrd-1 gclm expressions p 0.05 ho-1 expressions elevated cp pretreated mac cells undergoing mastitis challenges figure 3(a upregulated txnrd-1 unchanged cp treated mac cells figure 3(b p 0.05 regardless different mastitis pathogens furthermore cp treatment induce expression gclm substantially increased mastitis pathogen challenged cells along cp these results indicated cp could elicit antioxidant defense system bmecs cells undergoing mastitis challenges as shown figure 4 increased expressions proinflammatory cytokines il-6 figure 4(a tnf- figure 4(c suppressed cp time- dose dependent manner as another important chemokine il-8 expression significantly driven tnf- immediately peaked 3 h tnf stimulus figure 4(b cp treatment strongly promoted il-8 expression reached peak 9 h tnf stimulus we also found tnf- limited effects antioxidant gene expressions ho-1 txrnd gclm figures 4(d)4(f determine effects cp well purified compounds nf-b transcriptional activity luciferase reporter assays applied hek-293 cells shown figure 5 nf-b activity significantly decreased approximately 70% p 0.001 the luciferase activity derived promoter consistently increased approximately 4.7-fold treating 20 g ml cp figure 5(b p 0.001 moreover significant decreases nf-b activity found cells treated cape 5 45% p 0.001 quercetin 50 73% p 0.001 caffeic acid 50 12% p 0.05 ferulic acid 50 11% p 0.05 figure 5(a parallel luciferase activity derived promoter consistently increased treatment cape 5 2.5-fold p 0.001 quercetin 50 5.1-fold p 0.01 kaempferol 50 3.6-fold p 0.001 pinocembrin 50 2.9-fold p 0.01 regardless increased pressures cutting antibiotic usage husbandry european union us mastitis treatment continued initial usage antibiotics mainly chronically occurring subclinical mastitis the increasing scientific data benefit natural products encourages us explore novel nonantibiotic agents mastitis therapies study potential utilization chinese propolis anti inflammatory reagent immune modulator bovine mastitis examined bmecs previous studies demonstrated propolis great antimicrobial properties bacterial fungi protozoan even yeast pathogens despite chemical variations propolis different geographic origins plant sources antibacterial activity propolis always exists accordance published literature chinese propolis extracts gram positive s. aureus cells appear bactericidal show limited activity gram negative e. coli bacteria based literature applied 10 particles ml heat inactivated bacteria bmecs approximately 30 particles challenged per host cell 22 23 this approach represented reliable robust stimulus model considering 10 10 cfu bacteria particles per ml peak values milk produced cows mastitis infection also confirmed propolis bactericidal effects potent controlling mastitis causing s. aureus strains frequent difficult eradicate conventional antibiotic therapies it known acute coliform mastitis caused endotoxin producing acute coliform bacteria specifically e.g. e. coli enterobacter klebsiella spp characterized rapid intense increase somatic cell count scc subclinical mastitis caused s. aureus characterized moderate delayed scc increase leads chronic circumstances life long infection mammary tissue damages induced mastitis pathogens also shown linked increased scc mainly induced either apoptotic necrotic mammary cells we explored compared effects major different various mastitis pathogens bmecs cell viability cell apoptotic features we found tnf- lta stimulation cause significant losses cell viability cell apoptosis bmecs coinciding vitro studies using bovine mammary cells 1 5 meanwhile previous findings proapoptotic effects heat killed e. coli s. aureus inhibited cp pretreatment suggesting cp modulating effects cellular apoptosis cascade blocking activation caspases 1 26 we noticed e. coli cell wall component lps decreased cell viability induce cell apoptosis suggesting influences bacterial cell wall components bmecs may different mastitis bacteria strains moreover internalization process bacteria pathogens cells differs among bacteria strains different signal transduction mechanisms requiring interaction cp cell wall components well host cells need clarified bovine mastitis initiated entry bacteria teat canal shortly entry invading pathogen resident leukocytes together epithelial cells initiate inflammatory response necessary eliminate invading bacteria different mediators inflammation especially inflammatory cytokines expressed stage participate innate immune defense respond earliest stages infection mastitis pathogen stimulus exposure il-6 tnf- two predominant proinflammatory cytokines acute phase responses mastitis heat inactivated e. coli challenged bmecs significant increases il-6 tnf- gene expression observed figure 2 finding consistent previous study using different mastitis strain e. coli compared lps tnf- heat inactivated e. coli elicited stronger inductive effects inflammatory cytokines expressions suggesting virulence factors e. coli like lipoproteins flagellum may involved innate immune defense bovine epithelium cells 23 28 in contrast e. coli challenged models lower levels inflammatory response found s. aureus compared e. coli found previous studies studies increases concentrations tnf- il-1 il-8 milk found intramammary challenge s. aureus experiments notice significant changes inflammatory cytokine genes following s. aureus lta stimulation previous reports suggested s. aureus mastitis characterized moderate delayed inflammatory responses limited cytokine responses 22 25 expanded time course studies cp effects s. aureus lta stimulation need conducted propolis used historically folk medicine since ancient ages times since safely used substitute medicine supplement improve human health modern days although effective components propolis vary significantly according mother plant honeybees collect bioactivities propolis always present our previous studies confirmed anti inflammatory effects chinese propolis poplar type protecting murine macrophages lps challenges controlling proinflammatory cytokine releases lps induced mice endotoxemia similar previously published results proinflammatory cytokine expressions il-6 tnf- inhibited cp treatment following coliform mastitis pathogen challenges heat inactivated e. coli well endotoxin besides comprehensive tnf- stimulation model found cp effectively inhibits expression two genes time- dose dependent manner previous studies using lps challenged murine macrophages models the inhibition nf-b activation cp may source anti inflammatory effects we knew polyphenolic compounds among prominent components propolis considered responsible properties parallel previous studies cape quercetin caffeic it noted study expression il-8 also known cxcl8 increased cp treated cells several different stimulus models various animal models inflammation demonstrated il-8 principal chemotactic factor directing neutrophil recruitment activation inflammatory focus expression il-8 known controlled multiple transcriptional factors activator protein ap -1 nf-b nf-b repressing factor nrf involved coactivator cbp/300 complexes it also shown pivotal importance c ebp activate il-8 expression mecs independent nf-b activation therefore study found nf-b transcriptional activity inhibited cp bioactive compounds assumed transcriptional factors like c ebp possibly activated cp may contribute enhancement il-8 expression mastitis pathogens challenged mec it well known multiple antioxidant genes may induced diverse plant derived natural products these antioxidant genes ho-1 txnrd1 gclm sod nqo-1 encode several detoxifying phase ii enzymes endogenous antioxidants provide protections external stresses including oxidative stress inflammation in particular nrf2 shown involved inductions phase ii detoxifying enzymes antioxidants natural polyphenols bmecs suffered oxidative stress ho-1 well known major antioxidant enzyme plays important role antioxidant defense inflammatory stresses different cell types macrophages keratinocytes epithelial cells 38 39 thioredoxin reductase trxr catalyzes reduction active site disulfide thioredoxin trx nadph dependent homodimeric oxidoreductase as trxr antioxidant enzyme scavenge ros cp induced trxr1 expression may indicate activation cellular defense systems tnf mastitis pathogen challenges our recent study found endogenous antioxidant defenses systems could activated chinese propolis murine macrophages parallel study these increased antioxidant gene expressions keeping cp inductive effects nrf2-are transcription activity furthermore several specific active polyphenolic compounds propolis shown activate nrf2-are signaling including cape kaempferol quercetin pinocembrin our studies demonstrated chinese propolis strong protective effects various mastitis pathogen insults bmecs apart cp bactericidal effects clearly prevented cell viability losses apoptosis induced lps heat inactivated mastitis strains e. coli s. aureus bmecs these effects partly achieved modulating expression inflammatory cytokine genes boosting antioxidant defense genes the possible mechanisms cp bovine mastitis may attributed abundant polyphenolic components mainly cape quercetin strongly inhibited nf-b transcription activity increased transcriptional activity nrf2-are pathway field studies needed confirm propolis may developed nonantibiotic therapy strategy control cow mastitis	chinese propolis ( cp ) , an important hive product , can alleviate inflammatory responses . however , little is known regarding the potential of propolis treatment for mastitis control . to investigate the anti - inflammatory effects of cp on bovine mammary epithelial cells ( mac - t ) , we used a range of pathogens to induce cellular inflammatory damage . cell viability was determined and expressions of inflammatory / antioxidant genes were measured . using a cell - based reporter assay system , we evaluated cp and its primary constituents on the nf-b and nrf2-are transcription activation . mac - t cells treated with bacterial endotoxin ( lipopolysaccharide , lps ) , heat - inactivated escherichia coli , and staphylococcus aureus exhibited significant decreases in cell viability while tnf- and lipoteichoic acid ( lta ) did not . pretreatment with cp prevented losses in cell viability associated with the addition of killed bacteria or bacterial endotoxins . there were also corresponding decreases in expressions of proinflammatory il-6 and tnf- mrna . compared with the mastitis challenged cells , enhanced expressions of antioxidant genes ho-1 , txnrd-1 , and gclm were observed in cp - treated cells . cp and its polyphenolic active components ( primarily caffeic acid phenethyl ester and quercetin ) had strong inhibitive effects against nf-b activation and increased the transcriptional activity of nrf2-are . these findings suggest that propolis may be valuable in the control of bovine mastitis .
exercise tolerance generally decreases patients hemodialysis hd diminished musculoskeletal muscle strength muscle atrophy reduced muscle blood flow distribution decline cardiopulmonary function severely reduced activities daily living previous studies found low level physical activity pa affects physical function psychological effects influence prognosis survival1,2,3,4 recently exercise intervention high levels pa recommended patients hd studies found effective improving exercise tolerance i.e. increased maximum oxygen uptake anaerobic threshold pulmonary function i.e. lower ventilatory volume given submaximal load intensity cardiac function i.e. lower heart rate given submaximal load intensity coronary risk factors e.g. lower systolic blood pressure higher high density lipoprotein cholesterol level lower neutral fat level survival prognosis preventing progression coronary artery stenotic lesions1 5,6,7,8,9,10,11 although high level physical exercise exerts wide range beneficial effects far difficult improve low level pa patients hd patients low levels pa tend elderly women possess factors strongly correlated diabetes atherosclerosis9 particularly helping patients maintain high level pa issue given level physical function requires approach takes activity patterns psychological factors environmental adjustments account recent years many elderly patients 60 years old started undergo dialysis treatment 60 years old undergoing dialysis treatment addition long time since young age number elderly patients hd increases important maintain appropriate pa protect decreases physical function activities daily living function caused disuse daily life however japan rehabilitation targeted patients dialysis medical treatment many patients dialysis readily participate exercise classes fitness clubs communities dialysis treatment consequently miss opportunity exercise receive instruction as lack good exercise environment elderly patients hd large amount motivation required engage patients pa moreover elderly patients hd tend low participation social activity mostly stay indoors reduces physical levels pa in elderly patients hd amount intensity pa important many previous studies however focused solely amount pa terms number steps taken patients hd per day addressed level everyday activities patients hd engaged attitudes toward exercise state psychological preparedness assessing activity patterns patients hd focus pa levels determining attitudes toward exercise may enable establishment support methods best suited raising levels activity current study aimed identify characteristics elderly patients hd attitudes toward exercise ascertain everyday activity levels using pa monitor the protocol research project conformed provisions declaration helsinki revised tokyo 2004 a researcher described research purposes methods risks benefits participants then consent obtained research study questionnaire collect personal information administered subjects subjects recruited amongst outpatients visited two institutions japan hospital clinic specialize hd treatment the inclusion criteria age 60 years 4 h hd 3 times wk renal disease hd 12 wk measure pa subjects wore accelerometer kenz lifecorder ex 4s version measurement interval evaluate amount pa performed 1 wk number steps level exercise calculated they obligated wear device times bath the imported values exercise level obtained accelerometer included periods activity recorded periods treated periods inactivity the levels activity follows pa intensity 1 sedentary behavior sb 13 light intensity activity lpa 45 moderate intensity activity mpa 69 vigorous intensity activity vpa survey attitudes toward exercise covered subjects psychological state respect exercise based transtheoretical model10 five stage model comprising precontemplation interest contemplation interested yet taking action preparation engaging exercise irregular basis practice engaged continued regular exercise 6 months maintenance engaged regular exercise least 6 months acquired habit exercising items related exercise habits whether engaged habitual exercise type frequency period continued motivation exercise assessed four point scale agree somewhat agree somewhat disagree strongly disagree items concerning awareness need effects exercise negative attitudes toward exercise previous experience exercise wish instruction exercise medical staff yes answers evaluated regarding analytical methods accelerometer data used calculate mean time per day spent level pa inactivity sb lpa mpa vpa the number steps time spent level exercise also calculated separately subject hd non hd days two way factorial analysis variance anova performed hd non hd days activity levels independent variables activity time dependent variable the frequencies percentages responses survey psychological state calculated the subjects three men age 68.7 2.3 years height 163.7 1.2 cm weight 58.8 5.0 kg dialysis history 4.6 2.1 years seven women age 65.3 6.6 year height 152.7 3.7 cm weight 52.4 11.6 kg dialysis history 2.1 1.3 years the data 8 subjects data missing used calculate pa levels main outcome study 2 cases immeasurable levels accelerometer respond level movement walking even though subjects capable walking independently the number steps 2,805.1 1,742.0 hd days 4,717.0 2,991.6 non hd days p 0.069 effect size es 0.64 difference significant table 1table 1.physical activity intensity levels dialysis non dialysis daysdialysis daynon dialysis daymeanmediansdmeanmediansdsteps steps)2,805.12,428.31,742.04,717.04,604.72,991.6inactivity min)792.5720.4315.8610.4599.4253.7sb min)557.8639.5282.3619.4811.5268.8lpa min)20.920.910.332.934.019.7mpa min)7.72.210.511.45.114.7vpa min)0.70.21.51.20.21.3sb sedentary behavior lpa light intensity physical activity mpa moderate intensity physical activity vpa vigorous intensity physical activity the mean number steps lower hd elderly japanese patients non hd elderly japanese patients men 7,303 steps women 6,705 steps sb sedentary behavior lpa light intensity physical activity mpa moderate intensity physical activity vpa vigorous intensity physical activity verify whether significant difference exercise levels hd non hd days two way factorial anova performed hd non hd days activity levels independent variables activity time dependent variable tables 1 2 this showed significant interaction f 4 28 6.0 p 0.001 n 0.46 a test simple main effect level showed significant hd non hd days f 1 70 0.72 p 0.79 n 0.01 simple main effect significant activity level f 4 70 68.9 p 0.01 n 0.79 multiple comparison test showed significant correlations inactivity lpa mpa vpa sb lpa mpa vpa however significant correlation inactivity sb lpa mpa vpa the survey attitudes toward exercise showed 5 subjects 50.0% precontemplation stage 3 30.0% contemplation stage 2 20.0% practice stage habit engaging regular exercise table 2table 2.results concerning psychological staten=10%ttm stageprecontemplation550.0contemplation330.0practice220.0ex habityes220.0no880.0habitual ex typegroup ex1walking1habitual ex frequency wover 3 days110.02 days110.0none880.0habitual ex durationover 1 year110.016 months110.0less 1 month880.0motivation exagree550.0somewhat disagree550.0awareness need exagree550.0somewhat agree550.0negative attitude toward exagree110.0somewhat agree660.0somewhat disagree220.0disagree110.0effect exagree550.0somewhat550.0previous experience exyes770.0no330.0ttm transtheoretical model ex exercise motivation exercise awareness need exercise high 5 subjects 50.0% low 5 50.0% seven subjects 70.0% disliked exercise thought much trouble the purpose study ascertain characteristics pa levels attitudes toward pa elderly patients hd we found mean number steps per day lower reference value non hd elderly individuals additionally although significant difference numbers steps activity levels hd non hd days time spent inactivity long days activity sb over 80.0% subjects habit exercising although 70.0% previous experience exercising awareness need exercise low 50.0% additionally tended harbor negative feelings exercising 70.0% the decline physical function seen patients hd due effect chronic renal failure fact leading sedentary lifestyles low levels intensities exercise also important factor previous study pa 795 35.1% among 2,264 patients hd united states a follow investigation patients 1 year later found heart disease peripheral complications frequent among engaged exercise pa risk death 1 year 1.62 times higher engage exercise pa a 10 year follow study patients engaged regular aquatic exercise inactive also found mortality higher patients hd13 terms patterns pa great differences average values hd non hd days absence difference number steps may due wide standard deviation previous study pa hd non hd days majchrzak et al.12 14 15 showed patients hd particularly low activity levels hd days they found factors contributing decrease pa hd days included hd induced fatigue postural hypotension14 16 patients hd also spend 10 h wk treatment associated rest hemostasis hd post hd fatigue low blood pressure focusing activity intensity patterns study subjects spent longest amount time inactive even active time spent sb involved sitting similar activity extremely long hd non hd days johansen et al.17 used accelerometry measure activity levels patients hd 1-wk period showed patients hd significantly lower levels activity healthy individuals leading sedentary lifestyle guidelines many countries japan included recommend elderly people take least 6,000 steps day engage around 15 min moderate pa patients hd achieve even non hd days the length periods inactivity bed rest minimizes effect gravity meaning gravity resisting muscles subjected gravity continued periods resulting inactivity thus develop disuse muscle atrophy reduces muscle strength generating vicious cycle whereby declining physical function factors pa exert negative effect other15 16 18 19 patients hd therefore recommended proactive raising levels pa incorporating exercise therapy however question extent pa patients hd increased important one shown subjects study patients hd may low awareness exercise even regard necessary may engage due negative attitudes wide range intervention methods used encourage pa patients hd including intervention non hd days hd well use home exercises many patients hd also complications may worried heart failure hypertension immediately hd postural hypertension immediately hd thus necessary encourage pa best suited individual counseling efforts part staff involved hd encourage patients hd increase levels regular physical exercise also required5 the present findings also suggested patients hd looking support medical staff according bennett et al.6 20 specialist staff encouragement commitment part medical staff factors contribute successful continuous program medical staff possessing the appropriate knowledge also factor helps increase level physical exercise patients hd improving level physical exercise shown beneficial effect mental health physical function16 21 intervention appropriate pa may provide impetus patients hd generate virtuous circle this study included small number subjects thus attempt elucidate causal relationship pa body strength characteristics patients hd low levels pa however reportedly also poor physical function exercise tolerance survival prognosis22 addition study focused intensity rather number steps as may understood results study significantly difficult patients exercise absence exercise instructors due low motivation exercise recent years perspective health related behavioral science23 however emphasis placed eliminating negative factors reducing sitting time daily changing patterns inactive time i.e. sitting behavior rather positive factors improving pa promoting exercises case study therefore appropriate pa guidance required especially medical institutions without stationed specialists help exercise 2 cases immeasurable pa levels study accelerometer respond levels movement walking even though patients could walk independently determining indexes amount physical exertion patients dialysis important furthermore comprehensive care program includes guidance improving pa psychosocial aspects exercise needed	[ purpose ] the aim of this study was to ascertain the optimum strategy for implementing a physical activity intervention in patients on hemodialysis by investigating the physical characteristics of elderly patients on hemodialysis , and their attitude to physical activity and level of daily activity . [ subjects ] the subject were 10 elderly patients on hemodialysis . [ methods ] they wore a physical activity monitor for 1 week . data obtained were analyzed for hemodialysis and non- hemodialysis days , and two - way analysis of variance was used to compare the number of steps and activity levels . a questionnaire was administered to investigate the stage of psychological preparedness for exercise and attitudes toward / awareness of exercise . [ results ] there was no significant difference in the number of steps or exercise levels on hemodialysis and non- hemodialysis days . however , on both types of days , subjects spent long periods not engaged in any activity . most of their activity was either inactivity or sedentary behavior . [ conclusion ] patients on hemodialysis with low physical activity levels are considered to have poor physical function and exercise tolerance . to maintain and improve the physical function of patients on hemodialysis , it will be necessary to reduce their time spent in inactive , and comprehensive care that covers psychosocial aspects should be provided to promote the proactive improvement of physical activity and their attitudes to exercise .
endoscopic evaluation gastrointestinal tract offers diagnostic therapeutic options become preferred procedure evaluation gastrointestinal disorders presented illustrative example review world literature focus diagnostic management options a healthy 75-year old woman underwent screening colonoscopy outside facility developed left upper quadrant abdominal pain ensuing days cyst observational management elected next several months patient underwent serial ct scan examinations abdomen demonstrated slowly progressively enlarging splenic cyst approximately 4 months inciting colonoscopy patient referred facility management a 10x7-cm thin walled splenic fluid collection seen ct figure 1 abutting abdominal wall displacing spleen medially a fluid fluid level could seen within collection consistent hematocrit effect blood cells separating plasma settling time the collection percutaneously drained 8 french multi holed catheter 400cc brown fluid consistent old blood postprocedure ct confirmed complete collapse collection figure 2 catheter removed six days collection drained patient presented return abdominal pain found follow ct recurrent 6x4-cm subcapsular splenic collection small hematocrit level presumably ongoing small hemorrhages rapid reformation collection therefore patient immunized pneumococcal hib vaccines taken elective splenectomy 2 days later though laparoscopic splenectomy considered open resection chosen given patient age likelihood significant inflammatory changes at laparotomy noted mobile splenic flexure underdeveloped splenocolic ligament inflammatory adhesions found area spleen 8x5-cm white cyst slightly larger spleen found posterolateral spleen figures 3 4 postoperatively patient remarkably well discharged home 3 days later presenting computed tomographic scan patient large undrained hemorrhagic splenic cyst abutting left lateral abdominal wall though barium enema long gold standard identification colonic lesions colonoscopy affords ability identify lesion provide tissue pathologic examination often definitive procedure polyps hence colonoscopy considered accepted screening examination people 50 years age younger familial history colon cancer present though overall safe the 2 common complications hemorrhage following polypectomy range 1.8% 2.5% perforation range 0.34% 2.14% the injury first reported 1974 2 patients sustaining hemorrhage one resulted splenectomy since first report additional 36 cases reported world literature including current case the average age patients 64.9 years range 33 90 reflecting age colonoscopy routinely indicated preponderance females 66.7% difficult intubation colon may impart direct injury spleen passage splenic flexure dense adhesions colon spleen previous surgery disease may result tearing splenic capsule colonoscope passed colon telmos others later added technical maneuvers list risk factors including slide alpha maneuver straightening sigmoid loop externally applied abdominal pressure available literature only 6 patients reported difficulty intubation colon 21 specifically mentioned lack difficulty reports remaining 10 cases made mention ease difficulty procedure twelve 37 reported patients undergone previous surgery disease process may enabled adhesion formation crohn disease pancreatitis eighteen predisposition adhesion formation 8 reports lacked information regarding risk factors interestingly 12 patients possible adhesions 10 intubation difficulties most patients colonoscopic splenic injury present relatively soon injury signs symptoms suggestive problem the range reported literature extends within 2 hours long 10 days fourteen 32 patients available information presented symptoms within 12 hours colonoscopy the remaining 18 patients presented following days vast majority patients information available presented symptoms pain 28/32 approximately half patients also presented evidence hemorrhage shock 18/32 exception 1 patient successfully managed nonoperatively reports include pain presenting symptom also patients died suggesting patients moribund complain pain the diagnosis management colonoscopy related splenic injuries degree reflected available technology similar management traumatic splenic injuries although injuries diagnosed least confirmed laparotomy era 1987 21 24 cases since 1989 diagnosed noninvasive methods computed tomography ultrasonography report federle 1983 diagnosis splenic injury sustained trauma indirect prompted positive diagnostic peritoneal lavage dpl leading laparotomy proven utility ct blunt abdominal trauma hemodynamically unstable patients undergo dpl even largely replaced focused abdominal sonography trauma fast examination the recognition 100 years ago spleen role immunoprotection encapsulated organisms streptococcus pneumoniae haemophilus influenzae neisseria meningitidis largely ignored 1950s swing management splenic injuries began era splenic salvage besides splenorrhaphy splenic salvage maneuvers include nonoperative management splenic injuries splenic artery embolization pseudoaneurysms trauma literature nonoperative management lower grade injuries grades though none injuries induced colonoscopy graded available reports presumably pulverized high grade injuries seen trauma probably fall grade thru iii category however overall 27.8% patients splenic injury colonoscopy retained spleens 1988 rate dropped 61.5% still higher predicted trauma literature finally patient presented condition previously reported colonoscopy literature the formation secondary cyst rare characterized lack cellular lining seen primary cyst successful percutaneous drainage ultrasound guidance reported splenic cysts secondary blunt abdominal trauma related colonoscopy our attempt percutaneous drainage similarly intended prevent splenectomy unfortunately unsuccessful limited experience technique however remain armamentarium treatment injuries in history splenic injury colonoscopy experience first decade laparotomy splenectomy patients though ct scanning proven successful diagnosing injury relatively patients escaped experience intact spleen nonoperative management splenic artery embolization used significant success trauma setting used sparingly colonoscopic injuries though attempt percutaneous control secondary cyst formed result colonoscopic splenic injury unsuccessful believe could nevertheless represent alternative splenectomy future patients	injury to the spleen during routine colonoscopy is an extremely rare injury . diagnosis and management of the injury has evolved with technological advances and experience gained in the management of splenic injuries sustained in trauma . of the 37 reported cases of colonoscopic splenic injury , 12 had a history of prior surgery or a disease process suggesting the presence of adhesions . only 6 had noted difficulty during the procedure , and 31 patients experienced pain , shock , or hemoglobin drop as the indication of splenic injury . since 1989 , 21/24 ( 87.5% ) patients have been diagnosed initially using computed tomography or ultrasonography . overall , only 27.8% have retained their spleens . none have experienced as long a delay as our patient , nor have any had an attempt at percutaneous control of the injury . this report presents an unusual case of a rare complication of colonoscopy and the unsuccessful use of one nonoperative technique , and reviews the experience reported in the world literature , including current day management options .
classic little book life great theoretical physicist erwin schrdinger considered one biology central questions living organism accounted physics chemistry schrdinger 1944 attempting answer question schrdinger rightly focused centrality gene thus necessity understanding nature mutations given essential identifying investigating nature genes chemical nature gene unknown paper avery et al ( 1944 demonstrating dna genetic substance published life still press schrdinger drew max delbrck atomic physics based model genetic mutation structure gene timofeeff ressovsky et al 1935 suggesting gene linear one dimensional crystal i.e. one whose elements repeat periodic way common crystals although schrdinger little book universally well received especially biologists even critic like linus pauling willing conclude schrdinger formulation theory wave mechanics 1925 received nobel prize 1933 basically responsible modern biology developed largely basis new understanding chemistry quantum mechanics made possible pauling 1987 cited dronamraju 1999 quantum mechanics certainly also core schrdinger speculations nature gene molecular biologists many trained physical scientists especially crystallographers physical chemists max delbrck linus pauling francis crick matthew meselson name this dawn great molecular biology revolution led vast increase understanding genes genomes established fundamental nature gene nucleic acid molecule comprised string distinct nucleotide bases whose sequence normally specifies gene product effect influence expression phenotype growth development interestingly complementary way thinking nature gene came associated term epigenetics also origins 1930s 1940s the epigenetic perspective pointed toward complicated reality nature genes largely sidelined several decades molecular biology revolution good reason molecular biology would develop tools approaches eventually understand molecular basis epigenetic perspective thus two perspectives existed parallel little cross talk simply molecular biology develop mature point could consider address epigenetic perspective first noted brink 1960 the epigenetic perspective presaged none morgan 1934 noted possibility genes also building changing way development proceeds response part protoplasm come lie view gene dynamically changing development without losing fundamental properties ( morgan 1934 undergoing renaissance recent years become increasingly clear dna focused understanding gene revolutionized genetics biology actually incomplete without complement chromatin-centered perspective epigenetics the chromatin centered perspective gene first elaborated 50 years ago r. alexander brink classic paper brink 1960 inferred eukaryotic chromosomes genetic function also possess termed he proposed genetic locus thus comprised two types chromatin termed orthochromatin parachromatin brink defined orthochromatin substance locus remains qualitatively constant nuclei individual presumably comprised dna given locus parachromatin hand brink proposed comprised alternative states chromatin altered factors arising development response environment states adopt succession mitotically transmissible states together reflecting progressive history cellular lineage brink explicitly noted concepts euchromatin heterochromatin fundamentally different concepts orthochromatin parachromatin especially locations former pair mutually exclusive whereas latter pair co located intimately genetic locus brink based hypothesis paragenetic function chromosomes observations two maize geneticists barbara mcclintock edward coe made 1950s demonstrated existence two types genetic variations classical mutations termed paramutations paramutations broadest use term brink 1960 directed instance particular paramutations also typically reversible changeable often exhibiting series quantitatively qualitatively varying states brink argued although paramutations violate mendel laws occurrence implies existence processes genes change development supports morgan contention genes might change development without losing fundamental i.e. genetic properties brink definition parachromatin allowed great latitude nature composition dynamic behaviors parachromatin modern terms would include histone proteins various modification states also many diverse chromatin proteins complexes remodel chromatin new states may comprised conformational alterations covalent modifications and/or changes molecular composition explicitly included chromatin states would proteins also rna molecules various types including limited sirnas produced rna interference related chromatin complexes thus modern view chromatin given locus one highly dynamic entity fits well brink concept parachromatin even though brink understanding molecular nature chromatin hypothesis flexible enough fully encompass modern understanding chromatin brink concept parachromatin offered broad general perspective nature behaviors functions genes eukaryotes but impossible 1960 brink specify molecular details mechanisms comprise parachromatin only 1 year later jacob monod 1961 offered simple straightforward molecular biological model control gene expression prokaryotes revolutionized thinking genes expressed regulated seemed potential account gene regulation complex eukaryotes well parachromatin largely forgotten decades molecular biologists geneticists explored jacob monod model gene regulation great detail first prokaryotes eukaryotes eventually however came recognized simple models based transcription factors binding specific dna sequences insufficient explain control gene regulation complex eukaryotes molecular tools approaches developed could begin open window higher order complexities eukaryotic gene regulation chromatin gradually accepted first mediator modulator transcription complex formation active dynamic participant entire transcription process concept histone code histone language developed around 2000 molecular biology finally beginning catch brink 1960 concept parachromatin of course still far able say fully understand molecular basis parachromatin little doubt begun open door vast realm possibilities waiting explored defined molecularly mechanistically the chromatin centered perspective gene first elaborated 50 years ago r. alexander brink classic paper brink 1960 inferred eukaryotic chromosomes genetic function also possess termed he proposed genetic locus thus comprised two types chromatin termed orthochromatin parachromatin brink defined orthochromatin substance locus remains qualitatively constant nuclei individual presumably comprised dna given locus parachromatin hand brink proposed comprised alternative states chromatin altered factors arising development response environment states adopt succession mitotically transmissible states together reflecting progressive history cellular lineage brink explicitly noted concepts euchromatin heterochromatin fundamentally different concepts orthochromatin parachromatin especially locations former pair mutually exclusive whereas latter pair co located intimately genetic locus brink based hypothesis paragenetic function chromosomes observations two maize geneticists barbara mcclintock edward coe made 1950s demonstrated existence two types genetic variations classical mutations termed paramutations paramutations broadest use term brink 1960 directed instance particular paramutations also typically reversible changeable often exhibiting series quantitatively qualitatively varying states brink argued although paramutations violate mendel laws occurrence implies existence processes genes change development supports morgan contention genes might change development without losing fundamental i.e. genetic properties brink definition parachromatin allowed great latitude nature composition dynamic behaviors parachromatin modern terms would include histone proteins various modification states also many diverse chromatin proteins complexes remodel chromatin new states may comprised conformational alterations covalent modifications and/or changes molecular composition explicitly included chromatin states would proteins also rna molecules various types including limited sirnas produced rna interference related chromatin complexes thus modern view chromatin given locus one highly dynamic entity fits well brink concept parachromatin even though brink understanding molecular nature chromatin hypothesis flexible enough fully encompass modern understanding chromatin brink concept parachromatin offered broad general perspective nature behaviors functions genes eukaryotes but impossible 1960 brink specify molecular details mechanisms comprise parachromatin only 1 year later jacob monod 1961 offered simple straightforward molecular biological model control gene expression prokaryotes revolutionized thinking genes expressed regulated seemed potential account gene regulation complex eukaryotes well parachromatin largely forgotten decades molecular biologists geneticists explored jacob monod model gene regulation great detail first prokaryotes eukaryotes eventually however came recognized simple models based transcription factors binding specific dna sequences insufficient explain control gene regulation complex eukaryotes molecular tools approaches developed could begin open window higher order complexities eukaryotic gene regulation chromatin gradually accepted first mediator modulator transcription complex formation active dynamic participant entire transcription process concept histone code histone language developed around 2000 molecular biology finally beginning catch brink 1960 concept parachromatin of course still far able say fully understand molecular basis parachromatin little doubt begun open door vast realm possibilities waiting explored defined molecularly mechanistically the evolution mendelian genetics toward might call molecular epigenetics via molecular biology description gene nucleic acid molecule intriguing perhaps instructive parallel evolution physics newtonian mechanics toward quantum mechanics via planetary model atom electrons orbit nucleus the original concept atom fundamental entity newtonian mechanics held atom indivisible particle this concept transformed twice first planetary model quantum mechanics redefined atom field probabilities subatomic particles existing four dimensions three spatial dimensions time similarly original concept gene fundamental entity mendelian genetics also particulate indivisible concept also transformed twice first prism genetics molecular biology concept gene nucleotide sequence divisible recombination molecular biology looking prism epigenetics might referred field possibilities alternative chromatin states centered particular nucleic acid sequence i.e. parachromatin use brink terminology mentioned previously alternative parachromatin states assumed based diverse chromatin proteins rnas complexes exist various conformational covalent modification states adopted growth development differ among loci quantum mechanics subatomic particles may viewed two different ways i.e. waves particles likewise paramutations may viewed gene expression states mitotically cases meiotically heritable states classical genetics molecular biology established macro framework genetics way newtonian mechanics planetary model atom established macro framework physics quantum mechanics ultimately led idea wave particle duality description positions subatomic particles field probabilities determine chemical properties given atom similarly brink introduced idea genetic paragenetic duality genetic loci genetic entity dna paragenetic entity chromatin present genetic locus complementary interdependent partners might describe field possibilities determine expression states given locus drawing parallel trying suggest classical molecular biological view genetics neither correct useful newtonian mechanics planetary model atom neither correct useful rather simply suggesting represents early incomplete descriptions reality required important modification enrichment could fully understand nature genetical physical worlds respectively however ought try take analogy far level detail likely break in twentieth century physics evolved beyond deterministic view universe postulating future universe theory could extrapolated laws physics one could obtain complete knowledge positions directions velocities movement particles universe quantum mechanics especially heisenberg uncertainty principle raised fundamental questions challenged possibility precise knowledge future instance number times per second atoms lump uranium undergo radioactive decay known precision however particular atom decay unpredictable modern physics similarly although geneticists measure mutation frequency particular system specific conditions timing particular nucleotide substitution mutational event unpredictable thus evolutionary genetic perspective biology deterministic physics tautz 2000 analyzed terms population genetic theory tautz argued selective fitness advantageous mutation population time comprise canonically conjugated pair variables analogous pairs physical variables location momentum particle energy particle time measured he showed uncertainty largest low allelic frequency selective advantage small the specific trajectory allele population finite size well known population genetics unpredictable probabilities different trajectories determined advent genomics theoretically possible know absolute certainty sequence region chromosome carrying gene even sequence entire chromosome however stadler 1954 noted trivial precisely locate gene i.e. shown delimited neighboring genes definite boundaries this conclusion follows stadler definition gene operationally gene defined smallest segment gene string shown consistently associated occurrence specific genetic effect modern terms knowing complete sequence chromosome allow us precisely determine many interdependent elements gene including elements cis necessary normal operation given gene associated specific genetic effect jorgensen 2010 in addition expression selective value gene nature may often dependent environment encountered organism perhaps making impossible precisely identify boundaries gene distinct quantum mechanics also important recognize relevance biology complexity theory identified another type uncertainty physics resulting sensitive dependence initial conditions relatively simple newtonian systems may exhibit unpredictable chaotic behaviors due impracticality knowing initial conditions precisely enough similarly evident knowing alternative epigenetic states given gene environments may unachievable practical sense this essentially different postulated complexity theory namely impractical know enough precision locations movements particles system order predict future behavior certainty least certain systems certain conditions perhaps then hope achieve determine estimate field possibilities comprise orthochromatin parachromatin components gene the marriage epigenetics molecular biology promises deepen revolutionize understanding fundamental nature gene allowing us see deeply field possibilities it going interesting learn degree knowledge field possibilities comprise gene able obtain though happy proved wrong strong suspicion able learn lot given gene never know know i.e. complete field possibilities determinable simply impossible anticipate every gene every circumstance organism may encounter finally given rapidly increasing interest phenomenon transgenerational meiotic inheritance epigenetic paragenetic states possible evolutionary consequences also interesting consider epigenetics may also revolutionize understanding biological evolution perhaps similar understanding atomic particles continues revolutionize understanding evolution universe many biologists especially plant biologists long postulated information may sometimes flow backward environment gene via epigenetic impositions genome altering states brink parachromatin suggested possibility generation novel genetic variations words barbara mcclintock might this seemingly radical suggestion lamarckian rather modified darwinian mechanism led great deal criticism misunderstanding mcclintock unfair criticism argued previously rather repeat discussion would refer interested reader jorgensen 2004 the author declares research conducted absence commercial financial relationships could construed potential conflict interest	the perspective presented here is that modern genetics is at a similar stage of development as were early formulations of quantum mechanics theory in the 1920s and that in 2010 we are at the dawn of a new revolution in genetics that promises to enrich and deepen our understanding of the gene and the genome . the interrelationships and interdependence of two views of the gene the molecular biological view and the epigenetic view are explored , and it is argued that the classical molecular biological view is incomplete without incorporation of the epigenetic perspective and that in a sense the molecular biological view has been evolving to include the epigenetic view . intriguingly , this evolution of the molecular view toward the broader and more inclusive epigenetic view of the gene has an intriguing , if not precise , parallel in the evolution of concepts of atomic physics from newtonian mechanics to quantum mechanics that are interesting to consider .
world health organization states ~347 million people roughly 9.5% adult population suffering diabetes 2008 the incidence diabetes rapidly increasing estimates suggesting number almost double 2030 diabetes mellitus major cause chronic kidney disease ckd worldwide associated enhanced morbidity mortality particular accelerated cardiovascular disease 2 3 diabetic nephropathy dn common cause end stage renal failure western world clinical associations frequently precede overt dn hypertension poor glycaemic control although subset patients develop nephropathy despite proper glycemic control normal blood pressure once nephropathy established blood pressure often rises glycaemic control paradoxically improve result reduced renal insulin clearance it postulated interplay metabolic hemodynamic pathways plays important role development progression dn figure 1 increased systemic intraglomerular pressure activation renin angiotensin aldosterone system raas recognized key component dn progression additionally chronic hyperglycemia promotes generation advanced glycation end products ages it widely accepted ages mediate effects directly indirectly receptor dependent mechanisms the receptor age rage acts signal transduction receptor rage age interaction activates multiple intracellular signalling pathways increase production growth factors inflammatory cytokines oxidative stress figure 1 recent times novel class non coding rna microrna mirna mir found expressed tissues plays important roles tissue homeostasis disease progression 9 10 whilst role mirna pathogenesis dn extensively reviewed others relation growth factors fibrosis dn the focus review role mirna renin angiotensin system age rage signalling pathway downstream mediators oxidative stress immune response context diabetic nephropathy mirnas group small ~22 nucleotide single stranded non coding rnas ubiquitously expressed plants animals act posttranscriptionally modulate expression target genes 11 12 they first discovered 1993 lin-14 protein expression found regulated mature product lin-4 gene caenorhabditis elegans c. elegans the mechanism found rely upon sequence specificity 3-untranslated region utr lin-14 lin-4 bound whilst occurred partial complementarity the binding occurred sufficient affinity result inhibition protein translation time considered peculiarity worm it 2000 another regulator let-7 discovered c. elegans soon came realisation form regulation conserved across many species representing general mechanism regulating expression several genes mirnas found intergenic sequences antisense strand genes may possess promoter regulatory sequences 15 16 other mirnas almost 50% case human mirna found within gene sequences together regulated host gene 1719 approximately half found polycistronic units mature mirnas processed primary transcript pri mirna ) is processed number proteins including ribonuclease iii drosha rna binding protein digeorge syndrome critical region gene 8 dgcr-8 protein short hairpin rna molecule termed precursor mirna pre mirna subsequently exported nucleus exportin-5 2022 cytosol processing mediated another ribonuclease iii dicer followed incorporation mature strand duplex mirna rna induced silencing complex risc includes argonaute family proteins the mirna risc complex stabilises mirna nuclease attack mirna direct complex target rna transcripts via sequence complimentarity mirna seed sequence 28 nucleotides mirna recognition element mre target transcript mirnas modulate protein synthesis binding 3 utr mrnas via incomplete base pairing complementary seed sequence utr leading translational repression mres predominately located 3 utrs mammalian mrna however evidence indicating mirna also mediate translational repression via binding 5 utrs coding sequences 25 26 plants lower vertebrates complete complimentarity exists mirna seed sequence target mrna degradation target mrna in contrast mirnas exercise finer control protein expression mammalian cells repress protein translation 27 28 allowing comprehensive regulation protein expression single mirna target many mrnas mrna target several mirnas this potential mirnas regulate many genes adds significant complexity interpretation many studies focus single genes it therefore critical computationally detect combination mirnas target specific mrna molecules such analyses often demand complex algorithms need defined high stringency levels generate computational data could assessed validated wet lab added recent discovery circulating mirnas microparticles potential mirnas delivered sites distal generation renin production key regulatory step initiates enzymatic cascade leads angiotensin generation control blood pressure addition fluid electrolyte homeostasis renin synthesized released renal juxtaglomerular jg cells located entrance glomerulus early embryonic development renin producing cells broadly distributed along intrarenal arteries glomerular mesangium developing tubules maturation lineage studies demonstrate progressive restriction achieved differentiation renin cells vascular smooth muscle cells vsmcs mesangial cells subset tubular cells were first address role mirna maintenance jg cells generating mice conditional deletion dicer dicer cko mice specifically exclusively renin expressing cells resulting selective ablation mirna generation renin cells descendants deletion dicer resulted severe reduction number jg cells accompanied decreased expression renin ren1 ren2 genes decreased plasma renin concentration prc decreased bp abnormal renal function striking nephrovascular abnormalities including striped corticomedullary fibrosis this study clearly showed critical role mirna orchestration renal function importance mirna homeostasis specific organ functions marques colleagues conducted first time transcriptome wide study differential expression mrnas mirna kidneys hypertensive subjects 15 untreated hypertensive 7 normotensive white males microarray technology they confirmed differences expression nuclear receptor subfamily 4 group member 1 nr4a1 nr4a2 nr4a3 period circadian protein homolog 1 per1 salt inducible kinase 1 sik1 mrnas mirnas hsa mir-638 hsa let-7c real time quantitative pcr expression medulla functional experiments confirmed predicted binding hsa let-7c 3 untranslated region nr4a2 mrna renal cortex confirmed differences expression apoptosis inducing factor mitochondrion associated 1 aifm1 alpha-1-microglobulin bikunin precursor ambp apolipoprotein e apoe cluster differentiation 36 cd36 ephrin b1 efnb1 nadh dehydrogenase ubiquinone complex assembly factor 1 ndufaf1 peroxiredoxin 5 prdx5 ren renin binding protein renbp solute carrier family 13 sodium sulfate symporters member 1 slc13a1 syntaxin 4 stx4 troponin type 2 cardiac tnnt2 mrnas mirnas hsa mir-21 hsa mir-126 hsa mir-181a hsa mir-196a hsa mir-451 hsa mir-638 hsa mir-663 functional experiments demonstrated hsa mir-663 bind ren apoe 3 untranslated regions regulating ren apoe mrna levels whereas hsa mir-181a regulated ren aifm1 mrna a major discovery evidence ren mrna regulation via binding mirnas hsa mir-181a hsa mir-663 3 utr observed downregulation 2 mirnas hypertension could explain elevation intrarenal renin mrna due small sampling size findings need bolstered acquisition suitable samples larger cohorts untreated hypertensive subjects settings chronic kidney disease ckd known cardiovascular risk factor patients ckd die cardiovascular disease cvd reaching need dialysis chen colleagues measured vascular mirnas blood 90 patients ckd found association decreased circulating levels progressive loss egfr multivariate analyses expression vascular mirnas decreased thoracic aorta ckd rats compared normal rats concordant changes target genes runx2 at1r myocardin alteration drosha dicer indicating low levels expression due altered intracellular processing furthermore expression mir-155 negatively correlated calcification aorta process known preceded vascular dedifferentiation animals overexpression mir-155 vsmc ckd rats inhibited at1r expression decreased cellular proliferation confirming causative role low mir155 vsmc transformation synthetic proliferative phenotype however whether downregulation mirnas cause consequence widespread vascular phenotype abnormalities patients ckd remains determined jeppesen colleagues shown angii regulates five mirnas mir-29b -129 3p -132 -132 5p -212 vitro stimulation primary cardiac fibroblasts hek293n cells overexpressing at1r furthermore eskildsen colleagues undertook detailed analysis potential mirnas involved angii mediated hypertension rats hypertensive patients using mirna microarray qpcr analysis mir-132 mir-212 highly increased heart aortic wall kidneys rats hypertension 159 12 mm hg cardiac hypertrophy following chronic angii infusion addition activation endothelin receptor another gq coupled receptor also increased mir-132 mir-212 a significant downregulation mir-132 well robust attenuation mir-212 human arteries arb treated patients also observed whereas treatment -blockers effect conclusion mir-132 mir-212 upregulated angii induced hypertension organs associated blood pressure control possibly via gq dependent pathway table 1 contains mirnas known regulated renin angiotensin system kidney tissues associated kidney disease hypertension cardiovascular disease chronic hyperglycemia promotes generation advanced glycation end products ages result sequential biochemical reactions involving nonenzymatic glycation protein lipids known maillard reaction consequence age formation ages induce expression mcp-1 podocytes activation age receptor rage generation intracellular reactive oxygen species ros the induction oxidative stress results upregulation nuclear factor nf)-b various nf-b mediated proinflammatory genes eventually leading glomerular tubulointerstitial injury therefore age rage oxidative stress signalling important progression dn targeting axis modulating mirnas involved potential new therapy there studies examining role mirna age rage signalling related kidney disease most studies focussed role rage immune system cancer rage member immunoglobulin superfamily cell surface molecules dicer selectively inactivated mouse podocytes multiple abnormalities observed glomeruli mutant mice including foot process effacement irregular split areas glomerular basement membrane podocyte apoptosis depletion mesangial expansion capillary dilation glomerulosclerosis gene profiling microarray analyses revealed upregulation 190 genes glomeruli isolated mutant mice onset proteinuria compared control littermates target sequences 16 mirnas significantly enriched 3-untranslated regions 190 upregulated genes supporting validity silico analysis 6 8 top candidate mirnas identified mirna libraries generated podocyte cultures included mir-28 mir-34a four members mir-30 family mir-30c-1 mir-30b mir-30d mir-30c-2 among 15 upregulated target genes mir-30 mirna family rage vimentin heat shock protein 20 immediate early response 3 known expressed injured podocytes experimental models human kidney disease rage immediate early response 3 known mediate podocyte apoptosis whereas vimentin heat shock protein 20 involved cytoskeletal structure the findings demonstrate important roles mir-30 family podocyte homeostasis podocytopathies s100b rage ligand significantly increased cox-2 mrna accumulation thp-1 monocytes 2 h via mrna stability s100b decreased occupancy dna rna binding protein heterogeneous nuclear ribonuclear protein k hnrnpk cox-2 promoter simultaneously increased binding cox-2 3-utr additionally s100b significantly downregulated expression mir-16 acts destabilize cox-2 mrna binding 3-utr these results demonstrate diabetic stimuli efficiently stabilize inflammatory genes via opposing actions key rna binding proteins mirna ages delay spontaneous apoptosis monocytes contribute development inflammatory responses genome wide mirna expression analysis significant upregulation mir-214 consistently observed thp-1 human monocytes treated various ages striking increase mir-214 overexpression pre mir-214 led impaired pten expression delayed apoptosis thp-1 cells whereas knockdown mir-214 levels largely abolished age induced cell survival these findings define role mir-214-targeting pten age induced monocyte survival high mobility group box 1 protein hmgb1 late inflammatory cytokine signals danger immune system rage toll like receptor mir-221 mir-222 involved cell proliferation inhibition cell cycle regulator p27kip1 smooth muscle cells endothelial cells ecs hmgb1 increases expression mir-221 mir-222 primary cultures excised papillary lesions established papillary cancer cell line overexpression mir-222 mir-221 caused hmgb1 increases growth motility papillary thyroid cancer cells recently reported mir-21 mir-221 tissue inhibitors metalloproteinases timp)3-targeting mirna significantly upregulated kidneys diabetic mice compared control littermates mesangial cell line grown high glucose conditions mesangial expansion one main characters dn mainly due accumulation extracellular matrix ecm ecm turnover regulated timps activities diabetic conditions timp3 expression kidney mir-221/mir-222 cluster examined several cardiovascular disorders affects angiogenic activity stem cell factor scf targeting receptor c kit high glucose levels elevate mir-221 correlates decreased expression c kit reduced ec migration mir-221/222 targets synthase transcription factor ets-1 major contributors atherosclerotic process 47 49 50 taken together results indicate hmgb1/rage mir-221/222 axis may activated kidney vasculature resulting ecm accumulation atherosclerosis dn patients table 2 lists mirnas known modulated age rage kidney monocytes vsmcs ecs associated kidney disease vascular dysfunction reactive oxygen species ros collective term includes number reactive partially reduced oxygen o2 metabolites free radicals superoxide anion o2 hydroxyl radicals oh extremely reactive molecular species unpaired electron outer orbital number studies demonstrated type 1 type 2 diabetes associated overproduction oxygen derived free radicals increased ros production reduced levels antioxidants culminate increased level oxidative stress leading oxidative damage cellular components among many enzymatic systems implicated ros generation vascular tissues enzymes mitochondrial respiratory chain complexes iii xanthine oxidase uncoupled nitric oxide synthase nicotinamide adenine dinucleotide phosphate reduced form nadph oxidase nox appear particularly important 5254 increased nox mediated superoxide production reported experimental models diabetes occurs parallel upregulation nox1 nox4 55 56 nox mediated generation superoxide important mediator matrix accumulation renal fibrosis podocyte injury dn mir-377 upregulated spontaneous stz induced mouse models dn mesangial cells exposed high glucose tgf-1 furthermore genes potentially relevant pathogenesis dn confirmed experimentally including cytoskeletal regulator p21-activated kinase 1 pak1 superoxide dismutases sod1/sod2 catalyse ros accumulates response hyperglycemia it previously shown upregulation mir-23a~27a~24 2 cluster induces caspase dependent caspase independent cell death human embryonic kidney cells via c jun n terminal kinase jnk increases ros release proapoptotic factors cytochrome c cyt c addition apoptosis inducing factor aif intermembrane space mitochondria cytosol order better understand molecular mechanism responsible mir-23a~27a~24 2 cluster induced cell death gene expression profiling performed control mir-23a~27a~24 2 cluster overexpressing hek293 cells this revealed mir-23a~27a~24 2 cluster induced apoptosis associated endoplasmic reticulum er stress unfolded protein response upr pathways hek293 cells overexpression mir-23a~27a~24 2 cluster resulted er stress altered mitochondrial membrane permeability established increased intracellular mitochondrial calcium levels hek293 cells there reports mir-23b levels increased kidneys tgf-1 transgenic mice rats following subtotal nephrectomy found localized podocytes tubular epithelium situ hybridization mir-23b also upregulated tgf-1 cultured renal epithelial cells vitro gain loss function studies pointed several mir-23b targets including tgf- receptor type ii smad3 tgf-1 suggesting negative feedback loop regulating tgf-1 signaling modulation mir-23b cultured podocytes altered expression wt1 nephrin podocin also influenced motility cultured tubular cells studies found aged organs including kidney expression antioxidant enzymes sod catalase gpx peroxiredoxins downregulated 62 63 thus leading reduced antioxidant capacity bioinformatic analysis mirna expression profile young old rat kidneys mitochondrial sod2 thioredoxin reductase 2 txnrd2 ) are potential targets mir-335 mir-34a respectively aging mesangial cells exhibited significant upregulation mir-335 mir-34a marked downregulation sod2 txnrd2 further studies confirmed sod2 txnrd2 target genes mir-335 mir-34a coincided ros generation within mitochondria uncoupling protein 2 ucp2 recently reported negative regulator ros generation its ablation leads marked increase oxidative stress several cell types stroke prone spontaneously hypertensive rat shrsp kidneys severe renal damage along increased rate inflammation oxidative stress ucp2 gene protein levels downregulated paralleled differential expression kidney mir-24 -34a identified target ucp2 gene the silencing ucp2 gene renal mesangial cells led increased rate ros generation increased inflammation apoptosis reduced cell vitality increased necrosis suggesting ucp2 critical preventing oxidative stress damage renal mesangial cells specific mirnas including mir-205 mir-200 family mir-200a c mir-141 mir-429 shown mediate epithelial mesenchymal transition emt response tgf-1 madin darby canine kidney cells downregulation mirnas relieves cooperative repression mesenchymal transcription factors zeb1 sip1 turn free inhibit e cadherin expression promoting epithelial dedifferentiation assessed changes mirna expression cultured renal tubular cell line hk-2 hypoxia reoxygenation induced oxidative stress er stress using mirna microarray assay real time rt pcr among altered mirna expression mir-205 markedly decreased stress conditions functional analysis revealed decreased mir-205 led increase cell susceptibility oxidative er stresses increase associated induction intracellular ros suppression antioxidant enzymes furthermore mir-205 bound 3-utr prolyl hydroxylase 1 phd1/egln2 gene suppressed transcription level egln2 modulates intracellular ros level er stress state mirna profiling huvec treated 8 24 hrs 200 hydrogen peroxide h2o2 showed mir-200c cotranscribed mir-141 increased eightfold mir-200c overexpression huvec recapitulates many aspects oxidative stress induced phenotype since induces cell growth arrest apoptosis cellular senescence all effects mediated least part inhibition target zeb1 mir-200 family mir-200 family induction following h2o2 exposure confirmed different cell lines human mouse immortalized fibroblasts colon carcinoma ct26 mammary gland epithelial cells nmumg human cell lines melanoma cells mda mb-435s kidney cells 293 breast adenocarcinoma mda mb-436 bt-549 ovarian adenocarcinoma skov3 notably cell lines mir-200 family members upregulated recent study an analysis mirnas upregulated diabetic mouse heart compared control performed revealing mir-200c mir-141 among upregulated the authors show mir-141 targets inner mitochondrial membrane phosphate transporter solute carrier family 25 member 3 slc25a3 provides inorganic phosphate mitochondrial matrix essential atp production suggesting important role mir-200 family mitochondrial responses involved cardiac diseases associated diabetes obesity contrary role mir-200 family oxidative stress the mir-200 family also plays important role emt considered mediate production renal fibroblasts part targeting zeb1/2 transcriptional repressors e cad 68 77 78 hand another group demonstrated tgf- activated akt glomerular mesangial cells inducing mir-200b mir-200c target fog2 inhibitor phosphatidylinositol 3-kinase activation suggesting role mir-200 family glomerular mesangial hypertrophy progression dn some differences may relate variances experimental models and/or conditions however one often overlooked explanation effects mirna inhibitors likely indirect nature recent evidence demonstrates regulation gene expression via deadenylation altering message stability effects transcription bioinformatics utilising pathway analysis needed better understand crosstalk factors drive many downstream processes processes ultimately impact expression individual genes mirna profiling rat vsmcs treated 200 h2o2 6 hours revealed upregulation mir-21 this study showed mir-21 participates h2o2-mediated gene regulation via target programmed cell death 4 pdcd4 transcription factor ap-1 pathway activity elevated mir-21 thought contribute atherosclerosis directly targeting ppar leading increased inflammatory response ecs inhibition mir-21 causes activation ap-1 well upregulation proinflammatory factors vcam-1 mcp-1 mir-21 also act inhibitor angiogenesis reducing ec proliferation migration tube formation culture via inhibition rhob mir-21 also increase nitric oxide huvecs exposed shear stress via increased phosphorylation nitric oxide synthase nos decreased apoptosis this activity balanced ability mir-21 repress sod-2 important antioxidant defence furthermore mir-21 elevated angiogenic precursor cells asymmetrical dimethylarginine adma powerful nos inhibitor ultimately resulting elevated intracellular reactive oxygen ros species knockdown mir-21 decreased mesangial expansion collagen iv fn1 expression reduced macrophage infiltration tnf mcp-1 expression the gene expression changes replicated vitro ptc mesangial cells mcs mir-21 overexpression enhancing fibrogenesis via mechanism part involved direct targeting smad7 interestingly mir-21 targets pten also leads decreased mesangial expansion db db mice mir-21 also implicated regulation tgf- signalling number animal models tubulointerstitial fibrosis associated renal dysfunction in one model smad7 overexpression rat unilateral ureteral obstruction model restored mir-21 expression normal levels congruent improvements renal pathology line profibrotic role mir-21 upregulation mirna furthermore regulation pdcd4 mir-21 enhances podocyte apoptosis loss conjunction increased tubular epithelial cells survival growth arrest signals 85 86 mir-210 appears function master regulator hypoxic response found upregulated hypoxia virtually cell types tested date 87 88 recent data demonstrate hif1 block mitochondrial respiration via electron transport chain etc transcriptional activation mir-210 cell types 87 88 upregulation mir-210 along vegf vegfr2 expression confirmed renal ischemia reperfusion r injury male balb c mice furthermore overexpression mir-210 huvec-12 cells enhanced vegf vegfr2 expression promoted angiogenesis matrigel vitro these results suggest mir-210 may involved targeting vegf signaling pathway regulate angiogenesis renal r injury table 3 summarises mirnas regulated oxidative stress kidney tissues associated kidney disease vascular dysfunction resulting excessive ros production considerable progress made identifying number important roles mirna various biological processes disease there much excitement prospect mirnas appear important regulation several related processes diabetes complications including modulation raas oxidative stress pathways the number mirnas relevant conditions constantly increasing tables 13 it encouraging cases restoring expression dysregulated mirna attenuate even reverse disease our initial understanding gene regulation continued change simple concepts terms protein factors sitting dna complex epigenetics involving chromatin dynamics multiple histone dna modifications even complexity superseded ability mirna modulate expression multiple targets posttranscriptionally whilst biology around mirna continues generate new interesting findings challenge future translate exciting experimental findings potential therapeutic interventions	micrornas ( mirna ) are a novel class of small , noncoding rna molecules that have gained the attention of many researchers in recent years due to their ability to posttranscriptionally regulate the expression of families of genes simultaneously . their role in normal physiology and pathobiology is intriguing and their regulation in normal and disease states is fascinating . that the cells can return to a state of homeostasis when these small molecules are perturbed is truly remarkable given the multiple cellular targets of each mirna and that many mrnas are targeted by multiple mirnas . several reviews have covered aspects of mirna function in biology and disease . here , we review the role of mirna in regulating the renin - angiotensin system , age / rage signalling , and under conditions of oxidative stress in the context of diabetic nephropathy .
two distantly related groups eukaryotes similar lifestyles feed osmotrophy the cells secret enzymes decompose organic matter metabolites imported cell fungi closely related animals oomycetes whereas diatoms group photosynthetic algae sister group oomycetes oomycete fungi genomes among genomes traditional phylogenomic studies indicated significant role gene transfer eukaryotes nevertheless targeted evolutionary studies suggested gene transfer contributed similarities groups they could identify dozens gene transfers groups using wide range genomes groups together clustering phylogenetic methods interestingly transfers except one reported occurred direction fungi oomycetes many transferred genes encode secreted decomposing enzymes specifically acquired plant tissue colonizing oomycetes these results show oomycete likely recent plant pathogens fungi transfer genetic material distantly related eukaryotic group played important role evolution pathogenic lifestyle these fascinating results would obtained traditional phylogenomic approach genes strong sequence similarities eukaryotes would assumed present common eukaryotic ancestor studies gene transfer indeed able shed light diversification process eukaryotes choanoflagellates group free living microbial eukaryotes closest relatives animals sun coworkers used directed phylogenomic approach search genes algal origin genome monosiga brevicollis phagotrophic unicellular choanoflagellate using realistic filtering criteria able identify 103 genes strong support algal origin mostly haptophytes diatoms green algae this could result repeated transfer genes food choanoflagellates feed bacteria eukaryotes alternatively rather addition genes could introduced past algal endosymbiont lineage leading monosiga interestingly quarter identified genes appeared first transferred bacteria eukaryotic alga secondarily choanoflagellates however bacterial origin would detected using typical phylogenomic approach since strongest sequence similarity would algal gene bacterial origin functions amino acid carbohydrate metabolism dominated among gene transfer candidates indicating choanoflagellates adapted acquisition algal genes expand metabolic repertoire the two examples outline test well defined hypotheses gene transfers using directed phylogenomic methods combination careful filtering interpretation results they powerful characterize role gene transfers distantly related eukaryotic groups adaptation eukaryotes however one disadvantage approach relies existing knowledge biology organisms transfers two organismal groups addressed important contributions groups may missed phylogenomic approaches in addition kinds studies estimate minimal number transfers groups analyzed number false negatives may large circumvent problems applied alternative approach study issues i first identified patchily distributed proteins expected enriched gene transfer events fig 1 instead screening unexpected sequence similarities then performed phylogenetic analyses identified gene family evaluate whether patchy distribution consequence gene transfer differential loss eukaryotic domain the soil dwelling cellular slime mold d. discoideum selected case study two reasons active research community produced high quality annotation genome sequence http://dictybase.org/ 18 potential gene transfers reported original publication i identified 49 protein families dictyostelium genome shared least one prokaryotic species limited number eukaryotes prokaryotes fig 1 the evolutionary history patchily distributed families analyzed seven families the remaining 42 families contained sequences one eukaryotic species outside dictyostelium genus the closest relative completely sequenced genome human parasite e. histolytica represented two families in contrast amoeboflagellate naegleria gruberi representative 25 families dictyostelium naegleria somewhat overlapping lifestyles free living heterotrophs found soil undergo cell differentiation certain conditions however distantly related eukaryotes classified within two different supergroups amoebozoa excavata exist least two alternative plausible explanations striking gene sharing pattern these genes present common ancestor dictyostelium naegleria distributed eukaryotes strictly vertical inheritance lineages different lifestyles i.e. parasites ) alternatively genes distributed via gene transfer recent evolutionary timescales providing selective advantage recipient lineages the vast majority phylogenetic trees showed strong indications lateral gene transfer prokaryotes eukaryotes within eukaryotes.figure 1b shows example individual gene tree the exact details transfer events could many cases traced density organismal sampling low nevertheless strong indications proteins evolved solely via vertical inheritance gene loss gene transfer likely affected patchily distributed genes families identified analysis extent only single protein among 49 identified patchily distributed among 18 gene transfer candidates original d. discoideum genome publication among 184 lateral gene transfer candidates reported n. gruberi this may surprising logical details methods applied considered dictyostelium genes significant similarity bacterial specific pfam domain present dictyostelium among eukaryotes considered gene transfer candidates this conservative approach unlikely pick false positives prone false negatives genes acquired via gene transfer two different eukaryotes excluded genes without sufficient sampling among prokaryotes included pfam similarly n. gruberi gene set screened similarity searches genes significant similarity prokaryotes considered gene transfer candidates again gene families repeated transfers missed screen eukaryote eukaryote transfers even considered the true number gene families microbial eukaryotes likely much larger reported the spread patchily distributed genes part adaptation process reason assume microbial eukaryotes take part flux genetic material fig 1 for example gene provide ability utilize carbon compound present environment likely spread different microbes environment previously lacking ability provided mechanisms action assumption gene vertical eukaryotic history is violated soon two eukaryotic lineages inhabit similar environment acquire copy particular gene family independently adaptation process the traditional phylogenomic approaches fail identify members protein families gene transfer candidates assume vertical inheritance norm protein families gene transfer events rare exceptions however probably case universal core genes certainly patchily distributed proteins fig 1 traditional phylogenomic approaches probably scratched surface gene transfer events thereby drastically underestimated impact process eukaryotic genome evolution	phylogenomic approaches have shown that eukaryotes acquire genes via gene transfer . however , there are two fundamental problems for most of these analyses ; only transfers from prokaryotes are analyzed and the screening procedures applied assume that gene transfer is rare for eukaryotes . directed studies of the impact of gene transfer on diverse eukaryotic lineages produce a much more complex picture . many gene families are affected by multiple transfer events from prokaryotes to eukaryotes , and transfers between eukaryotic lineages are routinely detected . this suggests that the assumptions applied in traditional phylogenomic approaches are too nave and result in many false negatives . this issue was recently addressed by identifying and analyzing the evolutionary history of 49 patchily distributed proteins shared between dictyostelium and bacteria . the vast majority of these gene families showed strong indications of gene transfers , both between and within the three domains of life . however , only one of these was previously reported as a gene transfer candidate using a traditional phylogenomic approach . this clearly illustrates that more realistic assumptions are urgently needed in genome - wide studies of eukaryotic gene transfer .
surgery performed 12 patients among 239 patients diagnosed ps using inclusion exclusion criteria table 1 these surgery indicated pain buttock pain mainly sciatica relieved conservative measures including education habitual position physical activity change medication physical therapy local steroid injections piriformis muscle extracorporeal shock wave therapy eswt least 3 months twelve patients underwent surgery ps average age patients 4 males 8 females underwent surgery 61 years range 45 71 years the average duration symptoms surgery 22.1 months range 4 72 months mean follow period 22.7 months range 12 43 months of 12 patients piriformis muscle resection without neurolysis 8 underlying pathologies including spinal stenosis 5 managed spinal block 3 undergone lumbar spinal surgery symptoms relieved three patients long time occupation related habitual sitting position 1 patient history sacral fracture we evaluated buttock pain without sciatica using visual analog scale vas 0 pain 10 maximum pain recorded responses preoperatively 3 days 12 months postoperatively kruskal wallis mann whitney u tests used post hoc analysis compare changes vas pain time the gluteus maximus divided direction fibers blunt dissection fascia lata incised continuity overlaid trochanter removed trochanteric bursa the piriformis muscle inserted posterior aspect greater trochanter tendinous nature located obturator internus tendon fig the sciatic nerve explored found pass anteriorly piriformis muscle cases additionally divided tight piriformis tendon insertion site tendinous portion the proximal portion muscle retracted leg internally rotated division neurolysis around sciatic nerve sciatic notch performed two cases severely adherent sciatic nerve severely dilated engorged epineurial vessels found two cases intractable sciatica fig after surgery patient activity assistance cane encouraged relieve pain gluteal muscle repair diagnostic procedure involved detailed physical examination including palpation test tenderness origin sacroiliac joint insertion short external rotators behind trochanter fig the clinical examination also included several provocation tests pain weakness resisted abduction external rotation thigh sitting position pace test pain forced passive internal rotation extended thigh freiberg test buttock leg pain passive straight leg raising lasgue sign in addition electromyography various imaging studies including ct mri ultrasonography performed steroid injection piriformis muscle carried diagnostic treatment exclude sciatica caused spinal problems repeated patients greater 50% relief symptoms sciatica caudal block excluded diagnosis ps asymmetry piriformis muscle ct mri considered positive finding ps an electromyographic finding radiculopathy attributed spinal root compression ps fig the gluteus maximus divided direction fibers blunt dissection fascia lata incised continuity overlaid trochanter removed trochanteric bursa the piriformis muscle inserted posterior aspect greater trochanter tendinous nature located obturator internus tendon fig the sciatic nerve explored found pass anteriorly piriformis muscle cases additionally divided tight piriformis tendon insertion site tendinous portion the proximal portion muscle retracted leg internally rotated division neurolysis around sciatic nerve sciatic notch performed two cases severely adherent sciatic nerve severely dilated engorged epineurial vessels found two cases intractable sciatica fig after surgery patient activity assistance cane encouraged relieve pain gluteal muscle repair the diagnostic procedure involved detailed physical examination including palpation test tenderness origin sacroiliac joint insertion short external rotators behind trochanter fig the clinical examination also included several provocation tests pain weakness resisted abduction external rotation thigh sitting position pace test pain forced passive internal rotation extended thigh freiberg test buttock leg pain passive straight leg raising lasgue sign in addition electromyography various imaging studies including ct mri ultrasonography performed steroid injection piriformis muscle carried diagnostic treatment exclude sciatica caused spinal problems repeated patients greater 50% relief symptoms sciatica caudal block excluded diagnosis ps asymmetry piriformis muscle ct mri considered positive finding ps an electromyographic finding radiculopathy attributed spinal root compression ps fig for diagnosis ps physical examinations including several provocative tests radiographic studies plain x ray ct mri emg injection performed when diagnosis ps suspected various conservative treatments initially performed patients generally provided good results table 2 of 239 patients 12 patients refractory conservative treatment underwent surgical treatment.table 3 summarizes clinical features results surgical treatment physical examination tenderness gluteal area particularly iliac side sacroiliac joint detected 10 patients 83% pain provocative tests freiberg pace tests positive 7 patients 58% electrodiagnostic testing showed specific findings delayed h reflex flexion adduction internal rotation position suggesting ps opposed pathologies lumbosacral radiculopathy sciatic nerve palsy posterior cutaneous neuropathy thigh asymmetry piriformis muscle hyperintensity around sciatic nerve ct mri detected 5 patients 42% fig three patients occupations involved sitting long duration sewing driving of 12 patients undergoing surgical resection piriformis muscle neurolysis performed 2 patients due severely adherent scarred sciatic nerve engorged epineurial vessels around sciatic nerve shrank spontaneously resection piriformis muscle the average length skin incision 9.5 cm average amount postoperative bleeding 24.5 ml postoperative complications including hematoma infection delayed wound healing scar formation myositis ossificans the average duration hospitalization 5.3 days range 3 9 days compared preoperatively mean vas score 9 ) vas scores significantly decreased immediately surgery mean vas score 4 12-month follow mean vas score 3.1 table 4 persistent buttock pain surgery present 3 patients among 1 patient symptom relief 12 months the diagnosis ps mostly elusive remains controversial due lack consistent objective diagnostic criteria the differential diagnoses include herniation nucleus pulposus hnp myofascial pain sacroiliitis trochanteric bursitis sciatic nerve impinging conditions study diagnosis ps could established patient history careful physical examination local injection piriformis muscle etiological findings identified emg imaging studies including ct mri fig because lumbosacral hnp spinal stenosis commonly occurs l4 5 l5-s1 intervertebral space important determine whether pain originates root peripheral nerve.10 patients ps symptoms neurological claudication rare pain aggravation position change prolonged sitting frequently observed specific sensory changes dermatomes muscle weakness help exclude ps based cases suggest three cardinal symptoms ps buttock pain radiating pain posterior thigh knee pain aggravated position changes prolonged sitting piriformis muscle firm hard palpation greater sciatic notch posterior aspect greater trochanter in physical examination tenderness piriformis muscle 83% consistent finding although emg often normal patients ps continuous compression may result abnormal spontaneous activity muscles innervated sciatic nerve including delay h reflex affected leg flexed adducted internally rotated position.11 study electrodiagnostic testing helpful diagnosis ps useful ruling causes similar symptoms lumbosacral radiculopathy diagnostic imaging modalities including ct mri mrn used many studies diagnose ps.12131415 however studies limited cases showing atypical anatomy including asymmetry piriformis muscle hyperintensity sciatic nerve conditions accounted 5 12 surgical patients 42% study sayson et al.16 barton17 found preoperative mri failed identify atypical anatomy found intraoperatively mrn relatively new technique developed specifically enhance imaging nerves filler et al.1 used mrn prospectively investigate 87 patients sciatica like pain either standard testing failed yield diagnosis failed lumbar disc surgery 67% group diagnosed ps however tiel18 pointed methodological technical problems mrn some reports suggested diagnostic criteria ps.1920 recently michel et al.21 proposed use clinical scoring system ps considered probable score 8 12 points however includes negative findings spinal disease lower back pain painless axial spinal palpation negative lasgue maneuver absence perineal irritation 4 points scoring system including negative findings spinal problems result overdiagnosis ps in addition scoring system involves obscure physical tests provoke buttock pain sciatica stretching resisted contraction include diagnostic tests local steroid injection widely used tool establishing diagnosis they comprised 5 items buttock pain without sciatica prolonged sitting tenderness piriformis muscle positive provocative tests positive findings ct mri pain relief local injection additionally caudal epidural block tried least surgery study we suggest exclude diagnosis ps following findings symptoms neurologic claudication positive lasgue straight leg raise test sensory changes nerve root innervation radiculopathy emg effective caudal epidural block the sciatic nerve compression piriformis muscle surrounding fibrous bands different nerve root compression spinal origin absent clinical findings due nerve root compression important diagnosis ps initial nonoperative treatment ps includes medications nonsteroidal anti inflammatory drugs muscle relaxants medications effective neuropathic pain pregabalin gabapentin physiotherapy eswt injections local anesthetics corticosteroids recently investigated option botulinum neurotoxin injections.8 study eswt applied patients buttock pain twice interval 1 week pain subsides significantly eswt undertaken 2,000 pulses time 1 week interval totaling 4,000 6,000 pulses our clinical results demonstrated effective modality treatment ps reducing buttock pain eswt we satisfactory clinical results release piriformis muscle neurolysis sciatic nerve patients refractory sciatica fail respond successfully conservative treatments intraoperatively identification piriformis muscle among short external rotator muscles posterior retraction complete resection muscle important careful dissection fibrous tissues around sciatic nerve also essential avoid damaging nerve proper dilated vaso nervorum deep gluteal syndrome dgs disease entity characterized pain dysesthesia buttock area hip posterior thigh and/or radicular pain due nondiscogenic sciatic nerve entrapment subgluteal space.22 main pathology fibrous bands around sciatic nerve formed various pathological conditions piriformis syndrome obturator internus gemellus syndrome ischiofemoral impingement the causes dgs include traumatic iatrogenic inflammatory infectious vascular gynecological processes tumors pseudotumors therefore treatment dgs decompression sciatic nerve via open endoscopic surgery it clear whether resection piriformis muscle additional benefits decompression sciatic nerve ps however recurrence sciatic nerve adhesions avoided muscle resected.1 endoscopic surgery adhesiolysis sciatic nerve several advantages open methods including less invasiveness less postoperative pain.23 however endoscopic sciatic nerve release technically demanding limited efficacy release severely adherent sciatic nerve considering that no prospective randomized trial evaluated surgical treatment outcomes ps important finding study significant decrease symptoms surgery achieve good results indications surgery response physical therapy least one injection ) should determined upon proper diagnosis based exclusively clinical spine evaluations surgery important treatment option unresolved ps low morbidity simplicity overcome limitations work prospective study greater number cases longer follow period should performed establish gold standard methods diagnosis treatment ps furthermore several modalities diagnosis ps developed conclusions the diagnosis ps obscure elusive systematic approach helpful if diagnosis determined correctly surgical treatment good option patients refractory pain particularly sciatica despite application appropriate conservative treatment modalities	backgroundpiriformis syndrome ( ps ) is an uncommon disease characterized by symptoms resulting from compression / irritation of the sciatic nerve by the piriformis muscle . uncertainty and controversy remain regarding the proper diagnosis and most effective form of treatment for ps . this study analyzes the diagnostic methods and efficacy of conservative and surgical treatments for ps.methodsfrom march 2006 to february 2013 , we retrospectively reviewed 239 patients who were diagnosed with ps and screened them for eligibility according to our inclusion / exclusion criteria . all patients underwent various conservative treatments initially including activity modification , medications , physical therapy , local steroid injections into the piriformis muscle , and extracorporeal shock wave therapy for at least 3 months . we resected the piriformis muscle with / without neurolysis of the sciatic nerve in 12 patients who had intractable sciatica despite conservative treatment at least for 3 months . the average age of the patients ( 4 males and 8 females ) was 61 years ( range , 45 to 71 years ) . the average duration of symptoms before surgery was 22.1 months ( range , 4 to 72 months ) , and the mean follow - up period was 22.7 months ( range , 12 to 43 months ) . we evaluated the degree of pain and recorded the responses using a visual analog scale ( vas ) preoperatively and 3 days and 12 months postoperatively.resultsbuttock pain was more improved than sciatica with various conservative treatments . compared with preoperatively , the vas score was significantly decreased after the operation . overall , satisfactory results were obtained in 10 patients ( 83% ) after surgery.conclusionsps is thought to be an exclusively clinical diagnosis , and if the diagnosis is performed correctly , surgery can be a good treatment option in patients with refractory sciatica despite appropriate conservative treatments .
	the epitaxial growth of monocrystalline semiconductors on metal nanostructures is interesting from both fundamental and applied perspectives . the realization of nanostructures with excellent interfaces and material properties that also have controlled optical resonances can be very challenging . here we report the synthesis and characterization of metal semiconductor core shell nanowires . we demonstrate a solution - phase route to obtain stable core shell metal cu2o nanowires with outstanding control over the resulting structure , in which the noble metal nanowire is used as the nucleation site for epitaxial growth of quasi - monocrystalline cu2o shells at room temperature in aqueous solution . we use x - ray and electron diffraction , high - resolution transmission electron microscopy , energy dispersive x - ray spectroscopy , photoluminescence spectroscopy , and absorption spectroscopy , as well as density functional theory calculations , to characterize the core shell nanowires and verify their structure . metal semiconductor core shell nanowires offer several potential advantages over thin film and traditional nanowire architectures as building blocks for photovoltaics , including efficient carrier collection in radial nanowire junctions and strong optical resonances that can be tuned to maximize absorption .
recent evidences support using paclitaxel drug coated balloon dcb catheters therapeutic method de novo coronary lesions stent restenosis isr small coronary vessels coronary bifurcation lesions dcb designed achieve comparable efficacy neointimal proliferation local drug delivery without requiring foreign body implantation prolonged dual antiplatelet therapy dapt the advantages dcb include homogeneous high concentration drug delivery entire vessel wall absence stent layer absence polymer could lead chronic inflammation dcb promising device overcome limitations des percutaneous coronary intervention pci isr late late stent thrombosis risk bleeding caused prolonged dapt although dcb shown remarkable angiographic clinical effects coronary artery interventional therapy limitations treatment de novo coronary lesions elastic recoil flow limiting dissections may main reasons therapy failure lack mechanical scaffolding provided stent struts use dcb may ideal complex coronary lesions therefore strategy combining dcb bare metal stent bms potential solution overcome limitations the rapid endothelialization shorter dapt duration bms des beneficial certain scenarios however studies examining efficiency dcb bms compared stents alone de novo lesions yielded inconsistent results whether strategy provides additional benefits remains unclear hence conducted comprehensive meta analysis randomized controlled trials rcts assess compare clinical efficacy safety dcb bms stents alone de novo coronary lesions we comprehensively searched related papers electronic databases pubmed web science cochrane central register controlled trials september 2016 identify potential rcts paclitaxel eluting balloon drug eluting balloon drug coated balloon ethical approval required due systematic review meta analysis all included studies approved notified ethics committees institutional review boards study performed accordance preferred reporting items systematic reviews meta analyses prisma statement studies met following inclusion criteria included meta analysis rcts de novo coronary artery lesions intervention dcb bms treatment arm eligible angiographic clinical outcome data obtained follow data abstraction performed independently 2 investigators lu zhu discrepancies resolved consensus the following features eligible study extracted using standardized form study patient characteristics intervention procedures angiographic clinical outcomes the cochrane collaboration tool used methodologically assess risk bias evaluate quality included trials the following methodological domains considered random sequence generation allocation concealment blinding drop rates incomplete outcome data addressing incomplete outcome data selective reporting potential sources bias assessment included study labeled low risk l high risk h or primary endpoints segment late lumen loss lll major adverse cardiac events maces the secondary endpoints segment binary restenosis br segment minimum lumen diameter mld target lesion revascularization tlr myocardial infarction mi death maces defined composite death mi tlr similar endpoint used data mentioned endpoint unavailable we conducted meta analysis using cochrane program review manager v.5.0 oxford england stata software version 12.0 statcorp college station tx according inverse variance fixed effect model categorical variables calculated pooled risk ratio rr 95% confidence intervals cis continuous variables presented estimated mean difference md 95% ci if 50% substantial important heterogeneity random effect model used quantitative data synthesis whereas fixed model adopted begger funnel plots egger tests used assess publication bias p 0.05 threshold statistical significance we comprehensively searched related papers electronic databases pubmed web science cochrane central register controlled trials september 2016 identify potential rcts paclitaxel eluting balloon drug eluting balloon drug coated balloon ethical approval required due systematic review meta analysis all included studies approved notified ethics committees institutional review boards study performed accordance preferred reporting items systematic reviews meta analyses prisma statement studies met following inclusion criteria included meta analysis rcts de novo coronary artery lesions intervention dcb bms treatment arm eligible angiographic clinical outcome data obtained follow data abstraction performed independently 2 investigators lu zhu discrepancies resolved consensus the following features eligible study extracted using standardized form study patient characteristics intervention procedures angiographic clinical outcomes the cochrane collaboration tool used methodologically assess risk bias evaluate quality included trials the following methodological domains considered random sequence generation allocation concealment blinding drop rates incomplete outcome data addressing incomplete outcome data selective reporting potential sources bias assessment included study labeled low risk l high risk h unclear risk u the primary endpoints segment late lumen loss lll major adverse cardiac events maces the secondary endpoints segment binary restenosis br segment minimum lumen diameter mld target lesion revascularization tlr myocardial infarction mi death maces defined composite death mi tlr similar endpoint used data mentioned endpoint unavailable we conducted meta analysis using cochrane program review manager v.5.0 oxford england stata software version 12.0 statcorp college station tx according inverse variance fixed effect model categorical variables calculated pooled risk ratio rr 95% confidence intervals cis continuous variables presented estimated mean difference md 95% ci if 50% substantial important heterogeneity random effect model used quantitative data synthesis whereas fixed model adopted begger funnel plots egger tests used assess publication bias p 0.05 threshold statistical significance we initially screened total 7668 potential studies number searches eliminating duplicates 505 articles examined 11 rcts total 2196 patients met inclusion criteria included meta analysis figure 1 presents flowchart overall search strategy among 11 studies four studies 3-arm trials comparing subgroups dcb bms bms alone des alone therefore studies considered 2 separate trials we finally selected 9 studies comparing dcb bms des alone 6 comparing dcb bms bms alone the clinical angiographic primary endpoints provided trials follow durations 6 24 months furthermore dcb bms used 714 patients whereas control treatments namely bms alone des alone used 190 715 patients respectively the key demographic angiographic characteristics included studies summarized tables 1 2 respectively flow diagram identification processes general characteristics studies included meta analysis lesions devices characteristics included studies lll reported 9 11 studies within follow periods 6 9 months nine studies included dcb bms versus des subgroup analysis whereas 5 studies included dcb bms versus bms subgroup analysis compared des alone subgroup the dcb bms subgroup exhibited significant increase lll md 0.19 95% ci 0.060.32 p 0.0042 however dcb bms subgroup showed nonsignificantly lower lll bms alone subgroup md 0.14 95% ci 0.330.04 p 0.24 fig effectiveness dcb bms strategy versus des alone maces observed 10 11 studies within follow period 6 24 months fixed effect model used subgroup analysis indicated compared des alone dcb bms significantly increased maces rr 1.88 95% ci 1.442.45 p 0.0001 the subgroup analysis showed dcb bms strategy advantageous bms treatment reducing maces incidence borderline significant rr 0.67 95% ci 0.450.99 p 0.05 fig seven 3 studies follow periods 6 9 months included dcb bms versus des alone dcb bms versus bms alone subgroup analyses respectively subgroup analysis showed dcb bms strategy inferior des alone strategy reducing br incidence rr 2.15 95% ci 1.074.31 p 0.03 dcb bms versus bms subgroup analysis showed dcb bms beneficial difference strategies nonsignificant rr 0.74 95% ci 0.341.60 p 0.44 respectively fig effectiveness dcb bms strategy versus des alone secondary angiographic endpoints segment binary restenosis rate b segment minimum lumen diameter six 3 studies follow periods 6 9 months included dcb bms versus des alone dcb bms versus bms alone subgroup analyses respectively compared des alone dcb bms had significant lower mld md 0.25 95% ci 0.41 0.10 p 0.001 significant effect favoring dcb bms detected dcb bms versus bms alone subgroup analysis md 0.18 95% ci 0.030.33 p 0.02 fig all 3 endpoints reported 9 11 studies within follow periods 6 24 months because low degree heterogeneity used fixed effect model quantitative analysis tlr analysis indicated significantly higher risk tlr dcb bms subgroup des alone subgroup rr 1.94 95% ci 1.272.98 p 0.002 incidence rate tlr differ significantly dcb bms subgroup bms alone subgroup rr 0.71 95% ci 0.471.09 p 0.012 fig mi analysis showed significant difference mi incidence dcb bms des alone subgroups rr 0.88 95% ci 0.322.42 p 0.81 similarly incidence rate mi comparable following dcb bms bms alone implantation rr 0.51 95% ci 0.161.67 p 0.27 fig death analysis revealed death differ significantly dcb bms des subgroups rr 5.91 95% ci 0.7248.39 p 0.10 similar results observed dcb bms versus bms subgroup analysis rr 0.20 95% ci 0.021.70 p 0.14 effectiveness dcb bms strategy versus des alone secondary clinical endpoints target lesion revascularization b mi c death according results heterogeneity analysis conducted sensitivity analysis dcb bms control groups dcb bms vs des dcb bms vs bms subgroups observed endpoints we sequentially eliminated one study time observed study strongly influenced overall results egger test showed evidence significant publication bias meta analysis p 0.05 in addition funnel plot symmetrical suggesting publication bias fig seven 5 included studies showed low risk bias random sequence generation allocation concealment respectively five studies showed low risk bias blinding participants 5 high risk bias blinding outcome assessment all studies low risk bias regarding incomplete outcome data selective outcome reporting we initially screened total 7668 potential studies number searches eliminating duplicates 505 articles examined 11 rcts total 2196 patients met inclusion criteria included meta analysis figure 1 presents flowchart overall search strategy among 11 studies four studies 3-arm trials comparing subgroups dcb bms bms alone des alone therefore studies considered 2 separate trials we finally selected 9 studies comparing dcb bms des alone 6 comparing dcb bms bms alone the clinical angiographic primary endpoints provided trials follow durations 6 24 months furthermore dcb bms used 714 patients whereas control treatments namely bms alone des alone used 190 715 patients respectively the key demographic angiographic characteristics included studies summarized tables 1 2 respectively flow diagram identification processes general characteristics studies included meta analysis lesions devices characteristics included studies lll reported 9 11 studies within follow periods 6 9 months nine studies included dcb bms versus des subgroup analysis whereas 5 studies included dcb bms versus bms subgroup analysis compared des alone subgroup the dcb bms subgroup exhibited significant increase lll md 0.19 95% ci 0.060.32 p 0.0042 however dcb bms subgroup showed nonsignificantly lower lll bms alone subgroup md 0.14 95% ci 0.330.04 p 0.24 fig effectiveness dcb bms strategy versus des alone maces observed 10 11 studies within follow period 6 24 months fixed effect model used subgroup analysis indicated compared des alone dcb bms significantly increased maces rr 1.88 95% ci 1.442.45 p 0.0001 the subgroup analysis showed dcb bms strategy advantageous bms treatment reducing maces incidence borderline significant rr 0.67 95% ci 0.450.99 p 0.05 fig in segment br rate seven 3 studies follow periods 6 9 months were included dcb bms versus des alone dcb bms versus bms alone subgroup analyses respectively subgroup analysis showed dcb bms strategy inferior des alone strategy reducing br incidence rr 2.15 95% ci 1.074.31 p 0.03 dcb bms versus bms subgroup analysis showed dcb bms beneficial difference strategies nonsignificant rr 0.74 95% ci 0.341.60 p 0.44 respectively fig effectiveness dcb bms strategy versus des alone secondary angiographic endpoints segment binary restenosis rate b segment minimum lumen diameter segment mld six 3 studies follow periods 6 9 months included dcb bms versus des alone dcb bms versus bms alone subgroup analyses respectively compared des alone dcb bms significant lower mld md 0.25 95% ci 0.41 0.10 p 0.001 significant effect favoring dcb bms detected dcb bms versus bms alone subgroup analysis md 0.18 95% ci 0.030.33 p 0.02 fig all 3 endpoints reported 9 11 studies within follow periods 6 24 months because low degree heterogeneity used fixed effect model quantitative analysis tlr analysis indicated significantly higher risk tlr dcb bms subgroup des alone subgroup rr 1.94 95% ci 1.272.98 p 0.002 incidence rate tlr differ significantly dcb bms subgroup bms alone subgroup rr 0.71 95% ci 0.471.09 p 0.012 fig mi analysis showed significant difference mi incidence dcb bms des alone subgroups rr 0.88 95% ci 0.322.42 p 0.81 similarly incidence rate mi comparable following dcb bms bms alone implantation rr 0.51 95% ci 0.161.67 p 0.27 fig death analysis revealed death differ significantly dcb bms des subgroups rr 5.91 95% ci 0.7248.39 p 0.10 similar results observed dcb bms versus bms subgroup analysis rr 0.20 95% ci 0.021.70 p 0.14 effectiveness dcb bms strategy versus des alone secondary clinical endpoints target lesion revascularization b mi c death according results heterogeneity analysis conducted sensitivity analysis dcb bms control groups dcb bms vs des dcb bms vs bms subgroups observed endpoints we sequentially eliminated one study time observed study strongly influenced overall results egger test showed evidence significant publication bias meta analysis p 0.05 in addition funnel plot symmetrical suggesting publication bias fig 5 funnel plot publication bias primary angiographic endpoint segment late lumen loss b ) seven 5 included studies showed low risk bias random sequence generation allocation concealment respectively five studies showed low risk bias blinding participants 5 high risk bias blinding outcome assessment all studies low risk bias regarding incomplete outcome data selective outcome reporting our present meta analysis included largest number rcts date showed although dcb bms strategy performed favorably bms alone strategy superior des alone strategy treatment de novo coronary lesions its dramatic ability inhibit neointimal hyperplasia sustained elution cytostatic drugs turns significantly reduced repeat revascularization rate clinical trials nevertheless cases treatment failure mainly isr stent thrombosis st attracted attention considering sizeable number patients des implantation various factors required satisfactorily resolve slow drug release polymer induced inflammation endothelial dysfunction coronary vasoconstriction disturbance therefore paclitaxel dcb may emerging therapeutic alternative advantages operative simplicity homogeneous antiproliferative agent release along entire device avoid disadvantages des researchers tried combine dcb bms achieve benefits dcb provided local release antiproliferative agents bms prevented acute postangioplasty recoil although bello study showed compared pes small vessels reference diameter 2.8 mm dcb yielded significantly lower stent balloon late loss similar rates restenosis revascularization however well designed head head studies comparing dcb des strategies lesions lumen diameters 2.5 mm all studies included present meta analysis applied dcb bms therapeutic strategy de novo coronary lesions lumen diameter 2.5 mm nevertheless pooled results research showed clinical efficacy safety dcb bms strategy equivalent des alone strategy de novo coronary lesions regarding maces rate replacing des implantation dcb bms beneficial simple de novo coronary lesion intervention first lack sufficient uncoated balloon predilation included study may contributed result predilation dcb use could improve drug uptake vessel wall creation microdissections thus facilitating drug transport intima media particularly calcified lesions the valentines ii trial adopted regular balloon predilatation target lesion followed dior ii dcb reported low segment lll tlr rates meanwhile 1 rct adopted regular balloon predilatation compared efficacy bms dcb combination versus bms alone patients non st elevation acute coronary syndrome also reported significantly lower lll absence favorable effect patient clinical outcomes second speculated geographical miss caused unfavorable geometric proportions potential influencing factor reference point stent balloon placement missing one clinical trial reported patients treated dcb predilatation additional bms implantation high proportion geographical miss identified independent significant predictor restenosis if stent deployment precedes dcb dilatation contact surface balloon vessel wall reduced approximately 15% owing surface stent struts the octopus trial used optical coherence tomography reported dcb bms associated pronounced neointimal proliferation des the ivus study used intravascular ultrasound also showed pronounced neointimal hyperplasia dcb bms group leading revascularization des group possible influencing factors interaction mounted stent drug release dcb stent balloon lengths drug concentrations stent system our meta analysis included 2 strategies dcb application pre- post bms implantation theoretically dcb used bms implantation could increase risk geographical mismatch stent may implanted partly outside dcb treated segment contrast dcb used bms implantation might affect drug delivery vessel interposition stent struts optical coherence tomography oct study investigated effects sequence dcb bms i.e. dcb first bms first stated bms first sequence translated favorable apposition dcb first sequence evidenced significantly low proportion incomplete stent apposition isa struts nonsignificantly low isa areas volumes former however indicor trial another oct study used dcb different manufacturers suggested sequence dcb application affect lll maces stent neointimal hyperplasia similar clinical angiographic results reported pact coro trial finally possible explanation findings currently used dcb particularly first generation dcbs failed warrant sufficient bioavailability paclitaxel lesion site bondesson et al reported differential treatment outcomes various dcbs variation may even larger caused des drug delivery vessel wall crucial balloon inflation regarding lll pharmacokinetics paclitaxel first generation dcbs may insufficient provide comparable benefits a recent experimental study showed much higher drug concentrations vessel wall using dior ii dcb dior combined shorter inflation time hence using second generation dcb bms higher tissue drug delivery dose might lead better angiographic clinical outcomes de novo lesions second studies relatively short follow durations definitive conclusions necessitate clinical follow several additional years finally included studies conducted western countries hence data non western countries inadequate precisely assess clinical efficacy safety dcb bms strategy de novo lesions thus large multicenter well designed randomized trials recruiting patients countries required provide additional insights the present meta analysis favor dcb bms strategy alternative therapeutic method des implantation de novo coronary artery lesions pci additional well designed large rcts long follow periods required resolve concern	abstractbackground : studies examining the efficiency of drug - coated balloon ( dcb ) + bare metal stent ( bms ) compared with stents alone for de novo lesions have reported inconsistent results . the present comprehensive meta - analysis of randomized controlled trials ( rcts ) assessed and compared the clinical efficacy and safety of dcb + bms with those of stents alone for de novo coronary artery disease.methods:we formally searched electronic databases before september 2016 to identify potential studies . all rcts were eligible for inclusion if they compared dcb + bms with a control treatment ( drug - eluting stent [ des ] alone or bms alone ) in patients with de novo coronary artery disease.results:eleven rcts with a total of 2196 patients met the inclusion criteria were included in our meta - analysis . subgroup analysis indicated dcb plus bms was associated with poorer outcomes when compared with des alone in primary endpoint { ( in - segment late lumen loss [ lll ] : mean difference [ md ] , 0.19 ; 95% confidence interval [ ci ] , 0.060.32 ; p = 0.0042 ) and ( major adverse cardiovascular events [ maces ] : risk ratio [ rr ] , 1.88 ; 95% ci , 1.442.45 ; p < 0.0001)}. however , dcb + bms had nonsignificantly lower lll than bms alone ( in - segment lll : md , 0.14 ; 95% ci , 0.330.04 ; p = 0.24 ) , and was more advantageous in reducing mace incidence , with borderline significance ( maces : rr , 0.67 ; 95% ci , 0.450.99 ; p = 0.05).conclusions : in summary , the present results do not favor the dcb + bms strategy as an alternative therapeutic method to des implantation for de novo coronary artery lesions in percutaneous coronary intervention ( pci ) . additional well - designed large rcts with long - follow - up periods are required to clarify the inconsistent results .
minimally invasive surgical techniques revolutionized treatment many problems seen general surgeon although impact greatest treatment cholelithiasis many advantages achieved laparoscopic cholecystectomy realized advanced laparoscopic procedures since first initial reports laparoscopic right hemicolectomy february 1990 sigmoid resection october 1990 laparoscopic assisted colectomy lac found numerous advantages compared open colectomy among advantages less blood loss fewer wound complications rapid return intestinal function less pain shorter hospitalization quicker return work but lac widely accepted surgical treatment choice patients requiring colon resection first procedure technically much difficult second although reported good results lac yet proven yield equal better results treatment colon cancer compared open colectomy indeed much concern raised possibility increased recurrence rates port site metastasis possibility lac prove adequate resection cure cancer even though lac benign disease yielded good results small percentage surgeons offer lac treatment benign disease discussing options patients overall biggest impediment widespread adoption lac benign disease remains difficulty procedure experience colon mobilization division mesentery difficult parts procedure surgeon learn the anastomosis usually completed extracorporeally transanal circular stapler much would done open surgery the development ultrasonically activated shears laparosonic coagulating shears lcs ethicon endo surgery ultracision smithfield ri provided alternative technology mobilization colon division mesentery evaluate efficacy safety efficiency new energy source retrospectively reviewed portion series lac cases from october 1990 may 1997 118 laparoscopic colon resections completed variety indications thirty three patients colectomy right hemicolectomy sigmoid resection eliminated study the charts remaining 85 patients underwent either laparoscopic assisted right hemicolectomy laparoscopic assisted sigmoidectomy reviewed retrospectively authors patients underwent curative resection carcinoma colon entered institutional review board irb approved prospective study the operative notes reviewed determine method colon mobilized mesentery divided review two groups identified one dissection done without lcs lcs group one dissection done lcs lcs group the age sex indication surgery operative times estimated blood loss ebl length stay los documented group all surgical procedures performed similar fashion senior author laparoscopic surgery fellow direct supervision senior author patients the colon mobilized mesentery divided totally laparoscopic technique cases completed without lcs hemostasis obtained combination clips endoscopie linear cutting staplers monopolar cautery delivered scissors the technique using lcs varied according whether benign malignant disease cases benign disease other methods hemostasis usually necessary unless benign disease extensive required wide dissection mesentery cases malignancy a high ligation vascular pedicle ileocolic artery right colectomy inferior mesenteric superior sigmoid artery sigmoid resection accomplished endoscopie linear cutting stapler a plastic wound protector routinely placed mini laparotomy incision specimen extraction the anastomosis right hemicolectomy completed extracorporeally via minilaparotomy anastomosis sigmoid resection created intracorporeally using circular stapler passed transanally all surgical procedures performed similar fashion senior author laparoscopic surgery fellow direct supervision senior author patients the colon mobilized mesentery divided totally laparoscopic technique cases completed without lcs hemostasis obtained combination clips endoscopie linear cutting staplers monopolar cautery delivered scissors the technique using lcs varied according whether benign malignant disease cases benign disease other methods hemostasis usually necessary unless benign disease extensive required wide dissection mesentery cases malignancy a high ligation vascular pedicle ileocolic artery right colectomy inferior mesenteric superior sigmoid artery sigmoid resection accomplished endoscopie linear cutting stapler a plastic wound protector routinely placed mini laparotomy incision specimen extraction the anastomosis right hemicolectomy completed extracorporeally via minilaparotomy anastomosis sigmoid resection created intracorporeally using circular stapler passed transanally of 85 patients 36 procedures completed without lcs lcs group 49 use lcs lcs group the female male ratio 2:1 lcs group 1.6:1 lcs group the average age 67.9 years range 28 101 lcs group 62.6 years range 25 91 lcs group right hemicolectomy indicated carcinoma 74% time groups table 1 large adenomas arteriovenous malformations one case lymphoma indications sigmoid colectomy indicated diverticulitis 58% lcs group 79% lcs group table 2 the indications sigmoid colectomy lcs group sigmoid stricture sigmoid volvulus hence majority sigmoid resections completed diverticulitis majority right hemicolectomies carcinoma fifteen 36 patients 42% lcs group 22 49 patients 45% lcs group previous abdominal pelvic surgery average operating room time less lcs used 170 min vs. 187 min average blood loss nearly whether lcs used 95 ml vs. 98 ml p=0.7620 table 3 the los less lcs group 4.3 days vs. 6.9 days p=0.0018 reach statistical significance three patients overall postoperative bleeding stapled anastomosis incidence 3.5% another patient sigmoidectomy unsuccessful colonoscopic attempt control bleeding required transanal suture staple line 3 units blood transfused a third patient bled stapled ileocolic anastomosis heparin therapy started treat postoperative pulmonary embolus however heparin started patient rebled therefore vena caval filter placed of note none patients bled bled area dissection lcs even heparin therapy caused anastomotic bleeding hence early late bleeding complications areas dissection lcs additionally early late complications could related use shears of 85 patients 36 procedures completed without lcs lcs group 49 use lcs lcs group the female male ratio 2:1 lcs group 1.6:1 lcs group the average age 67.9 years range 28 101 lcs group 62.6 years range 25 91 lcs group right hemicolectomy indicated carcinoma 74% time groups table 1 large adenomas arteriovenous malformations one case lymphoma indications sigmoid colectomy indicated diverticulitis 58% lcs group 79% lcs group table 2 the indications sigmoid colectomy lcs group sigmoid stricture sigmoid volvulus hence majority sigmoid resections completed diverticulitis majority right hemicolectomies carcinoma fifteen 36 patients 42% lcs group 22 49 patients 45% lcs group previous abdominal pelvic surgery average operating room time less lcs used 170 min vs. 187 min p=0.1989 reach statistical significance average blood loss nearly whether lcs used 95 ml vs. 98 ml p=0.7620 table 3 the los less lcs group 4.3 days vs. 6.9 days p=0.0018 reach statistical significance three patients overall postoperative bleeding stapled anastomosis incidence 3.5% another patient sigmoidectomy unsuccessful colonoscopic attempt control bleeding required transanal suture staple line 3 units blood transfused a third patient bled stapled ileocolic anastomosis heparin therapy started treat postoperative pulmonary embolus however heparin started patient rebled therefore vena caval filter placed of note none patients bled bled area dissection lcs even heparin therapy caused anastomotic bleeding hence early late bleeding complications areas dissection lcs additionally early late complications could related use shears this report single institution single surgeon experience lac dates first reported cases lac although many new instruments technologies introduced since fundamental surgical techniques principles described changed the difficult steps lac intracorporeal mobilization colon division mesentery the learning curve techniques much longer techniques required laparoscopic cholecystectomy slowed widespread use lac patients needing colon resection this study done assess use new technology ultrasonically activated shears mobilization colon division mesentery the jaws shears consist active blade opposing passive ultrasonically activated movable tissue pad this allows surgeon grasp tissue vessels within jaws shears coapt endothelium vessels tissue the ultrasonic energy transmitted tissue seal blood vessels divide grasped the shears shown facilitate completion advanced laparoscopic procedures division short gastric arteries nissen fundoplication division infundibulopelvic ligament laparoscopic assisted vaginal hysterectomy depending power setting generator active blade move 50 100 microns oscillation touching active blade tissue transfers mechanical energy blade tissue this mechanical energy breaks hydrogen bonds protein tissue resulting sticky coagulum seals blood vessels this allow blood vessels 3 mm sealed shears without need method achieve hemostasis relatively little heat generated compared energy sources since energy delivered mechanical energy the relatively low level heat generated increases safety instrument used adjacent viscera small intestine great vessels the largest named arteries mesentery may need controlled means clips ligatures endoscopie linear cutting stapler we found ultrasonically activated shears utilized need scissors pre tied loops clips linear cutting staplers markedly reduced situations blood vessels less 3 mm colon resections benign disease high vascular pedicle division necessary longer needed entire dissection could completed shears compared lac done without shears overall operative times blood loss similar although operative times shears little bit shorter could due increase skills progressed along learning curve however skills improved partly due availability shears attempted completed many difficult procedures would tried without shears documented 20% higher incidence diverticulitis lcs group difficult cases inevitably would taken time cases tried initially shears therefore shorter length time group shears used although great probably significant since often difficult cases shears it opinion use shears greatly facilitated successful completion complex cases the literature documents decreased length stay following lac present study although los group used shears less difference probably due changes postoperative management became comfortable familiar recovery patients lac since patients treated without shears treated early experience shears available decrease length stay probably related experience experience we learned early advancement diet earlier discharge possible patient less pain shorter ileus following lac we see reason use ultrasonically activated shears would reduce pain shorten ileus see reason use lcs would explain shorter length stay the ultrasonically activated shears safe effective device mobilizing colon dividing mesentery lac experienced laparoscopic surgeon use shears reduce time required routine cases lac and for inexperienced laparoscopic surgeon substitute appropriate training shears potential shorten learning curve inexperienced surgeon facilitating two difficult technical parts lac	background and objectives : mobilization of the colon and dissection of the mesentery are difficult laparoscopic techniques . traditional methods have been used for this dissection , but often with great difficulty . the ultrasonically activated shears , when introduced in 1993 , had the possibility to make this dissection less technically difficult . this is a retrospective review of the use of these shears for these techniques during laparoscopic - assisted colectomy.materials and methods : eighty - five patients underwent a laparoscopic - assisted right hemicolectomy or sigmoid resection . colon mobilization and mesenteric dissection were completed intracorporeally . complications , operative time , estimated blood loss , and length of stay were compared for resections completed with and without the ultrasonically activated shears.results:thirty-six patients had laparoscopic - assisted colectomy without the shears , and 49 patients had the procedure with the shears . there were no complications due to the ultrasonic energy . use of the shears resulted in shorter operative times ( 170 min . vs. 187 min . , p=0.1989 ) , similar median blood loss ( 98 ml vs. 95 ml , p=0.7620 ) , and shorter lengths of stay ( 4.3 days vs. 6.9 days , p=0.0018).conclusions : the ultrasonically activated shears are safe and effective for colon mobilization and mesenteric division . the use of the shears may result in shorter operative times and shorter lengths of stay .
neurons arise small set progenitor cells divide spatially temporally controlled manner generate six layered structure fully functional adult cortex caviness et al 2009 ; gtz huttner 2005 pierani wassef 2009 rowitch kriegstein 2010 how different fates established daughter cells progenitors poorly understood early phases mouse brain development e9.0 the cortex consists neuroepithelial progenitors neps extend ventricular apical pial basal surface neural tube divide symmetrically amplify progenitor pool onset neurogenesis around e11.0 ) neps turn called radial glial cells rgcs adopt molecular morphological characteristics glial cells rgcs characterized apical fiber extending toward ventricle basal fiber extending toward pial surface caviness et al 2009 gtz huttner 2005 kriegstein alvarez buylla 2009 rgcs occupy apical area cortex called ventricular zone vz their nuclei undergo characteristic interkinetic nuclear migration mitosis phase occur apical basal areas vz respectively rgcs give rise cortical neurons two kinds asymmetric divisions anthony et al divide one rgc another cell migrates basally located cortical plate cp differentiates neuron ipcs also called basal progenitors bps nonsurface dividing ns div cells lose connection apical surface reside cortical area vz intermediate zone iz form called subventricular zone svz ipcs undergo one two rounds symmetric division generating either one two pairs neurons haubensak et al 2004 populate six layers cortex kowalczyk et al 2009 sessa et al 2008 gene expression profiles rgcs generating neurons characteristically different ones generating ipcs pinto et al 2008 two modes division seem occur distinct subpopulations rgcs whether orientation rgc divisions relevant neurogenesis matter intense debate early reports demonstrated vertical spindle orientation correlates asymmetric outcome terms daughter cell fates chenn mcconnell 1995 zhong chia 2008 leading models unequal segregation apical basal plasma membranes directs cell fate zhong chia 2008 consistent mitotic spindles vertical orientations found neurogenic phases brain development haydar et al 2003 early expansion phase keeping precise horizontal spindle orientation crucial maintain neural progenitor pool fish et al 2006 yingling et al 2008 frequency vertical divisions neurogenic phase however low account divisions asymmetric outcome chenn mcconnell 1995 haydar et al 2003 ; this could explained small size apical membrane domain rgcs even barely oblique mitotic spindles would give rise cleavage planes fail bisect domain resulting asymmetric segregation kosodo et al 2004 it demonstrated increasing rate vertical divisions affect progenitor cell number location konno et al 2008 shitamukai et al 2011 functional evidence demonstrate either vertical oblique spindle orientation required neurogenesis however remains established the molecular machinery spindle orientation neurogenesis best understood drosophila siller doe 2009 drosophila neuroblasts orientation mitotic spindle along apical basal axis important asymmetric segregation cell fate determinants numb hirata et al 1995 ; knoblich et al 1995 rhyu et al 1994 spana doe 1995 prospero hirata et al 1995 knoblich et al 1995 spana doe 1995 brat bello et al 2006 betschinger et al 2006 lee et al 2006 basal daughter cell bowman et al 2006 ; 2006 proteins prevent self renewal induce differentiation neuroblasts mitotic spindle oriented two protein complexes assemble apical cell cortex one complex consists pdz domain proteins par-3 par-6 atypical protein kinase c apkc contains goloco domain protein pins heterotrimeric g protein subunit gi microtubule binding protein mushroom body defect mud 2000 yu et al 2000 par-3 schober et al 1999 ; wodarz et al 1999 via multiple armadillo repeats within called asymmetry domain knoblich et al in insc mutants mitotic spindles neuroblasts randomly oriented leading missegregation cell fate determinants thus cell fate defects developing nervous system insc ectopically expressed epithelial cells pins mud recruited basolateral apical cortex mitotic spindle reorients horizontal apical basal direction therefore unlike components insc required also sufficient spindle orientation along apical basal axis while components drosophila spindle orientation machinery conserved mammals studied mainly regard roles epithelial cell polarity goldstein macara 2007 additional functions cell polarity microtubule dynamics woodard et al 2010 mammalian par-3 par-6 apkc important spindle orientation like drosophila counterparts also required epithelial apical basal polarity pins two mammalian homologs ags-3 lgn sanada tsai 2005 yu et al 2003 ags-3 appear expressed brain significant levels ags3 knockout mice show brain phenotype blumer et al 2008 by contrast lgn mediates planar spindle orientation developing brain konno et al 2008 morin et al 2007 consistent role mitotic spindle orientation epithelial morphogenesis zheng et al 2010 also required microtubule aster formation spindle morphology du et al 2001 regulates mitotic spindle orientation epithelial morphogenesis similarly mammalian mud homolog numa shown play conserved role spindle orientation complex du macara 2004 additional functions organizing bipolar mitotic spindle silk et al 2009 sun schatten 2006 overexpression rnai studies shown protein involved orienting mitotic spindle rat retina zigman et al 2005 similar function postulated mouse skin lechler fuchs 2005 moreover situ hybridization experiments showed mouse inscuteable minsc expressed developing neocortex time first neurons start appear zigman et al 2005 test role minsc cortical development we measure spindle orientation 3d show fraction oblique divisions increases decreases upon minsc overexpression deletion respectively we show loss minsc leads defects neurogenesis depletion bps minsc overexpression opposite effect our data consistent model oblique divisions preferentially give rise bps therefore suggest mechanism regulating balance direct indirect neurogenesis mouse brain development minsc expressed throughout developing cortex mid neurogenesis figures 1a 1b 1k zigman et al 2005 in vz protein enriched spindle midzone 90% anaphase cells yellow arrow figure 1c graph figure 1e 100% cp neurons however protein localized neuron cell body cytoplasm concentrates one side nucleus yellow arrow figure 1d test whether minsc functionally replace drosophila protein generated transgenic flies expressing c terminally myc tagged minsc minsc::myc expressed neuroblasts minsc::myc localizes apical crescent figures 1f 1 g like drosophila insc kraut et al 1996 minsc::myc induce reorientation mitotic spindle apical basal orientation ectopically expressed epithelial cells figures 1h 1i thus minsc functional homolog drosophila insc analyze function minsc mouse cortical development generated conditional loss function overexpression alleles called minsc r26 respectively figure 1j see figures s1a s1b supplemental experimental procedures available online details upon cre recombination the r26 line lost -gal expression showed strong ubiquitous expression minsc gfp r26 figure 1p brain specific recombination used nescre8 expresses cre forebrain e8.5 embryos petersen et al 2002 combined minsc line results near complete removal minsc cortex e14.5 figures 1k 1l we call recombined allele minsc residual minsc staining apical surface cortex white arrow presumably due truncated protein persistence mosaic expression cre figure 1l in addition detected nonspecific antibody staining around blood vessels yellow arrow due secondary antibody figures s1f 1 g when combined r26 allele nescre8 caused loss -gal expression compare figure 1 1n strong expression gfp fusion protein figures 1o 1p entire cortex e14.5 expression gfp fusion protein also detected 90 kda band immunoblots e13.5 heads figure 1q this band found addition 60 kda band endogenous protein nescre/;r26 nescre/ r26 mice figure 1q thus generated functional tools gain- loss function analysis minsc previous rnai experiments suggested function minsc controlling orientation neural precursor divisions conserved drosophila mice zigman et al 2005 we therefore asked whether minsc controls orientation mitotic spindles rgcs whether loss- gain function alleles influence spindle orientation lineage specification developing brain various conflicting reports exist wild type orientation mitotic spindles rgcs chenn mcconnell 1995 haydar et al 2003 konno et al 2008 in reports spindle orientations measured relative line representing ventricular surface as methodology neglects spindle orientations z direction focal plane therefore imprecise due curved apical surface ventricle used 3d image reconstruction computational analysis obtain precise measurements e11.5 and e13.5 embryos stained tubulin tub tubulin tub phosphorylated histone h3 ph3 mark centrosomes mitotic spindles mitotic chromatin respectively embryonic brains paraffin embedded individual anaphase rgcs reconstructed 3d confocal stacks coronal brain sections figures 2a2c figures s2a s2c asterisks figures 2a 2b point centrosomes using imaris 3d visualization software defined position two centrosomes placed five points different positions along apical surface 3d rendered cell these points used determine best fitting plane orthogonal distance regression calculate angle vector connecting two dots marking centrosomes normal vector plane marking apical surface the angle spindle orientation calculated 90 minus angle figure 2d using procedure determined division angle radial glia cells nescre/ ctrl nescre/;minsc cko nescre/;r26 cki mice e11.5 e13.5 e11.5 rgcs divide planar orientation mitotic spindles oriented parallel ventricular surface angles less 30 consistent previous observations haydar et al 2003 konno et al division angles cko cki mice significantly different controls figure 2e table s1 although exclude cre recombination efficient early stages suggests minsc functional early stages neurogenesis e13.5 however 63% mitotic spindles control embryos angles 0 30 33% 30 60. consistent previous reports found vertically oriented mitotic spindles 60 90 rare haydar et al 2003 seen 3% mitotic cells figure 2f blue bar figure 2 g cko mice however vast majority mitotic spindles 95% 0 30 oblique divisions 30 0 < 60 strongly reduced 5% vertical spindles never seen figure 2f red bar figure 2 g table s1 upon overexpression minsc cki mice however fraction oblique vertical divisions significantly increased 63% figure 2f green bar figure 2 g table s1 thus like drosophila minsc required sufficient orienting mitotic spindles along apical basal axis importantly minsc spindle orientation phenotype different one observed lgn knockout mice lgn knockdown chicken spinal cord konno et al 2008 ; morin et al 2007 spindle orientation randomized number horizontal spindles actually decreased we also tested subcellular localization minsc::gfp r26/ rgcs e14.5 figure 2h when nuclei close ventricular surface preparation mitosis protein concentrates apical stalk well basal side rgc body yellow arrow figures 2h 2i yellow bar figure 2 in about 80% mitotic cells minsc concentrates apical crescent orange arrow figures 2h 2j green bar figure 2 enlarges prometaphase basal staining disappears green arrow figures 2h 2k anaphase finally minsc becomes symmetric distributed sides 90% anaphase rgcs spindle midzone blue arrow figures 2h 2l blue bar figure 2 taken together these data demonstrate minsc important regulator spindle orientation developing mouse brain both nescre/ minsc nescre/;r26 mice survive adulthood although nescre/;r26 animals frequently show epileptic crisis despite viability however mutants show clearly visible reproducible defects cortical organization figure 3 nissl staining brains 2-month old animals shows cortical thickness reduced nescre/;minsc mice increased nescre/;r26 mice figures 3a3d very similar brain defects observed minsc mice figure 3b indicating time onset nescre8 expression relevant strength phenotype the different layers developing cortex recognized unique cell density morphology nissl stains analysis various minsc alleles reveals layer organization dramatically affected nescre/;minsc mice figure 3c nescre/;r26 mice layer iv barely recognizable seems fused layer v figure 3d in addition gfap staining indicates alteration white matter layer thickness figure s3 characterize adult brain phenotypes used layer specific markers we used foxp2 marker layer vi foxp1 marker layers iii v satb2 marker layers ii iv britanova et al 2003 cux1 marker layers iii iv nieto et al 2004 the number satb2-positive cells reduced nescre/;minsc mice figures 3e 3i nescre/;r26 mice number increased figure 3 similar results obtained using cux1 antibody marker upper layers figures 3h 3l 3p the nuclear marker foxp1 present two stripes corresponding layers iii v figure 3f cell density strongly reduced nescre/;minsc mice figure 3j number cells layers significantly increased nescre/;r26 mice figure 3n finally layer vi adult cortex first formed embryogenesis also affected mutant conditions shown immunostaining foxp2 antibody figures 3 g 3k 3o quantitative analysis cells positive for the various layer specific markers figure 3q confirms phenotypic analysis these data demonstrate minsc levels important neurogenesis suggest vertical orientation mitotic spindle relevant cortical development determine developmental origin cortical phenotypes analyzed cortical development minsc knockout overexpression mice figure 4 e11.5 brain sections control conditional knockout germline transmitted knockout conditional knockin show difference expression nestin tbr1 neurons tbr2 intermediate progenitors figure s4 indicating minsc obvious role early neurogenesis we stained coronal sections e14.5 control mutant brains cresyl violet figures 4a4j no major structural abnormalities detected stage nescre/;minsc brains smaller controls figures 4a 4b the lateral ventricles enlarged overall cortical thickness well protrusion lateral ganglionic eminence ventricles reduced figures 4a 4b 4e 4f nescre/;r26 brains hand exhibited increased cortical thickness figure 4a 4c 4e 4 g these alterations cortical thickness observed central lateral regions refer scheme figure 4k quantification phenotypes showed cortical thickness reduced around 20% medially laterally nescre/;minsc mice increased 20% medial region around 40% central lateral regions nescre/;r26 mice figure 4l detailed examination phenotypes revealed alterations cortical thickness largely due changes iz cp vz almost unaffected figures 4h4j nescre/;minsc mice the thickness iz cp reduced 25% 40% figure 4 nescre/;r26 mice layers thicker three times figure 4 test whether alterations due changes cellular composition stained e14.5 nescre/ nescre/;minsc nescre/;r26 embryos nestin bplp tuj1 label neural progenitors neurons respectively menezes luskin 1994 yachnis et al 1993 nestin staining nescre/;minsc mice reveal obvious abnormalities rgcs nescre/;r26 brains showed alteration radial organization rgc fibers menezes luskin 1994 figures 4n4p figure s5 tuj1 staining revealed neurons iz cp nescre/;minsc brains reduced nescre/;r26 brains area occupied neurons enlarged consistent observed increase cortical thickness figures 4q4s in nescre/;minsc brains however tuj1 neurons vz rarely found arrow inset figure 4r nescre/;r26 brains seemed abundant arrow inset figure 4s together data indicate changes spindle orientation affect neurogenesis developing cortex consequent alteration thickness although number rgcs strongly affected figure 5r characterize initial defects minsc deleted -overexpressing mice used markers cp neurons cp neurons first recognizable layer developing neocortex identified expression map2 transcription factor tbr1 fujimori et al 2002 hevner et al the number tbr1 cells reduced almost half nescre/;minsc brains nescre/;r26 mice number cells significantly increased figures 5a5c 5p staining map2 shows similar alterations cp neurons two genotypes figures 5h5j test whether decrease neurogenesis occurs expense cortical progenitor cells used nuclear rgc marker pax6 figures 5d5f 5l5n gtz et al 1998 although high density pax6 nuclei vz makes impossible obtain precise quantitative measurements find striking changes number sox2 vz progenitors nescre/;minsc nescre/;r26 mice figure 5r however vertical spindle reorientation nescre/;r26 mice leads frequent generation pax6 progenitors located outside vz iz cp figures 5f 5n the number frequency cells increased even cre recombination induced germline r26/ mothers using morecre e14.5 embryos mothers named r26/ clusters pax6 cells frequently seen iz pax6 cells present even cp replaced differentiating neurons forming gaps map2 layer cells figures 5 g 5k arrows figure 5o quantitative analysis revealed pax6 cells six times abundant iz three times abundant cp r26/ mice compared nescre/;r26 figure 5q these observations consistent previous utero electroporation experiments konno et al 2008 although previous conclusion endogenous minsc orient mitotic spindles mouse cortex fish et al 2008 konno et al 2008 ) changes cortical thickness neuronal differentiation observed minsc mutant minsc overexpressing brains could due alterations position mitotic cells and/or rgc proliferation order distinguish possibilities first stained e14.5 sagittal brain sections anti ph3 look proliferative cells vz svz control animals 80% mitotic figures seen cortex e14.5 located apical side vz 20% mitotic figures corresponds basally located intermediate progenitors figures 6a 6d 6h 6i nescre/;minsc mice however number basally located mitotic cells strongly reduced e14.5 figures 6b 6e 6h 6i nescre/;r26 mice hand number basal mitotic cells increased figures 6c 6f6i thus changes spindle orientation affect number basal mitotic cells without significantly altering number apical mitotic cells figure 6h alterations number neurons intermediate progenitors produced neurogenesis could due premature cell cycle exit vz progenitors test injected pregnant females brdu label phase cells sacrificed animals 24 hr hour later performed double immunostaining brdu proliferation marker ki67 experiment the fraction ki67brdu cells within total brdu positive population used indicator cell cycle exit progenitors we found significant differences nescre/;minsc nescre/;r26 r26/ mice figure 6j indicating minsc strong effect average cell cycle length apical bps the altered proliferation pattern could due difference position fate dividing cells in wild type animals proliferation basal vz due ipcs specifically marked staining tbr2 figure 6k englund et al 2005 in nescre/ minsc mice number tbr2cells reduced figure 6l number increased nescre/;r26 brains figure 6 this effect enhanced germline recombination r26 allele r26/ mice figure 6n interestingly extra bps longer confined svz frequently found basal parts cortex thus modifying spindle orientation changes frequency rgcs give rise intermediate progenitors proliferation cell cycle exit rates rgcs do change mutant conditions exclude consequence alterations rgc proliferation therefore postulate spindle orientation influences fate rgc daughters assume division obtain direct evidence proposed lineage changes used utero electroporation figures 7a7r this we electroporated construct expressing rfp brains e14.5 control knockout embryos r26 males crossed nescre/ r26 females we used nescre/ r26 embryos order avoid observed massive ectopic location apical bps long term time lapse experiments mid late neurogenesis show apical progenitors undergo one division 24 hr noctor et al 2004 in order look fate daughter cells one division apical progenitors embryos collected 1 day electroporation rfp cells found vz iz brains control knockout knockin embryos figures 7b 7e 7h 7k 7n 7q while electroporated rfp cells migrated beyond basal border pax6 expression zone control knockout animals rfp cells located right edge expression zone minsc overexpressing animals compare figures 7c 7i figure 7f determine identity cells used bp marker tbr2 control mutant brains tbr2 expressed subset rfp electroporated cells control animals tbr2 expressed 23% rfp electroporated cells fraction reduced 10% nescre/ minsc embryos minsc overexpressing animals contrast bp marker expressed 50% electroporated cells determined number tbr2 rfp cells divided total number rfp cells figure 7 percentage pax6/rfp progenitor cells among electroporated rfp cells change figure 7s results indicate reorientation mitotic spindle along apical basal axis causes rgcs preferentially generate intermediate progenitors division taken together data reveal spindle orientation along apical basal axis mediated minsc important promoting neurogenesis apical basal divisions likely give rise intermediate progenitors effect may responsible increased rates neurogenesis observed upon minsc overexpression to address role nonplanar spindle orientation cortical development generated conditional deletion minsc unlike drosophila pins par-3 par-6 apkc insc single clearly defined mammalian homolog katoh 2003 lechler fuchs 2005 zigman et al 2005 in drosophila embryos insc exclusively expressed asymmetrically dividing cells functions asymmetric cell division reported mutating centrosomal proteins like asp aspm mice fish et al 2006 2008 cnn cdk5rap2 mice barrera et al 2010 might affect signaling pathways disrupting primary cilia influence centrosome asymmetry proposed important cortical neurogenesis wang et al 2009 mutating dynein binding proteins like lis1 causes defects spindle morphology cell migration yingling et al 2008 therefore minsc knockout minsc overexpression mice particularly specific tools analyze spindle orientation the spindle orientation defects observe minsc deficient mice different one previously reported lgn mouse homolog insc binding partner pins lgn knockouts orientation mitotic spindle randomized lack minsc causes almost mitotic spindles assume planar orientation this agreement functions reported two genes flies explains two genes different effects cortical neurogenesis konno et al 2008 ; our results suggest intermediate progenitors likely arise oblique horizontal divisions spindle oriented oblique vertical respectively first increasing decreasing minsc expression elevates reduces number neurons respectively at time total number apical progenitors number mitotic cells vz remain constant second minsc levels affect number tbr2-positive intermediate progenitors number cells dividing outside vz finally apical progenitors labeled electroporation rfp expressing plasmids likely give rise tbr2-positive intermediate progenitors minsc levels increased we propose model minsc influences spindle orientation thereby regulates balance direct indirect neurogenesis figure 8) whether minsc required generating bps clear it remarkable terminal forebrain phenotype minsc mice similar one observed tbr2 intermediate progenitors essentially absent arnold et al 2008 cases thickness cp reduced 40% outer layers affected tbr2 mice this could explained intermediate progenitors initially form spindle orientation dependent mechanism later neurogenesis also proceed partially redundant minsc independent mechanism how could asymmetry established progenitor divisions quite likely minsc independent direct neurogenesis minsc dependent indirect neurogenesis might use different mechanisms both narrow apical plasma membrane domain basal process connects progenitors pial surface inherited one daughter cell oblique vertical division as bps maintain connection apical surface gtz huttner 2005 miyata et al 2004 contain basal process asymmetric inheritance structures could contribute intermediate progenitor formation for example intermediate progenitors could simply move vz phase attached apical surface alternatively apically localized proteins could perform direct signaling role it proposed asymmetric inheritance par3 activate notch signaling one daughter cell apical progenitor bultje et al 2009 levels notch signaling lower intermediate progenitors decreasing levels notch signaling promotes formation intermediate progenitors mizutani et al one could imagine loss par3 oblique division establishes bp fate one two daughter cells alternatively basal process could carry certain signaling molecules whose asymmetric inheritance alters daughter cell fate schwamborn et al 2009 how could minsc act molecular level drosophila expression insc recruits pins apical cortex acts molecular switch spindle orientation mouse cortex however progenitor cells seem express equal levels minsc regardless division orientation it demonstrated horizontal spindle orientation epithelial cells depends apkc mediated phosphorylation lgn hao et al minsc could simply inhibit pathway binding apkc par-3/par6 complex thereby promote nonplanar orientation mitotic spindle model the role minsc would instruct apical basal orientation binary manner introduce imprecision cause degree stochasticity orientation progenitor divisions this would explain minsc expression levels decide orientation individual progenitor divisions overall changes minsc expression strong influence fraction cells divide nonplanar fashion it proposed changes spindle orientation influenced cortical evolution bond et al 2002 fish et al 2008 zhang 2003 the gene aspm required correct orientation early proliferative neuroepithelial divisions fish et al 2008 evolved adaptively primates suggesting functional alteration primate evolution aspm localized spindle poles particularly important correct planar orientation symmetric progenitor divisions fish et al 2008 it proposed adaptations aspm function increased fidelity number early symmetric divisions thereby increasing progenitor pools neuron number brain size ponting jackson 2005 given minsc regulates spindle orientation could similar role primate evolution in fact intermediate progenitors play important role cortical evolution primates cells generate many two neurons thus amplifying total number neurons arising one ventricular progenitor human ferret brains contain population outer subventricular zone osvz progenitors attributed key role amplifying neuron numbers fietz et al live imaging experiments suggested spindle orientation crucial establishing cell population shitamukai et al 2011 wang et al 2011 given minsc key regulator intermediate progenitor formation could regulate osvz progenitor formation well case characterization evolutionary changes minsc locus functional analysis human brain might yield important information unique cell population arisen evolution primary antibodies used rabbit anti minsc 1:100 zigman et al mouse anti--gal promega chicken anti gfp 1:500 abcam rabbit anti satb2 1:500 abcam rabbit anti foxp1 1:500 abcam rabbit anti foxp2 1:500 abcam mouse anti tuj1 1:500 sigma aldrich rabbit anti nestin 1:500 becton dickinson rabbit anti pax6 1:300 covance rabbit anti tbr1 1:500 abcam mouse anti map2 1:500 chemicon rabbit anti tbr2 1:500 abcam rabbit anti ph3 1:500 upstate mouse anti ph3 1:500 cell signaling secondary antibodies conjugates alexa fluor 488 alexa fluor 568 alexa fluor 647 1:500 invitrogen fifteen micron coronal sections e11.5 e14.5 embryonic brains paraffin embedded stained mouse anti-tub 1:1000 sigma aldrich mouse anti-tub 1:1000 sigma aldrich rabbit anti ph3 upstate using staining protocol described supplemental experimental procedures z stacks interval 0.5 taken using zeiss axiovert 200 confocal microscope after 3d reconstruction confocal stacks dividing cell imaris software five points placed arbitrarily different positions 3d rendered plane ventricular surface two points placed positions two centrosomes the coordinates five points used determine best fitting plane orthogonal distance regression the angle vector connecting two points marking centrosomes normal vector regression plane calculated 90 minus angle used division angle calculations done using r programming environment order estimate upper limit error division angle calculation five points turn left determining best fitting plane thereby five planes determined four points received angles determined well standard deviation sd angles	summaryneurons in the mammalian neocortex arise from asymmetric divisions of progenitors residing in the ventricular zone . while in most progenitor divisions , the mitotic spindle is parallel to the ventricular surface , some progenitors reorient the spindle and divide in oblique orientations . here , we use conditional deletion and overexpression of mouse inscuteable ( minsc ) to analyze the relevance of spindle reorientation in cortical progenitors . mutating minsc almost abolishes oblique and vertical mitotic spindles , while minsc overexpression has the opposite effect . our data suggest that oblique divisions are essential for generating the correct numbers of neurons in all cortical layers . using clonal analysis , we demonstrate that spindle orientation affects the rate of indirect neurogenesis , a process where progenitors give rise to basal progenitors , which in turn divide symmetrically into two differentiating neurons . our results indicate that the orientation of progenitor cell divisions is important for correct lineage specification in the developing mammalian brain .
	cells comprising a tissue migrate as part of a collective . how collective processes are coordinated over large multi - cellular assemblies has remained unclear , however , because mechanical stresses exerted at cell - cell junctions have not been accessible experimentally . we report here maps of these stresses within and between cells comprising a monolayer . within the cell sheet there arise unanticipated fluctuations of mechanical stress that are severe , emerge spontaneously , and ripple across the monolayer . this stress landscape becomes increasingly rugged , sluggish , and cooperative with increasing system density . within that landscape , local cellular migrations follow local orientations of maximal principal stress . migrations of both endothelial and epithelial monolayers conform to this behavior , as do breast cancer cell lines before but not after the epithelial - mesenchymal transition . collective migration in these diverse systems is seen to be governed by a simple but unifying physiological principle : neighboring cells join forces to transmit appreciable normal stress across the cell - cell junction , but migrate along orientations of minimal intercellular shear stress .
growing recognition bipolar affective disorder associated neurocognitive deficits allied neuroanatomic neurophysiologic anomalies 1 2 while mood states psychotropic medication usage influence cognition brain physiology observations many neurocognitive structural functional neuroanatomic abnormalities predate symptom onset persist symptom remission raise possibility changes brain structure function central pathophysiology bipolar affective disorder 3 4 furthermore accumulating evidence suggests neurocognitive neuroimaging factors associated clinical outcome psychosocial functioning vocational disability bipolar disorder the goal review synthesize recent findings assess clinical relevance highlight areas need additional research almost two thirds bipolar patients level inter episode functional impairment 6 7 half unemployed reduced occupational functioning thus although many individuals bipolar disorder respond well treatments designed reduce affective psychotic symptoms ability achieve functional recovery capacity study work engage recreation live independently engage romantic relationships may significantly hindered therefore recovery mood episodes and/or residual symptoms necessarily translate functional recovery indeed many patients bipolar illness regain premorbid levels psychosocial functioning studies lifetime course bipolar disorder consistently find periods symptomatic recovery bipolar individuals often continue experience residual mood symptoms likely contribute increased levels disability decreased psychosocial functioning clinical factors particular disease chronicity severity subsyndromal depressive symptoms associated poor functional outcome 5 11 in addition reviewed detail growing evidence relationship neurocognitive function underlying neuroanatomic abnormalities functional outcome across range severe neuropsychiatric disorders including bipolar illness 1214 better understanding relationship neurocognitive neuroimaging measures clinical outcome potential improve current treatment options provide targets new treatment strategies although clear evidence patients bipolar disorder exhibit widespread neurocognitive dysfunction acute episodes mania depression discovery deficits endure symptom remission raises possibility cognitive impairment may represent trait rather state variable euthymic bipolar patients exhibit limitations several cognitive domains particularly measures executive function declarative memory sustained attention 1 1517 although euthymic patients often present residual affective symptoms may adversely affect performance cognitive tests even euthymic months prior assessment marked neuropsychological impairments indeed several recent meta analyses neuropsychological performance euthymic bipolar disorder documented impairment across wide variety cognitive domains 1 1517 recent meta analyses kurtz gerraty found nonsymptomatic bipolar patients performed 0.40.9 sd healthy individuals measures attention e.g continuous performance test cohen 0.69 processing speed e.g digit symbol substitution 0.66 working memory e.g digit span backward 0.65 declarative memory e.g rey or california verbal learning test 0.81 nonverbal declarative memory e.g visual reproduction subtest wechsler memory scale 0.91 executive functioning e.g trail making test b 0.72 observations neuropsychological deficits nonsymptomatic bipolar patients suggest impairments may related pathophysiology illness described subsequently also reasonable predictors psychosocial functioning disability 20 evidence clinically unaffected relatives patients bipolar disorder subtle neurocognitive impairments suggests deficits may reflect genetic liability illness a recent meta analysis reported small statistically significant differences e.g < 0.5 unaffected first degree relatives compared healthy individuals domains executive functioning verbal memory another recent meta analysis 17 published studies included 443 first degree relatives bipolar patients reported cognitive impairments range small medium effect sizes domains attention 0.080.51 verbal learning 0.270.33 executive functioning 0.220.36 glahn colleagues 22 recently reported three cognitive tests digit symbol coding object delayed response task immediate facial memory genetically correlated liability bipolar disorder suggesting genetic factors increase risk bipolar disorder influence performance tests although many neurocognitive impairments found individuals bipolar disorder present euthymia quite likely clinical course influences test performance bipolar disorder indeed age onset total number mood episodes number manic episodes number depressive episodes number duration hospitalizations factors associated degree neurocognitive impairment among individuals bipolar disorder furthermore use psychotropic medication could impact neurocognitive functioning bipolar patients recent meta analysis examining effects lithium cognitive performance bipolar disorder 12 studies involving 276 lithium treated 263 lithium free patients found small significant impairment lithium treated patients immediate verbal learning memory effect size 0.24 creativity effect size 0.33 in contrast significant impairments found delayed verbal memory visual memory attention executive functioning processing speed psychomotor performance some antidepressant medications shown yield adverse cognitive effects particularly anticholinergic properties however studies failed find significant effects medications cognition 24 25 although studies examined neurocognitive performance unmedicated bipolar patients goswami colleagues found significant differences neurocognitive test performance 22 drug free euthymic bipolar patients 22 medicated euthymic patients together data suggest although clinical course medication usage may influence cognitive performance bipolar disorder effects seem explain fraction observed impairments growing evidence indicates neurocognitive impairments contribute poorer psychosocial functioning increased functional disability bipolar disorder 1214 20 27 28 for example executive dysfunction initial assessment linked lower levels functional recovery population cross sectionally longitudinally 13 14 28 bonnin colleagues 29 recently found subthreshold depressive symptoms working memory function digits backward specific predictors occupational functioning 4 years later similarly bipolar patients declarative memory deficits less likely return premorbid psychosocial occupational functioning 11 14 28 29 schizophrenia research recently begun distinguish functional capacity i.e estimate one ability perform tasks relevant everyday functioning actual performance i.e one actually everyday settings this distinction important performance influenced functional capacity well environmental motivational factors bowie colleagues 20 recently performed series confirmatory path analyses determine neurocognitive deficit influences real world functioning disability bipolar disorder a total 130 community dwelling individuals bipolar disorder assessed neuropsychological tests symptom measures performance based social adaptive functional competence measures three domains real world functioning community household activities work skills interpersonal relationships models relationship neurocognition outcome these findings imply functional disability may persist patients bipolar disorder even symptomatic recovery due neurocognitive skill deficits conversely even patient acquires certain neurocognitive skills continues experience mild mood symptomatology changes real world behavior might lag manifest summary significant evidence suggests many individuals bipolar disorder least degree neurocognitive deficit although deficits may influenced clinical course severity psychotropic medication usage also seem associated genetic liability illness suggesting neurocognitive deficits important aspect presentation bipolar disorder finally neurocognitive impairments impact real world functioning patients bipolar disorder the consistently documented neuroanatomic abnormalities adult patients bipolar disorder lateral ventricle enlargement 17% increased rates deep white matter hyperintensities odds ratio 2.49 2 reduced area volume corpus callosum also robust finding across studies additional evidence white matter involvement bipolar disorder comes studies finding alterations white matter tract organization 31 32 regional white matter volume reductions in addition recent evidence indicates white matter abnormalities may stable trait based abnormalities reflect genetic liability illness 31 34 kieseppa colleagues found decreased left hemisphere white matter volume bipolar probands nonbipolar co twins similarly mcdonald colleagues found genetic risk bipolar disorder associated white matter reduction left frontal temporoparietal regions suggesting left frontotemporal disconnectivity may genetically controlled neuroanatomic abnormality associated bipolar illness finally large dutch twin sample van der schot colleagues 35 found reduction overall white matter volume related genetic risk bipolar disorder whereas significant environmental correlations observed cortical gray matter general findings gray matter alterations bipolar disorder variable across studies likely least partially attributable well documented effects lithium gray matter volume 2 36 although recent meta analysis revealed effect size 1.17 reduced volume left anterior cingulate bipolar patients relative controls finding significant across studies due high study heterogeneity 2 kempton colleagues using voxel based morphometry patients bipolar disorder relatives major depression healthy relatives controls found group differences left insula cerebellum substantia nigra increased left insula volume particular associated genetic preposition bipolar disorder independent clinical phenotype contrast increased left substantia nigra volume specific clinical phenotype bipolar disorder changes uniquely associated absence clinical diagnosis bipolar relatives observed left cerebellum suggesting may dissociable genetic phenotypic influences brain structure bipolar disorder given substantial body literature neuroanatomic changes bipolar disorder 2 surprisingly studies examined relationship outcome patients schizophrenia risk illness relationship examined several studies for example accelerated ventricular enlargement 3 years following illness onset associated poor outcome first episode schizophrenia whereas progressive decrement frontal lobe white matter associated greater negative symptom severity more recently karlsgodt colleagues found structural integrity medial temporal white matter tracts predictive functional outcome adolescents high risk developing psychosis given accumulating evidence disrupted white matter integrity may central pathophysiology bipolar disorder white matter abnormalities represent promising candidate neuroanatomic predictor outcome two prior studies examined white matter hyperintensities indicators treatment resistance poor outcome bipolar disorder moore colleagues categorized patients bipolar disorder good poor outcome based treatment response level functioning finding poor outcome group members significantly deep severe subcortical punctate white matter hyperintensities relative good outcome group healthy controls regenold colleagues found index treatment resistance correlated significantly deep white matter hyperintensity volume well measures abnormal brain glucose metabolism sorbitol fructose bipolar patients patients i.e schizophrenia neurologic controls summary strong evidence date implicating neurocognitive factors bipolar patients key determinants functional outcome given cognitive abnormalities likely reflective underlying abnormalities brain structure function propose microstructural white matter alterations may contribute poor outcome similar literature relating abnormalities brain structure poor outcome schizophrenia recent functional mri studies also begun document relationship particular fusar poli colleagues found youth prodromal signs psychosis clinical functional improvement follow associated longitudinal increase activation anterior cingulate right parahippocampal gyrus performance n back task similarly individuals high clinical risk psychosis sabb colleagues found baseline neural activity left inferior frontal gyrus performance language processing task predictive severity positive formal thought disorder poor social outcome follow date studies conducted patients bipolar disorder however emerging literature suggests neurophysiology bipolar disorder involves frontal hypoactivation concomitant disinhibition i.e relative hyperactivation limbic structures 44 45 the subgenual prefrontal cortex modulates affective output limbic paralimbic structures cognitive output prefrontal cortex recent evidence functional mri studies using affective processing paradigms ie reacting stimuli positive negative emotional valence suggests patients bipolar disorder may disproportionately engage limbic structures emotionally valent tasks regardless mood state 46 47 although direction effects consistent across studies taken together studies suggest corticolimbic dysregulation may underlie emotional dysregulation cognitive impairments associated bipolar disorder 45 48 moreover exaggerated medial prefrontal cortical subcortical putamen amygdala responses emotional signals observed bipolar patients nonbipolar relatives suggesting responses may represent heritable neurobiological abnormalities underlying bipolar disorder given similar cognitive impairments associated psychosocial functional disabilities seen patients bipolar disorder schizophrenia adaptation treatment strategies proven beneficial schizophrenia patients may also efficacious bipolar patients in particular cognitive remediation associated significant although modest improvements cognitive performance psychosocial functioning schizophrenia patients the development treatments target cognitive impairments functional status important area future investigation bipolar disorder two small studies found rehabilitative interventions cognitive remediation supported employment may effective improving vocational outcomes bipolar patients require replication larger investigations although bipolar disorder historically viewed disease involving episodic dysfunction increasing evidence indicates case substantial proportion patients collectively data reviewed provide compelling evidence cognitive impairments present across multiple domains particularly areas attention processing speed memory bipolar patients these difficulties observable soon illness onset persist throughout course illness given clinically unaffected relatives patients bipolar disorder similar milder neurocognitive impairments deficits may reflect genetic liability illness although investigation neural correlates functional disability bipolar disorder nascent stages given strong commonalities schizophrenia anticipated similar relationships structural functional neuroanatomic abnormalities outcome bipolar patients identified rich literature schizophrenia individuals risk illness could serve inform areas future research needed bipolar disorder recommended harvey colleagues approaches used schizophrenia research particular longitudinal assessment cognition neurophysiology psychosocial function across variations clinical state separate assessment functional capacity real world functioning highly informative applied study patients bipolar illness a clear need exists objective methods assessing real world functional abilities subjective self assessments likely influenced current symptoms illness features thus far studies investigated specific aspects functional status bipolar patients associations neuroanatomic clinical treatment related factors such investigations critical understanding array determinants disability bipolar illness	historically , bipolar disorder has been conceptualized as a disease involving episodic rather than chronic dysfunction . however , increasing evidence indicates that bipolar disorder is associated with substantial inter - episode psychosocial and vocational impairment . here we review the contributions of neurocognitive deficits and structural and functional neuroanatomic alterations to the observed functional impairments . in particular , compelling evidence now suggests that neurocognitive impairments , particularly in the areas of attention , processing speed , and memory , are associated with functional outcome . although investigation of the neural correlates of functional disability in bipolar disorder is only in its nascent stages , preliminary evidence suggests that white matter abnormalities may be predictive of poor outcome . a better understanding of the relationship between neurocognitive and neuroimaging assays and functional outcome has the potential to improve current treatment options and provide targets for new treatment strategies in bipolar disorder .
according current models cell death often proceeds via either two relatively independent subroutines apoptosis necrosis 1 2 long time apoptotic necrotic instances cell death exclusively identified based morphological criteria addition apoptosis believed constitute sole regulated i.e. genetically encoded hence susceptible pharmacological modulation modality cell death necrosis viewed purely accidental process recently functional classification cell death mechanisms based measurable biochemical features proposed concept regulated necrosis gained large consensus scenario true relevance additional processes previously catalogued bona fide cell death subroutines reevaluated particular macroautophagy hereafter referred autophagy turned constitute prominent homeostatic cytoprotective mechanism 5 6 autophagic cell death lethal subroutine mediated rather merely accompanied autophagy shown occur limited number mostly developmental scenarios 1 7 along similar lines mitotic catastrophe signaling cascade elicited mitosis incompetent cells initially viewed particular case apoptosis recently proposed constitute oncosuppressive mechanism multiple functional outcomes including cell senescence well apoptotic necrotic cell death apoptotic stimuli propagated via two distinct entirely disjointed molecular cascades extrinsic apoptosis transducing lethal signals originate extracellular microenvironment intrinsic also known mitochondrial apoptosis responding perturbations intracellular homeostasis extrinsic apoptosis initiated either ligand induced activation plasma membrane death receptors e.g. fas cd95 tumor necrosis factor receptor 1 tnfr1 called dependence receptors e.g. deleted colorectal carcinoma dcc concentration ligands falls specific threshold death receptors promote activation caspases class cysteine proteases play central role multiple instances apoptosis via formation multiprotein complex includes among components receptor interacting protein kinase 1 ripk1 fas associated protein death domain fadd cellular inhibitor apoptosis proteins ciaps multiple isoforms cellular flice inhibitory protein c flip such death inducing signaling complex disc allows proximity induced autoactivation caspase-8 turn catalyzing proteolytic maturation caspase-3 central effector cases apoptosis the mechanisms whereby dependence receptors connected execution apoptosis recently begun emerge appear involve caspase-9 caspase long believed exclusively regulate mitochondrial apoptosis intrinsic apoptosis triggered plethora perturbations intracellular homeostasis including among others independent initiating stimulus signaling cascades mediate intrinsic apoptosis well prosurvival signals generated alongside facilitate reestablishment homeostasis opposed level mitochondria 1315 lethal signals prevail majority mitochondria become permeabilized event de facto seals cell fate indeed upon mitochondrial outer membrane permeabilization momp mitochondrial transmembrane potential electrochemical gradient driving atp synthesis well many mitochondrial functions rapidly dissipated ii cytotoxic proteins normally secluded within mitochondrial intermembrane space e.g. cytochrome c apoptosis inducing factor aif endonuclease g endog released cytosol promote activation caspases well caspase independent cell death executioner mechanisms the former relies cytochrome c elicited datp- apoptotic peptidase activating factor 1 apaf1)-dependent assembly called apoptosome molecular platform activation caspase-9 caspase-3 cascade the latter involves caspase independent endonuclease activity aif endog well bioenergetic redox crisis ensues dissipation 13 14 note extrinsic intrinsic apoptosis entirely disjointed indeed cell types e.g. lymphocytes caspase-8 caspase-3 cascade sufficient mediate death receptor dependent apoptosis others e.g. hepatocytes process requires caspase-8-mediated cleavage bh3-only protein bid generating mitochondrion permeabilizing fragment see 16 17 given position frontier cell life death surprising momp constitutes highly regulated phenomenon so far two models put forward explain momp molecular terms 14 18 one hand momp suggested originate mitochondrial outer membrane om thanks pore forming activity multidomain proapoptotic members bcl-2 protein family namely bax bak 14 19 on hand proposed response specific triggers momp would stem called mitochondrial permeability transition mpt abrupt increase permeability small solutes mitochondrial inner membrane latter scenario a critical role ascribed permeability transition pore complex ptpc large molecular entity assembled junctions om several proteins including though presumably limited voltage dependent anion channels vdacs adenine nucleotide translocase ants cyclophilin cypd 13 18 importantly antiapoptotic multidomain members bcl-2 protein family including bcl-2 bcl xl mcl-1 counteract pore forming activity bax bak engaging direct inhibitory interactions also intercept upstream proapoptotic signals mediated bh3 proteins like bad bid bim bbcr3 best known p53-upregulated modulator apoptosis puma 20 21 ii bind hence regulating several components ptpc including vdac1 ant 2224 iii prevent generation proapoptotic cytosolic ca waves either interacting inositol 1,4,5-trisphosphate ip3)-gated ca channels endoplasmic reticulum er limiting capacity er ca stores 2527 in addition pro- antiapoptotic bcl-2-like proteins recently shown modulate multiple processes directly connected execution cell death including among others bioenergetic metabolism mitochondrial functions mitosis autophagy 28 29 here discuss multifaceted role bcl xl prototypic antiapoptotic member bcl-2 family hub cell death metabolism in humans bcl xl encoded bcl2l1 bcl2-related gene mapping chromosome 20q11.21 bcl2l1 shown beginning code two distinct protein products owing alternative splicing bcl2l1 mrna cytoprotective factor 233 residues bcl xl smaller polypeptide 170 residues exerts bcl xl antagonizing functions bcl xs similar bcl-2 bcl xl contains four distinct bcl-2 homology bh domains bh1bh4 well transmembrane region localizes least part several membranous compartments including om er nuclear envelope 3032 apply bcl xs lacks bh1 bh2 domains 30 33 note physiological settings bcl xl coding mrna expressed higher levels bcl xs coding counterpart conversely bcl xs often predominates situations developmental pharmacological cell death 35 36 importantly caspase generated cleavage product bcl xl lacking n terminal fragment recently shown mediate neuronal cell death rodent models ischemic brain injury suggesting chemical inhibitors bcl-2-like proteins might also employed least selected circumstances cytoprotective agents bcl-2 bcl xl soon recognized critical antiapoptotic factors although function initially attributed ability mediate antioxidant effects 38 39 this notion quickly abandoned favor called rheostat model proposing bcl-2 bcl xl would physically sequester proapoptotic counterparts bax bak inhibitory interactions 4042 following decade along discovery several members bcl-2 protein family model progressively refined include concepts activating derepressing bh3-only proteins according current viewpoints the former would promote momp engaging direct activatory liaisons bax bak latter would competitively displacing bax bak inhibitory interactions bcl-2 bcl xl mcl-1 note the core concept rheostat model first theorized stanley korsmeyer 1993 cell death governed balance pro- antiapoptotic bcl-2 family members remained remarkably unmodified since original formulation nevertheless last two decades antiapoptotic bcl-2 family members including bcl xl shown exert cytoprotective functions via myriad mechanisms necessarily rely capacity block pore forming activity bax bak although least instances involve bax-/bak antagonizing effect similar bcl-2 bcl xl prevents generation proapoptotic cytosolic ca waves reducing capacity er ca stores effect antagonized bax bak 2527 moreover bcl xl shown critically regulate opening status vdac1 hence ptpc thus influencing mpt dependent apoptotic cell death 23 24 44 of note authors proposed mpt would stem unselectively open conformation ptpc others concluded mpt would originate closed state pore 24 44 irrespective controversy yet fully resolved recent data confirmed critical role interaction vdac1 bcl xl antiapoptotic properties latter interestingly many bcl-2 family members bax bak bid bcl-2 appear interact hence modulate activity ptpc components i.e. vdac1 vdac2 ant 22 23 46 47 suggesting crosstalk two systems might constitute particularly important point functional regulation however actual relevance ptpc cellular demise physiological settings remains matter debate indeed mice lacking one critical ptpc components including vdac ant isoforms known thus far 4850 single exception ppif animals lacking cypd 5153 fail exhibit remarkable cell death defects response ischemic traumatic pharmacological challenges hence seems least physiological settings complex crosstalk bcl-2 family members ptpc mainly modulates cell death unrelated cellular functions impacts cellular demise via indirect circuitries see one central regulators apoptosis triggered perturbations intracellular homeostasis dna damaging conditions imbalances redox homeostasis oncogenic stress p53 besides operating stress responsive transcription factor regulates synthesis pro- antiapoptotic proteins including large panel bcl-2 family members i.e. bax bak bad bid puma bcl-2 bcl xl p53 also exert apoptotic functions transcription independent fashion 56 57 in particular p53 shown operate similar bh3-only proteins promote momp either engaging activatory though labile interactions bax displacing bax bak inhibitory liaisons bcl-2 bcl xl setting mitochondrial pools bcl-2 bcl xl constitute main target derepressor activity p53 in addition cytoplasmic pool bcl xl appears work puma sensitive inhibitor p53 de facto operating interface p53 transcriptional transcription independent functions thus bcl xl exerts cytoprotective effects antagonizes proapoptotic counterparts also counteracts activity p53 in addition bcl xl recently reported interact mitochondrial phosphatase phosphoglycerate mutase family member 5 pgam5 central effector regulated necrosis 62 63 hence although niture et al address question direct fashion bcl xl may soon discovered regulate necrotic instances cell death the hypothesis bcl-2 family members notably bax bad bcl-2 bcl xl would influence bioenergetic intermediate metabolism began gain consensus along discoveries proteins interact components ptpcs physiological circumstances regulate various facets mitochondrial functions e.g. ant vdac glucokinase 2224 44 64 ii proteins modulate ca homeostasis er 2527 iii p53 operates potent proapoptotic factor response stress also exerts homeostatic control metabolism particular bcl xl reportedly preserves physiological conformation vdac hence promoting exchange metabolites including adp across om ii functionally antagonizes bad found exert prominent metabolic functions regulating mitochondrial multiprotein complex involves among enzymes glucokinase protein kinase protein phosphatase 1 iii shown lower concentrations ca ions within er hence quenching bioenergetic burst normally results opening ip3-gated ca channels 2527 iv binds cytoplasmic p53 steady state conditions thus least theoretically modulating functions related bioenergetic redox metabolism 54 65 66 bcl xl also demonstrated regulate distinct facets intermediate metabolism direct fashion neurons pool bcl xl localized appears physically interact subunit f1fo atp synthase hence increasing enzymatic efficiency stabilizing consequently maximizing mitochondrial atp generation 67 68 similar functions attributed truncated variant mcl-1 localizes mitochondrial matrix in addition transfection enforced overexpression bcl-2 associated increased oxygen consumption higher rates mitochondrial respiration 70 71 taken together these observations suggest conserved role bcl-2 proteins regulation atp synthesis note antiapoptotic members bcl-2 family suggested exert prooxidant functions least selected circumstances 70 71 such slight prooxidant state presumably reflecting ability bcl-2 bcl xl stimulate mitochondrial respiration 67 68 70 appears linked interaction bcl-2-like proteins small gtpases rac family 72 73 exert cytoprotective effects contributing maintenance baseline energetic homeostasis recent data indicated bcl xl operates bax- bak independent manner limit intracellular levels acetyl coa acetyl coa critical intermediate krebs cycle also required protein acetylation including n--acetylation posttranslational modification consists addition acetyl moiety provided acetyl coa n terminus nascent polypeptides hence high expression levels bcl xl exert cytoprotective effects along establishment state characterized decreased levels virtually metabolites involved krebs cycle glycolytic substrates well reduced extents n--acetylation although yi colleagues ascribed antiapoptotic state could reversed exogenous supply citrate acetate inhibition n--acetylation reduced levels reactive oxygen species ros constitute normal byproduct mitochondrial respiration may equally well underpin least part cytoprotective effects originate bcl xl metabolic functions support notion overactivation several metabolic circuitries including glycogenolysis glutaminolysis overgeneration ros linked apoptotic necrotic cell death 13 76 ii predominantly glycolytic metabolism observed cancer cells even presence normal oxygen levels i.e. called warburg effect reportedly exerts cytoprotective effects increases amounts reduced glutathione potent antioxidant note pyruvate kinase m2 a glycolytic enzyme variant known sustain warburg effect shown stimulate expression bcl xl transcriptional level although cytoprotective transcription factor nf-b may play role setting precise molecular mechanisms underlying phenomenon remain identified in addition protein acetylation recently involved regulation autophagy see 7982 suggesting bcl xl might exert broad control multiple cellular functions autophagy catabolic pathway driving lysosomal degradation cellular constituents portions cytoplasm protein aggregates dysfunctional supernumerary organelles physiological conditions autophagy plays prominent role maintenance intracellular homeostasis 5 84 85 in addition autophagic flux dramatically upregulated response large panel stress conditions including limited glucose amino acid deprivation hypoxia intracellular pathogens cytotoxic xenobiotics 83 86 although mostly developmental scenarios autophagic program de facto mediates cell death 1 7 stress elicited autophagy near invariably exerts prominent cytoprotective functions line notion pharmacological genetic maneuvers block autophagy most often exacerbate rather limit cell death triggered several distinct stimuli the stress elicited upregulation autophagy tightly regulated phenomenon involving distinct molecular sensors signal transduction cascades impinge various levels autophagic machinery a detailed description proteins factors involved regulation execution autophagy largely exceeds scope paper found elsewhere 83 84 87 89 nevertheless important note settings autophagy critically relies class iii phosphoinositide-3-kinase pi3k enzymatic activity human cells function is mediated phosphatidylinositol 3-kinase catalytic subunit type 3 pik3c3 best known hvps34 operates control multiprotein complex involving among interactors haploinsufficient oncosuppressor beclin 1 91 92 importantly virtue bona fide bh3 domain beclin 1 physically interact antiapoptotic members bcl-2 protein family including bcl-2 bcl xl 9496 interacting beclin 1 bcl-2 bcl xl de facto prevent stress induced activation autophagy line notion both bh3-only proteins e.g. bad chemical inhibitors bcl-2-like proteins e.g. abt-737 shown activate autophagy displace beclin 1 inhibitory liaisons bcl-2 bcl xl 94 97 interestingly bh3-only proteins like bnip3 shown critical execution specific autophagic programs selective removal damaged mitochondria mitophagy 5 98 relevance cell death regulation seems rather limited the binding beclin 1 antiapoptotic bcl-2 family members also resolved phosphorylation either binding partner 100102 conversely seems bcl-2 bcl xl affect steady state levels autophagic flux direct fashion note tian et al recently suggested bcl-2/bcl xl targeting compounds might activate beclin 1- pik3c3-independent autophagic program leading cell death however authors failed provide robust data mechanistically explain findings besides direct autophagy modulatory function stemming interactions beclin 1 bcl-2-like proteins 94 96 bcl xl is expected regulate autophagy via less direct metabolic circuitries notably controls efficiency mitochondrial atp production 67 68 ii influences exchange critical bioenergetic metabolites e.g. atp adp ptpc components 24 44 iii reduces intracellular levels acetyl coa iv interacts cytoplasmic pool p53 60 65 66 hence expression levels bcl xl might also influence autophagic flux steady state opposed adaptive conditions aspect crosstalk bcl xl autophagy warrants investigation the implication bcl-2 family members including bcl xl cell death unrelated processes limited aspects cell biology discussed 28 29 for instance recently shown bcl xl phosphorylated multiple serine residues including s49 s62 cell cycle dependent fashion 104 105 the mitotic kinase polo like kinase 3 plk3 appears responsible cell cycle dependent phosphorylation bcl xl s49 starting phase abruptly falling onset mitosis whereas plk1 mitogen activated protein kinase 9 mapk9 suggested catalyze bcl xl phosphorylation s62 response dna damaging agents hence stabilizing cell cycle arrest g2 checkpoint hence similar bcl-2 106 107 bcl xl plays role physiological cell cycle progression dna damage induced cell cycle checkpoints 104 105 a years ago rather unspecific inhibitors bcl-2-like proteins abt-737 abt-263 generated intense wave enthusiasm quickly entered clinical trials part antineoplastic regimens treatment mostly hematological malignancies one prominent target side effects abt-737 abt-263 turned dose limiting thrombocytopenia 109 110 linked fact bcl xl critical survival platelets more recently bcl xl also involved adhesive function platelets 112 113 hence abt-737 abt-263 appear impair aggregation trigger demise consistent fraction circulating platelets also exert consistent thrombocytopathic effects among residual platelets the implication bcl-2 protein family mitochondrial dynamics well actual relevance mitochondrial fission fusion events apoptosis still subject vivid debate 114116 while detailed discussion topic largely exceeds scope paper worth noting bcl- xl recently shown interact stimulate gtpase activity dynamin related protein 1 drp1 central component mitochondrial fission machinery so bcl xl appears alter mitochondrial function neurons manner stimulates formation synapses as drp1 also participates execution regulated necrosis mitochondrial dynamics may constitute yet another point control cell death related -unrelated processes bcl xl bcl-2 bcl xl reported negatively regulate nlrp1 inflammasome supramolecular platform required full blown activation caspase-1and hence production interleukin il)-1 il-18in response proinflammatory stimuli 118 119 in particular flexible loop domain bcl-2 bcl xl located 1st 2nd helices proteins appears engage physical interactions nlrp1 thereby blocking capacity latter bind atp oligomerize 118 120 besides playing critical role innate immunity inflammasomes crucial translation immunogenic cell death functionally peculiar form apoptosis robust adaptive immune response it therefore tempting speculate yet remains formally proved interaction antiapoptotic bcl-2 family members inflammasomes may constitute promising therapeutic target enhancing immunogenicity cancer cell death following initial wave interest role bcl-2-like proteins regulation apoptosis several laboratories refocused attention distinct aspects biology pro- antiapoptotic members bcl-2 family 28 29 last decade intense investigational effort led identification several processes modulated bcl-2 family proteins independent least directly impacting cell death regulatory functions 28 29 discussed paper bcl xl shown exert consistent degree control various aspects bioenergetic metabolism including mitochondrial atp production ca fluxes autophagy protein acetylation well several cellular organismal processes mitosis platelet aggregation synaptic efficiency table 1 hence similar bcl-2 family members bcl xl appears operate critical hubs coordinately control multiple cellular functions including three step switch homeostatic metabolisms adaptive responses stress cell death scenario tempting speculate yet remains formally demonstrated bcl-2-like proteins may originated regulators non apoptotic functions later evolution may acquired capacity control cell death similar happened still happening p53 number cellular functions regulated bcl-2 family members including bcl xl grow	the bcl-2 homolog bcl - xl , one of the two protein products of bcl2l1 , has originally been characterized for its prominent prosurvival functions . similar to bcl-2 , bcl - xl binds to its multidomain proapoptotic counterparts bax and bak , hence preventing the formation of lethal pores in the mitochondrial outer membrane , as well as to multiple bh3-only proteins , thus interrupting apical proapoptotic signals . in addition , bcl - xl has been suggested to exert cytoprotective functions by sequestering a cytosolic pool of the pro - apoptotic transcription factor p53 and by binding to the voltage - dependent anion channel 1 ( vdac1 ) , thereby inhibiting the so - called mitochondrial permeability transition ( mpt ) . thus , bcl - xl appears to play a prominent role in the regulation of multiple distinct types of cell death , including apoptosis and regulated necrosis . more recently , great attention has been given to the cell death - unrelated functions of bcl-2-like proteins . in particular , bcl - xl has been shown to modulate a number of pathophysiological processes , including but not limited to mitochondrial atp synthesis , protein acetylation , autophagy and mitosis . in this short review article , we will discuss the functions of bcl - xl at the interface between cell death and metabolism .
deliberate self harm dsh one commonest cause death world higher rate noted low- middle income countries soman et al south india reported dsh responsible 6.6% deaths the average age 42 years males 34 years females half suicides occurred age group 1544 years reported women frequent dsh attempts mean age 24.5 9 years dsh attempts one commonest reasons emergency department ed admissions self poisoning common method used dsh study done across eight low- middle income countries suicide attempts common among low socioeconomic status common modes self poisoning organophosphorus compounds overdosage tablets the suicide rate high among elderly according study done south india common modes hanging organo phosphorous poisoning insecticide poisoning self immolation associated high mortality rate india south american country hanging jumping heights bad outcome wide variety poisons like insecticides pesticides plant poisons rodenticides freely available across country there wide variation method dsh used across different states india varies socioeconomic status this study done describe profile dsh attempts outcome patients presenting adult ed tertiary care hospital south india this retrospective study patients presenting dsh adult ed christian medical college vellore 45-bed department south india average 200 admissions daily all patients 15 years old presenting history alleged dsh january 01 2011 december 31 2013 included study a retrospective chart review performed said patients using hospital electronic medical database the following extracted demographics age sex date admission type dsh used discharge status duration admission the categorical variables expressed proportion chi square test fisher exact test used compare dichotomous variables tests this study approved institutional review board patient confidentiality maintained using unique identifiers password protected data entry software restricted users eighty seven percent medical surgical emergencies 13% trauma related cases the prevalence patients presenting dsh 1.08% 1228/1,13,243 figure 1 there slight female predominance 51.8% consistent study period 3 years table 1 almost half patients 48.1% age group 20 29 years age elderly population 60 years constituted 3.5% study population table 1 the month wise distribution dsh cases 3-year period shown figure 2 the time dsh admissions follows 37.1% 456/1228 nights 21000500 h following day 29% 356/1228 afternoons 12001700 h 18.9% 232/1228 evenings 17002100 h 15% 184/1228 morning hours 05001700 h patient flow emergency department classification dsh baseline characteristics mode deliberate self harm among men women consumption pesticide chemicals agricultural chemicals 46% common mode dsh followed tablet overdosing 29.8% consumption plant poisons 7.8% near hanging 5.3% corrosive chemical ingestion 4.7% ingestion rodenticides 4.2% common modalities dsh two wild plants locality consumed dsh oleander 52/96 oduvanthalai 42/96 the plants used dsh henna eucalyptus one case leaves consumed rare modes dsh 2% hydrocarbon ingestion 12 hair dye ingestion 5 self infliction sharp objects 4 ingestion crushed glass pieces 2 burns 1 ingestion copper oxychloride 1 table 2 the method dsh preferred women plant poisons 66.3% vs. 33.7% p 0.006 corrosives 63.8% vs. 36.2% p 0.047 tablet overdose 64.9% vs. 34.1% p 0.001 agricultural chemicals likely consumed men 59.5% vs. 40.5% p 0.001 dsh the preferred mode dsh males females shown figure 3 mode deliberate self harm month wise distribution number patients dsh 3 years outcome studied condition discharge hospital number days hospital majority 97.9% patients discharged alive hospital 19 1.5% died hospital the discharge status 7 patients mentioned either left medical advice discharged request the length hospital stay 2 days among 634 51.6% patients 3 6 days among 374 30.5% 7 13 days among 151 12.3% 2 weeks 69 5.6% patients respectively table 3 the objective study describe demographic features mode dsh outcome patients presenting dsh tertiary care hospital south india nearly 1% admission ed related dsh study the male female ratio 0.93 slight female predominance 51.8% study done low socioeconomic country reported male female suicide ratio 1.7 a study conducted middle income country showed women frequent dsh attempts men a similar study revealed average age 42 years males 34 years females half suicides occurring age group 1544 years the average age commonly resorting dsh 24.5 9 years reported nojomi et al study dsh common among young 82.7% patients 40 years age almost half patients 48.1% age group 20 29 years age patients 60 years constituted 3.5% dsh attempts reported dsh uncommon among elderly dsh attempts usually present ed self poisonings common mode dsh according study done eight low- middle income countries study average least one dsh presented ed every day self poisoning common method dsh agricultural chemicals 46% commonly used commit dsh other studies india also reported insecticide poisoning tablet overdosage frequent modes dsh the modes dsh reported near hanging self immolation jumping heights self infliction inhalation automobile gases etc the less frequently reported modes dsh study consumption plant poisons 7.8% near hanging 5.3% corrosive chemical ingestion 4.7% ingestion rat killer poisons 4.2% multiple modes dsh observed 3 patients one patient presented near hanging consuming insecticide poison second patient consumed combination kerosene insecticide paint third patient consumed zinc phosphide along paracetamol tablets since hospital study done separate triage resuscitation policy burns exact numbers could presented study suicides geographical area reported total mortality rate 82.2/100000 population as age group affected 15 40 years total years life lost also high 26.9 years however study total 1228 patients attempted dsh 1202 97.9% patients discharged alive hospital 19 1.5% died hospital this reflects though suicide attempts posed high risk death hospitalization aggressive treatment positively affect outcome analysis found adult dsh attempts 51.6% discharged hospital 2 days the length hospital stay 3 6 days 30.5% patients 7 13 days 12.3% 2 weeks 5.6% study population psychiatric illness depression personality disorders found majority first attempters dsh alcohol abuse ethnicity low income marital discord loss job change weather conditions also associated dsh all patients dsh attempt receive psychiatric evaluation follow arranged general practitioner psychiatrist preventive health activities psychiatric screening follow socioeconomic upliftment counseling regarding difficult times life loss job marital discord alcohol abuse result decreased dsh attempts banning restricting use fatal agricultural chemicals reduce morbidity mortality associated dsh low socioeconomic countries hazard classification agricultural chemicals also include dsh potential warnings issued accordingly since still large number dsh attempts agricultural chemicals political legal changes regarding sale poisonous chemicals indirectly lead decrease mortality morbidity associated dsh attempts the retrospective nature study provide information risk factors co morbid conditions associated dsh the retrospective nature study provide information risk factors co morbid conditions associated dsh	background : deliberate self - harm ( dsh ) is a major under - recognized epidemic in the low- and middle - income countries . this is a large retrospective study form the emergency department ( ed ) of tertiary care center of south india to describe the clinicodemographic features of dsh cases.materials and methods : this is a retrospective study conducted at ed of christian medical college , vellore , india from january 01 , 2011 to december 31 , 2013 . all cases of dsh were included in the study . the demographic details , mode of dsh and clinical outcome were extracted from the electronic medical record . descriptive statistics are presented . chi - square test was used to compare categorical variables . for all tests , a two - sided p 0.05 was considered statistically significant.results:total of 1228 patients were admitted to ed for dsh during the study period . male and female occurred in equal ratio . more than half of the cases occurred among age group below 30 years . consumption of pesticides ( agricultural chemicals ) was the single most common mode of dsh ( 46% ) , especially among men , followed by medication overdose ( 29.8% ) . consumption of plant poison and tablet overdose was higher among women . overall mortality due to dsh was low ( 1.5% ) in our study.conclusion:dsh is under - recognized major public health problem in low - middle income countries like india . most cases occur among young and productive age group and in equal frequencies among men and women . timely and the appropriate institution of treatment can decrease the morbidity and mortality due to dsh remarkably .
dense vision obscuring calcification posterior aspect silicone intraocular lenses iols often amenable neodymium yttrium aluminum garnet capsulotomy prior reports required iol exchange we report successful removal dense calcium deposition posterior surface three piece silicone lens using pars plana vitrectomy ppv a light pipe used retroilluminate iol dense fibrous tissue setting low cut rate high aspiration rate able clear visual axis dystrophic calcification without damaging iol optic small gauge ppv may utilized remove dense dystrophic calcium deposits lens surface lieu iol exchange dystrophic calcification silicone intraocular lenses iols rare complication diminish visual acuity contrast sensitivity dystrophic calcification reported use silicone iols vitreous hemorrhage patients asteroid hyalosis primarily treated lens explantation neodymium yttrium aluminum garnet nd yag laser treatment often remove dense deposits.1,2 first report published 2004 wackernagel et al describing composition deposits explanted silicone lens 4 years implantation.3 recently mamalis et al reported presence calcium phosphate 16 explanted opacified silicone lenses various manufacturers 86.4% lenses patients confirmed asteroid hyalosis concurrently authors analyzed 111 calcified hydrophilic acrylic lenses none associated history asteroid hyalosis.4 previous treatments lens opacification relied lens explantation alone without subsequent reimplantation new lens.14 requires large incision risks refractive change herein describe novel approach treating patients vision obscuring dense calcification silicone lenses without explantation iol a 78-year old woman underwent bilateral phacoemulsification three piece clariflex silicone iol insertion abbott medical optics inc santa ana ca usa she significant past medical history past ocular history asteroid hyalosis greater right eye wet macular degeneration left eye central scar also 9 years later described decreased vision right eye visual acuity 20/100 right eye count fingers left eye examination revealed dystrophic calcification posterior surface right intraocular lens figure 1 time nd yag capsulotomy unable clear calcification to access dystrophic calcification pars plana approach taken using stellaris pc 23-gauge vitrectomy system bausch lomb incorporated bridgewater nj usa performing core anterior vitrectomy a dense fibrous tissue setting used high aspiration rate 600 variable cut rate less 1,500 cuts minute slowly remove calcified material posterior aspect iol along posterior capsule clearing central optic her visual acuity 20/25 without correction postoperative day one central optic clear dystrophic material figure 2 1 year material reaccumulated central optic vision remained stable 20/25 figure 3 calcification posterior surface silicone iols patients asteroid hyalosis rare well described late complication cataract surgery.2 prior reports treatment dystrophic calcification required iol explantation exchange a case series studying 22 iol exchanges identified complications 36.4% procedures including corneal decompensation loss capsular support vitreous prolapse uncertain refractive outcome.57 comparison united kingdom national ophthalmology database study vitreoretinal surgery found 7.8% pars plana vitrectomies ppv intraoperative complication common iatrogenic retinal breaks 3.2%).8 use high speed small gauge vitrectomy system clear calcification lasting results via posterior approach allows use existing iol rapid surgical visual recovery compared iol exchange patients maintain intraocular optics achieved immediately cataract surgery chance refractive alteration associated iol exchange minimized theory removing asteroid bodies vitrectomy decreases risk future calcium deposition silicone iol optic interest saving patient risks refractive uncertainty iol exchange small gauge ppv may utilized remove dense dystrophic calcium deposits lens surface	purposedense , vision - obscuring calcification on the posterior aspect of silicone intraocular lenses ( iols ) is often not amenable to neodymium : yttrium - aluminum - garnet capsulotomy , and , in prior reports , has required iol exchange . we report the successful removal of dense calcium deposition on the posterior surface of a three - piece silicone lens using pars plana vitrectomy ( ppv).materials and methodsa 23-gauge ppv was performed using the stellaris vitrectomy system . a light pipe was used to retroilluminate the iol , and a dense fibrous tissue setting with a low cut - rate and high aspiration rate was able to clear the visual axis of the dystrophic calcification without damaging the iol optic.resultsvisual acuity improved from 20/100 to 20/25.conclusionsmall - gauge ppv may be utilized to remove dense dystrophic calcium deposits on the lens surface in lieu of iol exchange .
presented data literature determinations prove adiposis pancreas treated seriously since often symptom multi factor damage organ the identification factors supposed induce apply well thought health promoting strategy time may contribute risk reduction especially cardiovascular accident diabetes our manner classification pancreas adiposis seems simple possible applied use class ultrasound device authors report financial personal connections persons organizations might negatively affect contents publication and/or claim authorship rights publication	so far , a fatty pancreas has been related to obesity and the ageing processes in the body . the current list of pathogenetic factors of the condition is clearly extended with genetically conditioned diseases ( cystic fibrosis , shwachman - diamond syndrome and johanson - blizzard syndrome ) , pancreatitis , especially hereditary and obstructive , metabolic and hormonal disorders ( hypertriglyceridemia , hypercholesterolemia , hyperinsulinemia and hypercortisolemia ) , alcohol overuse , taking some medicines ( especially adrenal cortex hormones ) , disease of the liver and visceral adiposis . as regards lipomatosis of that organ resulting mainly from dyslipidemia and hyperglycemia , the term nonalcoholic fatty pancreas disease was introduced . experimental studies on animals and histological preparations of the pancreatic fragments show that the lipotoxicity of the collected adipocytes collected ion the organ release a cascade of proinflammatory phenomena , and even induces the processes of carcinogenesis . pancreas adiposis is best defined in computed tomography and magnetic resonance imaging . however , a series of works proved the usefulness in the diagnostics of that pathology of transabdominal and endoscopic ultrasonography . in that method , the degree of adiposis was based on the comparison of echogenicity of the pancreas and the liver , renal parenchyma , spleen and/or retroperitoneal adipose . recently , the evaluation was expanded by the evaluation of the degree of pancreatic adipose with the pancreas - to - liver index , utilizing to that end a special computer program . according to our experience , the simplest solution is the method utilized by us . on one crosssection of the body of the pancreas , its echogenicity is assessed in comparison to retroperitoneal adipose and the visibility of the splenic vein , pancreatic duct and the major retroperitoneal vessels . depending on the visualization of these structures , it is possible to determine the degree of pancreas adiposis . such a study applies to 250 people , in whom the adiposis was detected in 16.5% , which is close to other cohort us examinations results .
malocclusion defined occlusion molar relationship arches planes spaces anomalies tooth position beyond normal limits individuals malocclusion usually feeling shame facial appearance also feel shy society various factors adverse oral habits anomalies number dentition shape developmental position teeth cause malocclusion need identify awareness levels children respect oral health children play important role filling healthy lifestyle lifetime age groups 12 15 years would benefitted knowledge orthodontic treatment orthodontic treatment early ages could beneficial preventing malocclusion complications furthermore may assist orthodontist educating patients parents providing advice orthodontic treatment improving quality life bring physical psychological social changes the major benefits orthodontic treatment improve physical function prevention tissue damage correction esthetic component date studies evaluate level awareness among preadolescents regarding orthodontic treatment study planned an epidemiological survey conducted period month september december 2013 a multi staged simple random sampling technique used selecting six schools three urban areas three rural areas bilaspur district the students age group 12 15 years approached different classes pilot study done validate closed ended questionnaire constituted nine items aware orthodontist seen irregular teeth believe straitening teeth makes better smile helps mastication better oral hygiene easier speak healthy lifestyle aware duration braces treatment aware cost orthodontic treatment there single examiner obtaining details questionnaire subjects intra examiner reliability 0.87 after obtaining prevalence awareness regarding orthodontic treatment subjects total sample obtained using sample size calculation formulation taking consideration prevalence obtained students pursuing education selected schools all available students selected age group agreed participate survey selected formed sample size 1010 subjects mean age years 13.02 2.146 a survey proforma prepared using self administered structured questionnaire written english assess level awareness regarding orthodontic procedures the selected students schools invited participate survey prescheduled time purpose study informed explained students those voluntarily agreed participate survey gave written informed consent asked answer questionnaire after scoring data analyzed using statistical package social sciences version 16.0 software descriptive statistics obtained mean percentage scores standard deviation frequency distribution calculated know level awareness the student test anova test applied statistical evaluation means after scoring data analyzed using statistical package social sciences version 16.0 software descriptive statistics obtained mean percentage scores standard deviation frequency distribution calculated know level awareness the student test anova test applied statistical evaluation means the total sample composed 1010 subjects including 556 boys 454 girls categorized according area location 606 belong urban locality 404 remote areas the age study population varies 12 15 years mentioned table 1 age wise awareness children toward orthodontic procedures using anova test overall awareness orthodontist among school going children 45.1% around 55.0% answered seen irregularity dentition asked straightening teeth makes better smile 69.8% replied positively orthodontic treatment helps mastication view 55.2% students 55.3% said makes better oral hygiene 45.0% mentioned treatment easy pronounce also results healthy lifestyle only 19.9% aware duration orthodontic treatment 35.2% exactly knew cost orthodontic procedure the mean scores awareness orthodontic procedures significantly higher among girls 4.46 1.671 compared boys 4.00 1.489 illustrated table 2 results compared according area location students urban areas gave positive response regarding awareness compared children rural community table 3 awareness children toward orthodontic procedures using student test awareness children toward orthodontic procedures according location using student test anova test revealed significant difference according age wise regarding awareness orthodontist children 14 years aware 4.35 1.499 children 12 years less aware 3.61 1.203 mentioned table 1 stepwise multiple linear regression showed best predictors descending order according awareness orthodontic procedure age gender area residence table 4 malocclusion second common dental diseases children young adults next dental caries the aim orthodontic procedure improve dental occlusion results better smile good functioning harmony face overall seen increase awareness orthodontic treatments dental specialty among children well adults a similar fashion observed among nigeria population associated increase orthodontic treatment care many individuals aware orthodontic treatment malocclusion craniofacial abnormalities ensuring proper relationship temporomandibular joint may improve phonation facial esthetics beneficial effects general oral health results improvement quality life information oral health knowledge among indian population still limited especially rural people constitute 70% population this type study give indication changing attitudes toward malocclusion among preadolescents around less half participants aware orthodontist procedures done in study done kaur found level dental awareness parents preschool children indian context revealed poor level dental awareness parents data showed girls better aware treatment malocclusion males agreement studies it might explained basis girls care appearance would tend educated oral health irregularity dentition however studies shown boys significantly higher knowledge scores compared females similarly urban children shown positive attitude like visiting dentist study done singh et al 2012 considering influence age awareness orthodontics similar findings seen study conducted friedman et al 1976 survey found moderate awareness children toward orthodontic awareness this group preadolescents showed moderate level awareness regarding orthodontic procedures believe helps esthetics better oral hygiene mastication healthy lifestyle	objective : this study was carried out to know the level of awareness regarding orthodontic procedures among preadolescents as there is very high prevalence of malocclusion.methods:this cross - sectional study was conducted among a sample of 1010 subjects with a mean age of ( in years ) was 13.02 2.146 . a self - administered structured questionnaire proforma was used . pilot study was done to validate the questionnaire , which was constituted of nine items . the student 's t - test and anova test along with stepwise multiple linear regression were applied for the statistical evaluation of means . the level of significance was set at 0.05.results:the overall awareness of orthodontist among the school going children was 45.1% . the knowledge of orthodontic procedures was significantly higher among girls ( 4.46 1.671 ) when compared to boys ( 4.00 1.489 ) . when the results were compared according to the area of location most of the students in the urban areas gave a positive response regarding awareness when compared to children in the rural community.conclusion:this group of preadolescents showed moderate level of awareness regarding orthodontic procedures as they mentioned that it helps in esthetics , better oral hygiene , mastication , and healthy lifestyle .
nonhuman primates nhps high level genetic homology humans make invaluable experimental models biomedical research messaoudi et al 2011 zhang et al 2014 however also increasingly important source emerging zoonotic diseases humans including human immunodeficiency virus hiv ebola virus malaria etc poinar 2009 miller et al several intestinal parasites occur nhps causing asymptomatic mild disorders karim et al potentially zoonotic protozoans including enterocytozoon bieneusi giardia duodenalis cryptosporidium spp entamoeba spp ) could maintained transmitted attendant risk human outbreaks originating animal reservoirs legesse erko 2004 ye et al 2012 the health nhps therefore important terms management objectives also concerning public health compared developed countries america europe china relatively rich primate resources currently leading producer major supplier nhps international market zhang et al 2014 nhps commonly maintained zoos natural reserves zoological gardens different feeding habitats china karim et al therefore important understand epidemiology intestinal parasites potential transmission nhps humans the molecular characterization nhp parasites increasingly studied berrilli et al 2011 2012 betson et al 2014 li et al 2015a li et al 2015b lack comprehensive studies intestinal parasites nhps prevalence parasites nhps china reported molecular characterization enterocytozoon bieneusi giardia duodenalis cryptosporidium spp entamoeba spp this study conducted accordance chinese laboratory animal administration act 1988 the research protocol reviewed approved research ethics committee henan agricultural university appropriate permission obtained director animals properties samples collected veterinarians notified parasitic infections identified nhps soon possible expedite management a total 3349 fresh fecal specimens collected 17 districts two cities beijing shanghai one autonomous region guangxi zhuang autonomous region eight provinces hebei henan hubei hunan guangdong sichuan yunnan shanxi china period july 2009 april 2015 fig 1 912 fecal specimens subsequently collected animals zoos 1402 farms 918 free range 117 research laboratories table 1 fresh fecal samples captive nhps kept separate pens day collected early morning the specimens free living animals immediately collected ground defecation specimen 10 g ) was collected plastic container labelled number district species clinical symptoms animal specimens transported laboratory soon possible stored 2.5% w v potassium dichromate solution 4 c prior microscopy the fecal specimens sieved sieve 7.62 cm diameter pore size 245 transferred 50 ml centrifuge tube containing water precipitated centrifugation 5000 rpm 10 min a portion specimen microscopically examined detect protozoan helminthic parasites sheather sugar flotation technique lugol iodine staining huang et al 2014 wet smears examined bright field microscope 100 400 magnification determine shape size colour eggs cysts giardia duodenalis a total 1882 fecal specimens nhps examined characterized ssrrna appelbee et al 2003 triosephosphate isomerase tpi sulaiman et al 2003a glutamate dehydrogenase gdh cacci et al 2008 beta giardin bg gene cacci et al 2002 2660 specimens identified cryptosporidium spp pcr amplification 18s rrna xiao et al 2001 70 kda heat shock protein hsp70 xiao ryan 2008 genotyped 60 kda glycoprotein gp60 gene alves et al 2003 for enterocytozoon bieneusi total 1882 fecal specimens nhps screened genotyped ssu rrna gene sulaiman et al 2003b entamoeba spp 531 specimens 1059 entamoeba spp positive samples microscopy randomly selected pcr amplification based ssu rrna using specific primers e. histolytica clark diamond 1991 e. dispar clark diamond 1991 e. moshkovskii ali et al 2003 e. nuttulli verweij et al 2001 e. coli tachibana et al 2009 e. chattoni tachibana et al 2009 order identify molecular characterization the infection rates compared test differences considered significant p 0.01 eleven genera intestinal parasites five protozoan six helminths genera found nhps fig 2 were frequently detected species incidence 36.4% 1218/3349 followed trichuris spp the ratio intestinal parasitic infections ranged 46.0% 73.0% among four feeding habitats zoos farms free range research laboratories table 1 the highest infection rate found animals free range 73.0% 670/918 followed research laboratories 63.2% 74/117 lower infection rates zoos 46.3% 422/912 farms 46.0% 645/1402 p 0.01 the sample prevalence infection ranged 32.6% 64.8% among 11 sampling locations the guangxi zhuang autonomous region highest rate 64.8% 566/873 lowest found guangdong province 32.6% 107/328 table 2 the majority 74.3% 1345/1811 infected nhps carried one parasitic species 22.2% 402/1811 carried two parasitic species 3.5% 64/1811 carried three parasite species table 2 the parasites often involved mixed infections entamoeba spp trichuris spp strongyloides spp six families 20 genera 34 species nhps 3349 individual specimens detected infections rates ranged 0% 100% different nhp species table 1s 6.5% 122/1882 specimens tested giardia duodenalis positive pcr analysis the assemblages n 4 b n 118 found zoonotic potential table 3 thirty two assemblage b isolates data three loci yielded 15 multi locus genotypes mlgs including 2 known 13 new karim et al the occurrence giardia duodenalis assemblages different species nonhuman primate species shown table 2s for cryptosporidium spp 0.7% 19/2660 positive pcr amplification karim et al 73.7% 14/19 positive specimens found cryptosporidium hominis whilst 26.3% 5/19 c. muris the subtypes c. hominis identified iba12g3 7/14 iia17 1/14 gp60 gene sequence analysis table 4 occurrence cryptosporidium spp and subtypes nonhuman primate species based pcr analysis shown table 3s for enterocytozoon bieneusi 16.3% 306/1882 positive specimens detected pcr analysis altogether 34 genotypes observed including 16 known genotypes type iv henan v henan iv peru8 pigebits5 pigebits7 ebpa ebpc ebpd peru11 beb4 beb6 cs-1 18 new genotypes cm1 cm18 table 5 the new genotypes cm1 cm3 cm6 cm 8 cm 10 cm 17 belong previously described group 1 zoonotic potential genotypes cm5 cm7 cm9 clustered group 2 whereas genotypes cm4 cm18 formed new cluster karim et al 2014b karim et al the occurrence enterocytozoon bieneusi genotypes different species nonhuman primate species shown table 4s for entamoeba spp overall amplification efficiency 87.19% 463 among 531 positive specimens entamoeba dispar 72.69% 386/531 entamoeba coli 54.05% 287/531 amplified successfully the mixed infections e. dispar e. coli 27.1% 144/531 unpublished data this study demonstrates high sample prevalence 54.1% 1811/3349 diversity five protozoan genera six helminths genera intestinal parasites nhps china similar infection ratio found pet macaques 59.1% 52/88 indonesia jones engel et al 2004 zoo malaysia 54.5% 54/99 lim et al 2008 pet monkeys cameroon 51.1% 24/47 pourrut et al 2011 a diversity intestinal parasites frequently reported infect nhps jones engel et al 2004 2005 lim et al 2008 pourrut et al 2011 greater parasite species diversity observed ta national park cte divoire nine protozoans 14 helminths 3142 specimens kouassi et al 2015 several studies reported entamoeba spp prevalent intestinal parasites nhps pourrut et al 2011 whereas others reported strongyloides spp prevalent gillespie et al 2005 all five genera protozoans detected microscopy well enterocytozoon bieneusi zoonotic mansfield gajadhar 2004 ye et al 2012 giardia duodenalis particularly zoonotic parasitic protozoan infects wide range mammals including nhps feng xiao 2011 animals infected ingest food water contaminated giardia cysts graczyk et al 2003 the assemblage b nhps host adaptated 96.7% 118/122 positive isolates zoonotic assemblage karim et al 2015a are usually associated intestinal pathology resulting diarrhea humans animals ryan hijjawi 2015 they transmitted via fecal oral route either direct contact ingestion contaminated food water the protozoan disperse rapidly monoxenous life cycle low infective dose short prepatent period graczyk et al however prevalence rate found study much lower found sri lanka 27.2% 27/125 ekanayake et al 2006 and e. bieneusi common parasitic pathogen nhps high prevalence 16.3% difficult detect light microscopy lower infection rate 12.3% e. bieneusi reported kenya li et al 2011 higher infection rates 28.2% 18.5% found free range macaque monkeys guizhou cynomolgus monkeys guangxi china respectively ye et al 2012 ye et al 2014 altogether 34 e. bieneusi genotypes found involving 26 genotypes 263/306 86.0% belonged group 1 zoonotic potential karim et al thus genotypes nhps zoonotic potential nhps could act reservoirs human microsporidiosis the entamoeba spp highest infection rate 36.4% microscopy observed majority nhp species 25/34 examined table 1s they also known highly prevalent intestinal parasite ethiopia uganda senegal tanzania italian cameroon etc legesse erko 2004 gillespie et al 2005 petrov et al 2010 are human pathogens transmitted various forms contact due direct life cycle pedersen et al 2005 although e. dispar e. coli found study unpublished data non pathogenic species low risk zoonotic transmission nhps human zoonotic transmit also pay attention are obligate intracellular parasites inhabit bile duct intestinal mucosal epithelial cells various vertebrates legua seas 2013 now 1999 ortega sanchez 2010 li et al 2015b one humans zhou et al 2011 the highest prevalence cyclospora spp found ethiopia 22.0% 13/59 legesse erko 2004 cyclospora like organisms also detected monkeys zhao et al the helminths including trichuris spp strongyloides spp ascaris spp parasitic high potential transmission humans simple life cycles they reported several populations primates ocaido et al 2003 legesse erko 2004 gillespie et al 2005 bezjian et al 2008 ( table 1s contrast colobus monkeys cte divoire kouassi et al 2015 unfortunately difficult identify helminths species based morphology oocysts eggs a comprehensive study genetic diversity necessary confidently distinguish species genotypes intestinal parasites conclusion investigation parasites nhps china detailed parasites infection status reviewed molecular characterization four intestinal protozoans this baseline parasitological data provides important information elimination parasites monitor potential transmission zoonotic infections nhps	parasites are a well - known threat to nonhuman primate ( nhp ) populations , and potentially cause zoonotic diseases in humans . in this study , the basic data was provided of the parasites in nhps and the molecular characterization of the enterocytozoon bieneusi , giardia duodenalis , cryptosporidium spp . , and entamoeba spp . were reviewed , which were found in these samples . a total of 3349 fecal samples were collected from 34 species reared at 17 districts in zoos , farms , free - range , or research laboratories , and examined microscopically . eleven genera of intestinal parasites were detected : five genera of protozoans ( isospora spp . , entamoeba spp . , giardia sp . , cryptosporidium spp . , and cyclospora spp . ) and six genera of helminths ( trichuris spp . , strongyloides spp . , ascaris spp . , physaloptera spp . , ancylostoma spp . , and enterobius spp . ) . the overall sample prevalence of parasitic infection was 54.1% ( 1811/3349 ) . entamoeba spp . was the most prevalent ( 36.4% , 1218/3349 ) . the infection rate was the highest in free - range animals ( 73.0% , 670/918 ) ( p < 0.01 ) and guangxi zhuang autonomous region ( 64.8% , 566/873 ) . mixed infections were mostly detected for entamoeba spp . , trichuris spp . , and strongyloides spp .. molecular characterization was reviewed of enterocytozoon bieneusi , giardia duodenalis , cryptosporidium spp . , and entamoeba spp . , as these are zoonotic species or genotypes . this parasitological data for nhps in china , provides important information for veterinarians and public health authorities for the elimination of such parasites and monitor the potential transmission of zoonotic infections from nhps .
microencapsulation processes generally used isolating protecting sensitive substances bioactive molecules facilitating controlled release.1 formulation microparticles generally tailored suit target administration route microparticles built core shell structure composed two materials ie called core materials wall materials active ingredients either entrapped core materials form core material enclosed protected wall material the different formulation processes used produce microparticles divided three groups 1 chemical methods eg polymerization interface polycondensation 2 physicochemical methods coacervation solvent diffusion solvent evaporation phase separation rapid expansion supercritical fluids 3 physicomechanical methods including spray drying fluidized bed technology pan coating.2 paper focus third group methods notably use spray drying process formulation microparticles spray drying widely used technology microencapsulation food pharmaceutical industries the process rapidly converts liquid solution suspension emulsion dried powder core materials homogeneously solubilized dispersed aqueous media sprayed contact hot gas flux the sprayed droplets still quite small ranging hundred micrometers thus developing large air/ water interface area resulting effective heat transfer result the drying process complete temperature particle equal air.3 point active ingredients appear homogenously dispersed matricial dried microparticulate structure.4 spraying drying particles rapid process performed within seconds it speed makes process suitable use sensitive thermosensitive compounds without resulting degradation when process performed biodegradable biocompatible wall materials adapting particle sizes densities administration route spray drying shown suitable inhalation route5,6 intraocular administration.7 solid forms generated also used make tablets capsules oral administration enhancing intestinal absorption bioavailability the nature solid formed helps increase stability compounds liable oxidize solution such micrometric systems present many advantages pharmaceutical applications easy manipulation administration microparticles instance reduced clearance subcutaneous intraocular administration however major disadvantage low penetration diffusion tissues counter problem these multiscaled systems known trojan particles.7 dried suspension nanoparticles usable due low stability aggregation hydrolysis water their manipulation greatly improved encapsulated aforementioned trojan systems however date recent work proposes formulations using polymeric nanoparticles.79 although used drug carriers polymeric nanoparticles present ongoing drawbacks due polymers limit drug encapsulation rates leave polymeric residues living tissues the innovative concept work creation trojan microparticles spray drying encapsulation polymeric nanoparticles nanoemulsions fundamentally different systems pharmaceutical applications nanoemulsions prove extremely stable systems suspension spray drying also droplets conserved process water dissolution powder the core droplet often made active ingredients case thus encapsulation rates yields need orders magnitude higher polymeric nanoparticles instance gomez gaete et al7 encapsulated bioactive hydrophobic molecules dexamethasone nanoparticle encapsulation rates low 0.7% optimized solubilization lipophilic compounds oils increased rate direct emulsification liquid lipids gave full encapsulation 100% such innovative trojan particles also provide solutions drying lipids lipophilic bioactive molecules nanoscaled formulation increases optimizes bioavailability administration site the major potential problem concerning microencapsulation nanoemulsions propose address conservation nanoemulsion structure size distribution throughout spray drying process nanoemulsions generally defined oil water emulsion droplets size ranging nanometric scale typically 20300 nm.1012 owing small size nanoemulsions great stability several months the reasons stability well documented literature,1315 originate unlikeliness droplets flocculate coalesce nanoemulsions used new tool chemical pharmaceutical applications instance providing homogeneous dispersion otherwise poorly soluble materials water nanoemulsions used nanocarriers drugs contrast agents applications targeting controlled delivery as regards formulation processes nanoemulsions divided two groups ie high energy low energy methods.13,14 high energy methods use specific devices form nanoemulsions high pressure homogenizers ultrasound generators whereas low energy methods make intrinsic physicochemical properties components formulation attain nanometric range case nanoemulsions formed spontaneously room temperature.14 work chosen use low energy methods also solvent free polymer free generation definitively stable oil suspension dispersed aqueous phase.1315 worth noting many studies done microencapsulating emulsions using spray drying.1622 however objectives scope published works restricted drying oily fatty species deal conservation structure eg size dispersed system emulsified forms recent works reported efficient methods obtaining 90% oil content dried powder.23 however emulsion droplet size plays important role encapsulation efficiency spray drying,1618 ie smaller size encapsulated emulsion efficient encapsulation respect microencapsulation nanoemulsions enhance result without using specific interface crosslinking technology.23 returning main objective ie formulation trojan particles aim conserve nanometric scale encapsulated droplets entrapped microparticles ensure delivery resolubilization dried microparticle powder water work this open new doors application simple promising nanoparticulate systems low energy nanoemulsification methods performed room temperature associated gentle process spray drying make whole formulation process suitable encapsulation sensitive molecules study used formulation vitamin e acetate model lipophilic molecule encapsulated this molecule constitutes hydrophobic phase formulation consequently nanoemulsion core made exclusively vitamin e acetate the sample characterization obtained scanning electron microscopy sem particle size distributions worked analyzing sem pictures thus allowing quantitative comparison powders the microencapsulation process first evaluated function various formulation parameters nature wall materials concentration solution spray drying these preliminary results subsequently allowed us optimize microencapsulation vitamin e acetate nanoemulsion a number biodegradable polymers evaluated use wall materials process namely gum arabic whey protein polyvinyl alcohol modified starches maltodextrin hydroxypropyl beta cyclodextrins pregelatinized hydroxypropyl pea starch the stability nanoemulsions controlled throughout process dynamic light scattering integrity stability vitamin e acetate molecules followed 3 months using high performance liquid chromatography hplc vitamin e acetate dl alpha tocopheryl acetate purchased sigma st louis mo nonionic surfactants basf ludwigshafen germany ie cremophor elp polyoxiethylated-35 castor oil hydrophilic lipophilic balance approximately 1214 kindly provided laserson etampes france used received the wall materials selected gum arabic cni colloides naturels international rouen france whey protein davisco foods international inc eden prairie mn cleargum co 03 modified starch roquette lestrem france glucidex 12 maltodextrin de 12 roquette polyvinyl alcohol pva sigma kleptose hpb parenteral grade hydroxypropyl beta cyclodextrins roquette nutriose fb 06 modified starch roquette lycoat rs 780 pregelatinized hydroxypropyl pea starch roquette finally ultrapure water obtained using milliq filtration system millipore saint quentin en yvelines france the samples composed nanoemulsions dispersed aqueous solution dissolve wall materials vitamin e acetate nanoemulsions selected model suspensions controllable size polydispersity nanoemulsions formulated according low energy emulsification process described elsewhere.14 short nanoemulsion droplets spontaneously formed bringing two phases contact the first composed vitamin e acetate oily phase plus hydrophilic surfactant totally miscible gently homogenized room temperature second phase pure water once two liquid phases mixed hydrophilic species immediately solubilized aqueous phase inducing demixing oil spinodal decomposition form nanometric emulsion droplets vitamin e acetate chosen model oily phase mixed nonionic surfactants brought contact aqueous phase thus generating nanoemulsions the spontaneous emulsification processes characterized described previously,14 following impact surfactant oil weight sow ratio wsurfactant/[wsurfactant woil 100 hydrodynamic diameter polydispersity index the optimized formulation compromise nanoemulsions presenting good monodispersity size nanometric range lowest possible amount surfactant the water added generation nanoemulsions influences neither physicochemical properties size polydispersity index the size distribution polydispersity nanoemulsions assessed dynamic light scattering using malvern nano zs instrument malvern orsay france a heliumneon laser 4 mw operated 633 nm scatter angle fixed 173 temperature maintained 25c the polydispersity index measure broadness size distribution derived cumulative analysis dynamic light scattering single gaussian population standard deviation mean size xpcs the polydispersity index indicates quality dispersion values lower 0.1 acceptable measurements good quality colloidal suspensions values close 1 poor quality samples either droplet sizes colloidal range high polydispersity measurements performed triplicate spray drying process filtered 0.45 case regards polymers used wall materials dissolved swelled ultrapure water 1 day prior performing experiments the amount wall material impact spray dried particles studied respective proportions core wall materials also appear important parameter formulation these parameters studied optimized order incorporate highest possible amount oil dried powdery aspect samples the wall material solution incorporated nanoemulsions vitamin e acetate stirring homogenous suspension obtained the liquid suspensions atomized powders bchi mini spray dryer b-290 flawil switzerland the two fluid nozzle dispersed liquid suspensions thin droplets heated drying chamber the speed process acknowledged well suited spray drying sensitive thermosensitive molecules the operational conditions follows aspiration rate 100% inlet temperature 150c solution feed rate 10 ml minute the size distribution morphology spray dried microparticles evaluated sem philips xl20 university strasbourg philips amsterdam netherlands the specimen fixed carbon support coated palladium layer analyzed 20 kv the particle size distributions analyzed sem micrographs using software assisted method previously developed laboratory already described elsewhere.24 exact number particles diameters calculated raw images even agglomerated particles hence even particles form aggregates method isolates particle rest defines surface area thus allowing individual identification disclosing particle size distribution a log normal extrapolation applied probability density function form f x exp [ln x ]/2)/(x[2 mean standard deviation respectively thus making possible quantitative comparison sem pictures consequently enabling us compare spray dried samples the powders formulated carefully selecting wall material nanoemulsion ratio aggregates formed sample remains powdered form even drying conventional imaging sem sample needs fixed carbon support followed coating conductive metallic layer makes particles appear aggregated however advantage software used analyzing size distribution lies ability distinguish single particles even look aggregated the originality approach lies possibility quantitative analysis sem pictures thus sample comparison each specimen wall material encapsulating nanoemulsions spray dried twice sem measurements one performed three distinct sem carbon supports for each given experiment representative picture sem results obtained selected reported figures accompanying paper hplc used pump lc-126 detector lc-168 injector lc-508 beckman coulter fullerton ca follow stability integrity vitamin e acetate encapsulated spray dried microparticles the operational conditions defined stationary phase column c8 length 0.125 4.0 mm cc125/4 lichrospher 100 5 rp-8 macherey nagel dren germany mobile phase mixture 50 vol acid aqueous phase ph 2.3 950 vol mixture 85% methyl alcohol 15% isopropanol flow rate 1.2 ml minute spectrophotometer operated 285 nm injection volume 20 l the reference samples vitamin e acetate selected concentration 89 g ml quantification vitamin e acetate trapped spray dried microparticles performed collecting amount powder vitamin acetate content identical reference sample the powder dissolved mixture water isopropanol however accordance wall material properties different ratios water isopropanol used adapted wall materials the amount vitamin e acetate determined initial time ie immediately spray drying process week wall material 3 months each specimen wall material spray dried twice hplc measurements powder carried triplicate vitamin e acetate dl alpha tocopheryl acetate purchased sigma st louis mo nonionic surfactants basf ludwigshafen germany ie cremophor elp polyoxiethylated-35 castor oil hydrophilic lipophilic balance approximately 1214 kindly provided laserson etampes france used received the wall materials selected gum arabic cni colloides naturels international rouen france whey protein davisco foods international inc eden prairie mn cleargum co 03 modified starch roquette lestrem france glucidex 12 maltodextrin de 12 roquette polyvinyl alcohol pva sigma kleptose hpb parenteral grade hydroxypropyl beta cyclodextrins roquette nutriose fb 06 modified starch roquette lycoat rs 780 pregelatinized hydroxypropyl pea starch roquette finally ultrapure water obtained using milliq filtration system millipore saint quentin en yvelines france the samples composed nanoemulsions dispersed aqueous solution dissolve wall materials vitamin e acetate nanoemulsions selected model suspensions controllable size polydispersity nanoemulsions formulated according low energy emulsification process described elsewhere.14 short nanoemulsion droplets spontaneously formed bringing two phases contact the first composed vitamin e acetate oily phase plus hydrophilic surfactant totally miscible gently homogenized room temperature second phase pure water once two liquid phases mixed hydrophilic species immediately solubilized aqueous phase inducing demixing oil spinodal decomposition form nanometric emulsion droplets vitamin e acetate chosen model oily phase mixed nonionic surfactants brought contact aqueous phase thus generating nanoemulsions the spontaneous emulsification processes characterized described previously,14 following impact surfactant oil weight sow ratio wsurfactant/[wsurfactant woil 100 hydrodynamic diameter polydispersity index the optimized formulation compromise nanoemulsions presenting good monodispersity size nanometric range lowest possible amount surfactant the water added generation nanoemulsions influences neither physicochemical properties size polydispersity index the size distribution polydispersity nanoemulsions assessed dynamic light scattering using malvern nano zs instrument malvern orsay france a heliumneon laser 4 mw operated 633 nm scatter angle fixed 173 temperature maintained 25c the polydispersity index measure broadness size distribution derived cumulative analysis dynamic light scattering single gaussian population standard deviation mean size xpcs the polydispersity index indicates quality dispersion values lower 0.1 acceptable measurements good quality colloidal suspensions values close 1 poor quality samples either droplet sizes colloidal range high polydispersity measurements performed triplicate spray drying process filtered 0.45 case regards polymers used wall materials dissolved swelled ultrapure water 1 day prior performing experiments the amount wall material impact spray dried particles studied respective proportions core wall materials also appear important parameter formulation these parameters studied optimized order incorporate highest possible amount oil dried powdery aspect samples the wall material solution incorporated nanoemulsions vitamin e acetate stirring homogenous suspension obtained the liquid suspensions atomized powders bchi mini spray dryer b-290 flawil switzerland the two fluid nozzle dispersed liquid suspensions thin droplets heated drying chamber the speed process acknowledged well suited spray drying sensitive thermosensitive molecules the operational conditions follows aspiration rate 100% inlet temperature 150c solution feed rate 10 ml minute the size distribution morphology spray dried microparticles evaluated sem philips xl20 university strasbourg philips amsterdam netherlands the specimen fixed carbon support coated palladium layer analyzed 20 kv the particle size distributions analyzed sem micrographs using software assisted method previously developed laboratory already described elsewhere.24 exact number particles diameters calculated raw images even agglomerated particles hence even particles form aggregates method isolates particle rest defines surface area thus allowing individual identification disclosing particle size distribution a log normal extrapolation applied probability density function form f x exp [ln x ]/2)/(x[2 mean standard deviation respectively thus making possible quantitative comparison sem pictures consequently enabling us compare spray dried samples the powders formulated carefully selecting wall material nanoemulsion ratio aggregates formed sample remains powdered form even drying conventional imaging sem sample needs fixed carbon support followed coating conductive metallic layer makes particles appear aggregated however advantage software used analyzing size distribution lies ability distinguish single particles even look aggregated the originality approach lies possibility quantitative analysis sem pictures thus sample comparison each specimen wall material encapsulating nanoemulsions spray dried twice sem measurements one performed three distinct sem carbon supports given experiment representative picture sem results obtained selected reported figures accompanying paper hplc used pump lc-126 detector lc-168 injector lc-508 beckman coulter fullerton ca follow stability integrity vitamin e acetate encapsulated spray dried microparticles the operational conditions defined stationary phase column c8 length 0.125 4.0 mm cc125/4 lichrospher 100 5 rp-8 macherey nagel dren germany mobile phase mixture 50 vol acid aqueous phase ph 2.3 950 vol mixture 85% methyl alcohol 15% isopropanol flow rate 1.2 ml minute spectrophotometer operated 285 nm injection volume 20 l the reference samples vitamin e acetate selected concentration 89 g ml quantification vitamin e acetate trapped spray dried microparticles performed collecting amount powder vitamin acetate content identical reference sample the powder dissolved mixture water isopropanol however accordance wall material properties different ratios water isopropanol used adapted wall materials the amount vitamin e acetate determined initial time ie immediately spray drying process week wall material 3 months each specimen wall material spray dried twice hplc measurements powder carried triplicate first different wall materials individually spray dried order evaluate potential influence spray drying process microparticle properties ie size polydispersity morphology the samples spray dried 15 wt% water processing representative concentration the sem pictures presented figure 1 including quantitative study size maxima standard deviation values the results significant size distribution polydispersity also particle shape morphology closely linked interface properties compounds spray drying process the first observation shows microparticle sizes quite small generally 14 furthermore fluctuations maxima different species relatively reduced significantly different however differences exist could due surfactant properties polymers ie gum arabic whey protein maltodextrin polyvinyl alcohol giving rise smaller particles whereas kleptose nutriose cleargum lycoat produced bigger ones although samples appear globally homogeneous regardless materials used microparticles show smooth surfaces spherical geometry eg figures 1b 1c 1d 1f 1 g show intense invaginations shape resembling deflated ball explain result an interesting parallel drawn deflated shapes global microparticulate sizes deflated shapes tend correspond bigger particles this understandable drying wall material concentrations water droplets began dry periphery this clearly illustrated hydroxypropyl beta cyclodextrin particles kleptose figure 1c bigger specimens shapes thin shells these particular morphologies appear linked size sprayed droplets ie spraying drying thus surface properties wall material solutions conversely polyvinyl alcohol known surfactant properties forms spherical microparticles figure 1h the picture also shows presence polymer wires physically link particles formation influenced interface phenomena low surface tensions this series experiments designed observe effect polymer concentration solution properties morphology spray dried microparticles we thus studied representative case gum arabic solutions 5 10 15 20 30 wt% the results presented figure 3 including quantitative study size maxima standard deviation values sizes standard deviations appear similar concentrations ranging 1.5 2.0 standard deviations 0.8 1.6 however significant difference samples regards global aspect particle shape homogeneity the higher polymer concentration larger size distribution reaching huge particle sizes larger 10 shown figures 3d 3e fact visible statistical analysis proportions within whole population small this probably due higher viscosity suspension increases concentration accordingly representative wall material concentration 15 wt% chosen rest experiments as described methods section nanoemulsification process characterized studying influence surfactant to- oil ratio size polydispersity nanoemulsions the general trend expected found various systems,14 shows lowering droplet size polydispersity index amount surfactant increased ie increase surfactant oil ratio the first results highlight efficiency nanoemulsification process significant formulation proposed uses vitamin e acetate hydrophobe totally substituting oily compounds generally used spontaneous emulsification processes eg oleic macrogols triglycerides nanoemulsions relatively monodispersed droplets polydispersity index 0.2 dh 189 nm obtained surfactant oil ratio 20% surfactant oil ratio 40% droplet size falls 100 nm order ensure efficient nanoemulsion encapsulation spray dried microparticles present proof concept study used nanodroplets 100 nm hence chosen value surfactant oil 40% indicated arrow figure 4 giving rise nanoemulsions exhibiting hydrodynamic diameter dh 84 nm polydispersity index 0.11 the production dried microparticles entrap oily nanoemulsion droplets performed described earlier spray drying nanoemulsion droplets suspension aqueous bulk phase thereby solubilizing wall material polymers the impact oil surfactant wall material weight ratio microparticulate properties morphology size distribution evaluated representative case whey protein the results reported figure 5 quantitative study size maxima standard deviation values reported figure 6 four different ratios tested ie 1:1 1:2 1:3 1:4 corresponding vitamin e acetate loadings 37.5 27.3 21.4 17.6 wt% respectively the samples appear homogenous generally presenting similar aspect compared pure formulations shown figure 1a first point observe almost perfect spherical shape particles the deflated morphology particles discussed longer present replaced spherical shapes smooth surfaces this could due global increase droplet loading drying doubled ratio 1:1 hence empty cavities formed pure wall materials longer exist giving way spherical morphologies size distribution clear difference observed ratios 1:1 1:2 1:3 1:4 looking result terms interface properties note nanoemulsions show significant surfactant properties droplet loading reduced ratio 1:4 thus affording decrease particle size furthermore results obtained whey protein ratio gave rise powdery homogeneous samples however using wall materials limit fluctuated 1:1 1:4 wall materials spray dried along surfactant alone vitamin e acetate alone surfactant vitamin e acetate formulated nanoemulsion experiment using surfactant alone and vitamin e acetate alone compound amounts strictly corresponded required nanoemulsion formulation the aim experiments see whether nanodispersed forms could influence spray drying process the results presented figure 7 representative wall materials including quantitative study size maxima standard deviation values gum arabic figure 7b whey protein figure 7c kleptose nutriose figure 7d summarized figure 8 first observation concerns morphology microparticles function compounds added wall materials discussed earlier the deflated aspect particles generally inhibited presence oily phase nanoemulsions conversely seems enhanced surfactant except whey protein deflated effect appears less pronounced indeed similar amount surfactants using wall material surfactant alone system wall material nanoemulsion system resulting microparticle sizes significantly different especially gum arabic whey protein however even result apparent kleptose nutriose global trend highlighted figure 8 shows generally size slightly reduced wall material surfactant alone system slightly increased wall material vitamin e acetate alone system these results corroborate idea nanoformulated materials present enhanced effects induced nonformulated compounds case only surfactant likely affect interface phenomena governing spray drying process this illustrated comparison wall material surfactant alone system wall material nanoemulsion system this suggests nanoemulsion droplets trapped water air interface reducing surface tension even surfactant alone giving rise smaller droplets one objective study prove possible microencapsulate nanoemulsion droplets order propose new solutions delivery nanoemulsions thus allowing enhanced absorption encapsulated compounds the microencapsulation nanoemulsion droplets also requires entrapped dried microparticles nanoemulsion oil droplets conserve size individual nature the polymer rapidly solubilized due huge specific surface powder kept intact process nanoemulsion droplets redispersed water their resolubilization water allowed redispersion nanoemulsion droplets wall materials used soluble water times within nanoemulsions redispersed water appear relatively short ie minutes they depend water particle ratio nature wall materials ie kinetics wall material solubilization water for instance given amount powders mixed water 10 wt% redispersion nanoemulsions achieved different wm follows gum arabic 5 minutes whey protein 5 minutes kleptose 3 minutes nutriose 3 minutes after redispersion samples like typical nanometric dispersions translucent characterization performed dynamic light scattering the results reported table 1 presenting hydrodynamic diameter polydispersity index nanoemulsion droplets formulation called raw nanoemulsions mixing wall materials spray drying redispersion volume water summarize comparison samples spray drying showed significant increase size generally doubled samples this results slight droplet coalescence simply due turbulence heat spray drying process the results also vary function wall materials indicating oil polymer interactions affinities could play role droplet merging nevertheless average size redispersed droplets remained 150 nm polydispersity index around 0.2 suspension still rightly considered nanoemulsion taking account results present study schematic illustration microparticulate structure shown figure 9 these multiscaled systems fact used carriers nanoemulsions ensuring easy manipulation concentration administration stability studies performed powders results reported figure 10 we first note initial time measurements show approximately 100% vitamin e acetate seven wall materials tested this simply indicates spray drying process destroy encapsulated molecules it also worth noting one peak vitamin e acetate observed wall materials studied peaks appeared 3 months words this result confirmed corroborated overall aspect curves figure 10 indicating constant amount vitamin e acetate recovery approximately 100% these results confirm spray drying process considered efficient method microencapsulation nanoemulsions ensuring integrity molecules throughout process well conservation storage dried product first different wall materials individually spray dried order evaluate potential influence spray drying process microparticle properties ie size polydispersity morphology the samples spray dried 15 wt% water processing representative concentration the sem pictures presented figure 1 including quantitative study size maxima standard deviation values the results significant size distribution polydispersity also particle shape morphology closely linked interface properties compounds spray drying process the first observation shows microparticle sizes quite small generally 14 furthermore fluctuations maxima different species relatively reduced significantly different however differences exist could due surfactant properties polymers ie gum arabic whey protein maltodextrin polyvinyl alcohol giving rise smaller particles whereas kleptose nutriose cleargum lycoat produced bigger ones although samples appear globally homogeneous regardless materials used microparticles show smooth surfaces spherical geometry eg figures 1b 1c 1d 1f 1 g show intense invaginations shape resembling deflated ball explain result an interesting parallel drawn deflated shapes global microparticulate sizes deflated shapes tend correspond bigger particles this understandable drying wall material concentrations water droplets began dry periphery this clearly illustrated hydroxypropyl beta cyclodextrin particles kleptose figure 1c bigger specimens shapes thin shells these particular morphologies appear linked size sprayed droplets ie spraying drying thus surface properties wall material solutions conversely polyvinyl alcohol known surfactant properties forms spherical microparticles figure 1h the picture also shows presence polymer wires physically link particles formation influenced interface phenomena low surface tensions this series experiments designed observe effect polymer concentration solution properties morphology spray dried microparticles we thus studied representative case gum arabic solutions 5 10 15 20 30 wt% the results presented figure 3 including quantitative study size maxima standard deviation values sizes standard deviations appear similar concentrations ranging 1.5 2.0 standard deviations 0.8 1.6 however significant difference samples regards global aspect particle shape homogeneity the higher polymer concentration larger size distribution reaching huge particle sizes larger 10 shown figures 3d 3e fact visible statistical analysis proportions within whole population small this probably due higher viscosity suspension increases concentration accordingly representative wall material concentration 15 wt% chosen rest experiments as described methods section nanoemulsification process characterized studying influence surfactant to- oil ratio size polydispersity nanoemulsions the general trend expected found various systems,14 shows lowering droplet size polydispersity index amount surfactant increased ie increase surfactant oil ratio the first results highlight efficiency nanoemulsification process significant formulation proposed uses vitamin e acetate hydrophobe totally substituting oily compounds generally used spontaneous emulsification processes eg oleic macrogols triglycerides nanoemulsions relatively monodispersed droplets polydispersity index 0.2 dh 189 nm obtained surfactant oil ratio 20% surfactant oil ratio 40% droplet size falls 100 nm order ensure efficient nanoemulsion encapsulation spray dried microparticles present proof concept study used nanodroplets 100 nm hence chosen value surfactant oil 40% indicated arrow figure 4 giving rise nanoemulsions exhibiting hydrodynamic diameter dh 84 nm polydispersity index 0.11 the production dried microparticles entrap oily nanoemulsion droplets performed described earlier spray drying nanoemulsion droplets suspension aqueous bulk phase thereby solubilizing wall material polymers the impact oil surfactant wall material weight ratio microparticulate properties morphology size distribution evaluated representative case whey protein the results reported figure 5 quantitative study size maxima standard deviation values reported figure 6 four different ratios tested ie 1:1 1:2 1:3 1:4 corresponding vitamin e acetate loadings 37.5 27.3 21.4 17.6 wt% respectively the samples appear homogenous generally presenting similar aspect compared pure formulations shown figure 1a first point observe almost perfect spherical shape particles the deflated morphology particles discussed longer present replaced spherical shapes smooth surfaces this could due global increase droplet loading drying doubled ratio 1:1 hence empty cavities formed pure wall materials longer exist giving way spherical morphologies size distribution clear difference observed ratios 1:1 1:2 1:3 1:4 the latter presents outstanding submicronic size particle diameters around 500 nm looking result terms interface properties note nanoemulsions show significant surfactant properties droplet loading reduced ratio 1:4 thus affording decrease particle size furthermore results obtained whey protein ratio gave rise powdery homogeneous samples however using wall materials limit fluctuated 1:1 1:4 wall materials spray dried along surfactant alone vitamin e acetate alone surfactant vitamin e acetate formulated nanoemulsion experiment using surfactant alone and vitamin e acetate alone compound amounts strictly corresponded required nanoemulsion formulation the aim experiments see whether nanodispersed forms could influence spray drying process the results presented figure 7 representative wall materials including quantitative study size maxima standard deviation values gum arabic figure 7b whey protein figure 7c kleptose nutriose figure 7d summarized figure 8 first observation concerns morphology microparticles function compounds added wall materials discussed earlier the deflated aspect particles generally inhibited presence oily phase nanoemulsions conversely seems enhanced surfactant except whey protein deflated effect appears less pronounced indeed similar amount surfactants using wall material surfactant alone system wall material nanoemulsion system resulting microparticle sizes significantly different especially gum arabic whey protein however even result apparent kleptose nutriose global trend highlighted figure 8 shows generally size slightly reduced wall material surfactant alone system slightly increased wall material vitamin e acetate alone system these results corroborate idea nanoformulated materials present enhanced effects induced nonformulated compounds case only surfactant likely affect interface phenomena governing spray drying process illustrated comparison wall material surfactant alone system wall material nanoemulsion system this suggests nanoemulsion droplets trapped water air interface reducing surface tension even surfactant alone giving rise smaller droplets one objective study prove possible microencapsulate nanoemulsion droplets order propose new solutions delivery nanoemulsions thus allowing enhanced absorption encapsulated compounds the microencapsulation nanoemulsion droplets also requires entrapped dried microparticles nanoemulsion oil droplets conserve size individual nature the polymer rapidly solubilized due huge specific surface powder kept intact process nanoemulsion droplets redispersed water their resolubilization water allowed redispersion nanoemulsion droplets wall materials used soluble water times within nanoemulsions redispersed water appear relatively short ie minutes they depend water particle ratio nature wall materials ie kinetics wall material solubilization water for instance given amount powders mixed water 10 wt% redispersion nanoemulsions achieved different wm follows gum arabic 5 minutes whey protein 5 minutes kleptose 3 minutes nutriose 3 minutes after redispersion samples like typical nanometric dispersions translucent characterization performed dynamic light scattering the results reported table 1 presenting hydrodynamic diameter polydispersity index nanoemulsion droplets formulation called raw nanoemulsions mixing wall materials spray drying redispersion volume water summarize comparison samples spray drying showed significant increase size generally doubled samples this results slight droplet coalescence simply due turbulence heat spray drying process the results also vary function wall materials indicating oil polymer interactions affinities could play role droplet merging nevertheless average size redispersed droplets remained 150 nm polydispersity index around 0.2 suspension still rightly considered nanoemulsion taking account results present study schematic illustration microparticulate structure shown figure 9 these multiscaled systems fact used carriers nanoemulsions ensuring easy manipulation concentration administration stability studies performed powders results reported figure 10 we first note initial time measurements show approximately 100% vitamin e acetate seven wall materials tested this simply indicates spray drying process destroy encapsulated molecules it also worth noting one peak vitamin e acetate observed wall materials studied peaks appeared 3 months words this result confirmed corroborated overall aspect curves figure 10 indicating constant amount vitamin e acetate recovery approximately 100% these results confirm spray drying process considered efficient method microencapsulation nanoemulsions ensuring integrity molecules throughout process well conservation storage dried product this study proposes novel technique using spray drying process microencapsulate nanoemulsions the dried powder obtained consists multiscaled objects form microparticles size range around 2 the present study also demonstrates microparticles able encapsulate precisely entrap nanoemulsion droplets around 150 nm polymeric matricial structure the low energy nanoemulsification method chosen associated gentle form spray drying makes whole process suited encapsulation sensitive molecules the model lipophilic molecule tested vitamin e acetate encapsulated around 20% dried powder we show presence nanoemulsion solutions spray drying significant impact size distribution morphology microparticles however process destroy oily nanodroplets easily redispersed powder contact aqueous phase hplc follow vitamin e acetate integrity shows molecules remain intact throughout process well conservation dried form	backgroundnanoemulsions consist of very stable nanodroplets of oil dispersed in an aqueous phase , typically below 300 nm in size . they can be used to obtain a very fine , homogeneous dispersion of lipophilic compounds in water , thus facilitating their handling and use in nanomedicine . however , the drawback is that they are suspended in an aqueous media . this study proposes a novel technique for drying lipid nanoemulsion suspensions to create so - called trojan particles , ie , polymer microparticles ( around 2 m ) which very homogeneously entrap the nano - oil droplets ( around 150 nm ) in their core.methodsmicroencapsulation of the nanoemulsions was performed using a spray - drying process and resulted in a dried powder of microparticles . by using a low - energy nanoemulsification method and relatively gentle spray - drying , the process was well suited to sensitive molecules . the model lipophilic molecule tested was vitamin e acetate , encapsulated at around 20% in dried powder.resultswe showed that the presence of nanoemulsions in solution before spray - drying had a significant impact on microparticle size , distribution , and morphology . however , the process itself did not destroy the oil nanodroplets , which could easily be redispersed when the powder was put back in contact with water . high - performance liquid chromatography follow - up of the integrity of the vitamin e acetate showed that the molecules were intact throughout the process , as well as when conserved in their dried form.conclusionthis study proposes a novel technique using a spray - drying process to microencapsulate nanoemulsions . the multiscale object formed , so - called trojan microparticles , were shown to successfully encapsulate , protect , and release the lipid nanodroplets .
technology based assessments increasingly implemented medical assessment monitoring individuals variety medical psychiatric disorders weight management diabetes monitoring programs use technological based programs effectively 1 2 web based assessments monitoring programs place monitor psychiatric symptoms several years 35 telephone based systems demonstrated efficacy technology field worldwide 6 7 including ecuador tablet based systems capturing survey data well established used clinically extension medical data recording method adapting technology based assessments and monitoring tools psychiatric disorders critical may improve efficiency responses standardized questions generate measures clinical monitoring automated accessible the versatility computer tablet allows technology adapted widely primary care clinics however use computer tablets emerging health system quito ecuador studied the feasibility level patient population capacity gather record symptoms depression critical successfully adapting technology based screening monitoring system psychiatric symptoms primary care the effective clinical management major depression primary care represents significant opportunity improvements health terms quality individual life financial sustainability community health delivery programs enhanced adherence medical interventions depression common disorder among prominent leading medical causes disability worldwide 10 11 depression recognized major problem primary health care setting point prevalence 5 10% twice many experience depressive symptoms rise full major depression diagnosis individuals depression threefold increase comorbid chronic diseases less likely seek receive effective treatment medical conditions lower rates appropriate preventative health services screening less adherent medical recommendations the majority individuals depression treated primary care providers prescribe 80% antidepressant medications usa the burden untreated depression primary care level substantial depressions go unrecognized untreated in addition personal vocational cost untreated depression shown overall medical care costs increased greater numbers patient care provider interactions investigations treatments variety medical complaints identification diagnosis implementation treatments specific depression primary care level substantial personal medical implications effective patient management community 17 18 the studies address prevalence depressive disorders ecuador limited public health sector collecting data use health services year 2007 rate major depression 72 per 100,000 inhabitants low clear increase effectively double rate previous decade 2012 rate major depression 162 per 100,000 compared usa rates lower rates however increasing rates likely reflect increased awareness depression care provider patient focused levels there clear evidence depressive disorders throughout ecuadorian society including indigenous populations 21 22 a study conducted rural urban sectors quito health area using ghq-12 found 37.1% individuals surveyed positive scores mental health issues the global health perspective rates depression throughout world suggests prevalence likely 10% range significantly higher estimated public health records ecuadorian government 1.6% consistent observations elsewhere 75% depressions go undiagnosed therefore untreated we tested use computer tablet clinical setting screen depressive symptoms sample attendees primary clinic program quito ecuador order determine feasibility acceptance implementation novel technology assess depression symptoms patient population compare two depressive symptom severity instruments 9-item patient health questionnaire phq9 quick inventory depressive symptoms self report qids sr 12-item general health questionnaire ghq-12 we find technology readily embraced find identified rates depression attendees primary care clinic similar usa we hypothesized clinic attendees would embrace novel technology screening questionnaires would identify individuals depressive symptoms increasing efficiency clinical interaction patients attending primary health care clinic affiliated universidad san francisco de quito quito ecuador invited participate anonymously series self administered questionnaires individuals offered participation clinic staff arrival evaluated prior seeing primary care physician pcp after informed consent procured participants completed short tutorial use tablet ipad completing questionnaires embedded polldaddy survey software application participants asked independently complete three screening tools the patients screened team medical students ds ef gj depressive symptoms using dsm iv checklist major depressive disorder clinical researchers finally clinical global impression severity cgi rating primary health care provider recorded clinician impression patient level depression 1 depressed 7 critically depressed the cgi completed survey questions completed individual seen pcp the instruments used nine item patient health questionnaire phq-9 29 30 ghq-12 general health questionnaire 27 31 qids sr quick inventory depressive symptomology self report 26 32 the spanish language versions assessment instruments uploaded central website http://www.polldaddy.com designed host survey questionnaires could administered field using computer tablet ipad the qids sr scored according method described epidemiology data center university pittsburg http://www.ids-qids.org/index2.html#scoring reliability evaluated comparing scores phq-9 measure reflecting depression symptomology previously studied latin american patients ghq-12 convergent divergent validity assessed spearman rho comparing phq-9 scores scores ghq-12 qids sr feasibility assessed quantitatively recording proportion patients able complete questionnaires agreed participate it also qualitatively assessed observations research assistants regarding ease use among different demographics participated study this study engaged 226 participants ages 18 65 attending primary care clinic nonpsychiatric reasons agreed participate anonymously survey depressive symptomatology using computer tablet based technology all 226 patients completed phq-9 ghq-12 qids sr based average number daily contacts clinic estimated approximately 500600 individuals attended clinic study time a total 131 cgi scores patients collected well proved somewhat difficult gather required clinical researcher interact primary care clinician whose availability often limited the dsm iv major depressive episode checklist review conducted 188 patients table 1 table 2 presents correlation coefficients phq-9 depression assessment tools the phq-9 results compared data ghq-12 qids sr dsm iv cgi the phq-9 showed significant correlation measures ghq-12 r 0.64 p 0.0001 qids sr r 0.68 p 0.0001 dsm iv symptom count r 0.67 p 0.0001 cgi r 0.39 p 0.0001 figure 1 demonstrates relationship phq measures qids sr ghq-12 cgi despite apparent correlation broad range cgi scores 2/3 individuals cgi 3 less phq9 8 implication depressive symptoms suspected clinically all participants started survey 226/226 able complete self assessments ipad tablet computer five patients unable read text tablet screen result bringing reading glasses doctor office therefore excluded participating the integration technology assessment monitoring depression represents tangible advance clinical care increases efficiency detection treatment particularly communities limited resources capacity medical care device costs decreasing screening depression primary care setting quito ecuador using computer tablet based technology proved efficient adaptable method gathering information readily accepted clinic attendees used without difficulty following brief orientation process researchers a phq9 score 8 used threshold screening purposes well known somatic symptoms common 75% latin american culture tendency represent mood symptoms many primary care clinics 75% patients subsequently found depressed initiated clinical visit somatic concerns depression self identified driving need medical attention this argues lower threshold phq9 cultures wherein psychological aspects depression likely less frequently acknowledged believe increase sensitivity screening there instances initially wherein presbyopic participants challenged bring along reading glasses solved shelf corrective reading glasses available 4 patients unable complete forms included total 226 participants all self report questionnaires applied psychiatric research construct validity measures established usa clinical setting 33 36 37 in addition piloting use technology clinical primary care level quito intent evaluate depressive symptom screening severity instruments estimate clinical utility we considered control group paper based screening however project designed assess well technological approach could adapted active clinic we elected use participation completion assessments measure acceptability view fact integrating clinic process wished gather data expedited manner elected gather information perspective participant process while may considered weakness study feel strength approach assumption measurement based care integral health care primary level there excellent correlation depression symptom severity assessment scores phq-9 qids sr 0.68 expected designed measure depression however correlation important fact measuring whether depression identified 2 separate measurement instruments there excellent correlation number dsm iv symptoms acknowledged participant phq-9 scores finally good correlation ghq scores consistent previous findings studies phq9 latin america however study honduras indicated feasible measure depression culture the ghq validated chile efficacious measure depressive symptomology used ecuador thus conclude based correlated results consistent strong convergent validity measures valid measures depressive symptoms ecuadorian population the clinical global impression severity cgi scale 7-point scale used record clinician impression severity patient illness time assessment it subjective scale generally reflective knowledge clinician patient illness the correlation cgi depressive symptom ratings generally good expected predict symptomatic states the observation substantial number individuals cgi 3 present despite relatively substantial symptoms depression suggests clinicians asked give impression patient depressive symptoms unaware depression could number reasons patient may attended clinic reasons related feeling disclose primary care physician depressed the pcp may asked depressive symptoms unable determine therefore depression present pcp may attuned patient medical complaints concerned physical complaints could driven part underlying depressive symptoms health care system ecuador state funded ministry health ; the first line contact health care system primary care physician responsible implementation government health care policies ongoing efforts focused strategic implementation preventative health screening several dimensions diabetes hypertension currently policies screening depression psychiatric disorders there every advantage national screening program implemented systematically primary health care providers there considerable efficiency screening depression primary care setting 41 42 particularly available care hand hand if specific interventions follow screening process questionable utility screening population primary care level depression since management depression done primary care providers health systems logical ecuadorian health system engage pcps screening management depression the paucity published research depression latin american countries implies similar challenges ecuador there several advantages screening depression use electronic methods provides efficiency data collection management the instruments used current study easily adapted electronic versions showed high correlation scores suggests consistency measure condition depression designed assess this importance level primary care frequently psychiatrist mental health professional available perform clinical evaluations the importance screening reflected next steps specifically happens information subsequent actions severity level we find 20% individuals phq-9 8 would recommend evaluation primary care level major depression possible treatment given level comorbid medical chronicity potential personal medical social consequences depression combined economical health benefits treatment depression clear there evidence medical assistants effective follow screening assessments facilitators treatment intervention strategies providing practical assessment primary care team referral specialty evaluation the strategies electronically based screening process performed project effective first step identification management depression limitations report include lack thorough follow examination detailed clinical interview verify diagnosis further systematic screening attendees rate depression established the primary purpose work assess efficiency tablet based screening clinics we find one five individuals attending primary health care clinic reports phq-9 8 individuals small percentage cgi scores 3 suggesting concerns noted clinician infrequently the cut 810 phq-9 suggested populations somatic complaints this consistent observation literature approximately 50% depressions missed primary care we able gather cgi half participants availability pcp limited reflects busy nature primary health care clinic depression frequently overlooked clinical setting ecuador reflected low rates depression reported ministry public health the recent increases reported rates depression suggest increasing awareness disease however rates still substantially lower elsewhere every likelihood ecuadorian rates parallel elsewhere primary care clearly clinical contact point individuals screened depression use computer technology screening process demonstrated effective acceptable population the phq-9 shorter phq-2 excellent methods screening depressive symptoms followed detailed assessment treatment screening depression one step overall management depression clearly necessary detect diagnose illness order effectively treat however merely detecting depression primary care level absence program manage disorder minimal consequence 46 47 detecting elevated blood glucose use unless system place diagnose treat diabetes they range diagnostic interview clinician experience mental health determine nature problems specific needs patient education programs health illness management the treatment plan subsequently tailored needs patient capacity care providers critical management systematic method screening monitoring symptoms demonstrated tablet based system effective acceptable method easy use clinic setting	depression is a frequent yet overlooked occurrence in primary health care clinics worldwide . depression and related health screening instruments are available but are rarely used consistently . the availability of technologically based instruments in the assessments offers novel approaches for gathering , storing , and assessing data that includes self - reported symptom severity from the patients themselves as well as clinician recorded information . in a suburban primary health care clinic in quito , ecuador , we tested the feasibility and utility of computer tablet - based assessments to evaluate clinic attendees for depression symptoms with the goal of developing effective screening and monitoring tools in the primary care clinics . we assessed individuals using the 9-item patient health questionnaire , the quick inventory of depressive symptoms - self - report , the 12-item general health questionnaire , the clinical global impression severity , and a dsm - iv checklist of symptoms . we found that 20% of individuals had a phq9 of 8 or greater . there was good correlation between the symptom severity assessments . we conclude that the tablet - based phq9 is an excellent and efficient method of screening for depression in attendees at primary health care clinics and that one in five people should be assessed further for depressive illness and possible intervention .
often deceptive facial eruption mimic variety cutaneous dermatoses the pattern infection depends geographic location endemic dermatophyte strains given area cultural population habits tinea faciei infections common children rare infants although neonatal tinea rare cases reported occasionally a 20-day old female child presented multiple annular lesions face last 4 days examination erythematous annular plaques size 23 cm diameter present face cheeks forehead well defined irregular raised margins figure 1 the child apparently normal birth uneventful labor normal vaginal delivery breastfed on enquiring mother gave history itching extensive annular erythematous plaques axilla inframammary area abdomen thighs inguinal folds buttocks since first month pregnancy figure 2 she given topical treatment avoid side effects drugs pregnancy neonatal tinea faciei left annular lesion cheeks active periphery top right right cheek forehead bottom right left cheek tinea corporis mother left inframammary area top right buttocks bottom right inguinal folds child potassium hydroxide koh examination skin scrapings active edge revealed presence numerous thin long septate branched hyaline hyphae figure 3 culture sabouraud dextrose agar grew white granular powdery colonies 10 days incubation figure 4 koh examination skin scrapings showing branched hyphae creamy white powdery colonies trichophyton mentagrophytes sabouraud dextrose agar lcb mount revealing abundant microconidia clusters mother treated oral terbinafine 250 mg topical luliconazole 4 weeks neonate responded within 7 days topical clotrimazole alone without clinical adverse effects figure 6 healed lesions neonatal tinea faciei 7 days by definition dermatophyte infections face women prepubertal boys tinea faciei tinea faciei often misdiagnosed seborrhoeic dermatitis atopic dermatitis bacterial infections irritant contact dermatitis cutaneous lupus erythematosus rosacea granuloma annulare perioral dermatitis pityriasis alba pityriasis rosacea the clinical manifestations mainly attributed immune response host invading fungal species although antigen presentation neonates intact cell function still inadequate mount appropriate immune response fungal infections the rare presentation neonatal tinea faciei probably explained immaturity immunological system also dermatophytes require incubation period 13 weeks produce clinical manifestations atypical features common tinea faciei forms ringworm infections complex anatomy face the variable expression attributed degree inflammation depth invasion onset disease clinical features vary considerably often associated burning itching photosensitivity mycological examination vital arriving confirmatory diagnosis especially cases variable morphology smears labeled provisionally positive branched translucent nonpigmented thin septate mycelia seen culture sabouraud agar done 34 weeks presence characteristic fungal colonies microscopic culture examination neonate positive t. mentagrophytes mother child previous case reports neonatal tinea faciei reported trichophyton rubrum microsporum canis microsporum gypseum ghorpade et al reported t. mentagrophytes tinea corporis 2-day old neonate best knowledge tinea faciei 20-day old neonate caused t. mentagrophytes reported earlier the neonatal tinea faciei patient shared pathogenic fungus causing concurrent tinea corporis mother illustrating epidemiological association close contact infection the contact baby face mother breast breast feeding may main reason transmission infection face same species reported previously ghorpade et al cause tinea corporis 2-day old neonate controversy remains whether topical systemic antifungals used treat dermatophytoses neonates ironically topical antifungals proposed work effectively infants due risk factor predisposes tinea infection increased permeability due immature epidermis although terbinafine carefully used pregnancy lactation considered extensive tinea corporis infections category b drug mother extensive tinea corporis axilla inframammary area abdomen thighs inguinal folds buttocks onset first month pregnancy taken topical antifungal combinations pregnancy partial relief she previous history partially treated tinea corporis 5 years grounds extensive area disease severe itching rural background given oral antifungals neonatal tinea rare therefore occurrence gives clue dermatophyte infection occurring due intimate contacts hence complete examination source treatment infected pets carried control infection although person person transmission route likely role environmental reservoirs bed linen mattresses ignored although neonatal tinea corporis due t. mentagrophytes reported past makes case interesting fact never reported cause neonatal faciei earlier 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	although candidiasis in newborns is not uncommon , superficial dermatophyte infections of infants is quite rare . the causative agents of neonatal tinea reported in various case studies have been trichophyton rubrum , microsporum canis , microsporum gypseum , and trichophyton violaceum . to the best of our knowledge , no case report of neonatal tinea faciei caused by trichophyton mentagrophytes has been reported earlier .
status disease ranges gingivitis advanced periodontitis destruction connective tissue attachment alveolar bone ultimately lead tooth loss periodontal tissue damage caused direct effect toxic products released bacterial plaque action host immune system stimulated bacterial infection the important characteristic periodontal disease pathogenesis generation free radicals derived bacteria others derived host immune response it suggested increase reactive oxygen species ros hydroxyl oh radical hydrogen peroxide h2o2 singlet oxygen o2 hypochlorous acid hocl reactive nitrogen species nitric oxide peroxynitrite anion onoo peroxynitrous acid onooh periodontitis responsible oxidative damage periodontal tissues this disturbed balance pro oxidant antioxidant systems may result added oxidative attack extensive worsening periodontal tissues it affects many physiologic processes control circadian rhythm regulation body temperature activation immune system release melatonin blood stream the fraction plasma melatonin passing salivary glands mouth appears constant ranging 24% 33% 70% plasma melatonin this study conducted aims objectives observe melatonin levels saliva gingivitis periodontitis cases a total thirty participants age group 18 65 years selected study department periodontics faculty dental sciences king george medical university lucknow uttar pradesh india ten participants taken control group without disease gingivitis group periodontitis group basis disease severity participants without presence diseases may affect immune system chronic infections oncological disorders treatment change melatonin levels enrolled starting study informed written consent participants obtained all participants selected study underwent oral examination periodontal assessments medical history taken gingival index loe silnes method probing depth measured unc-15 probe recorded participant beverages containing artificial colorants well alcohol coffee bananas avoided sampling period salivary flow stimulation chewing gums eating lemons also avoided prevent possible interference cotton swab provided device kept patient mouth tongue frozen samples thawed centrifuged 1000 g 2c8c 5 min assay the amount melatonin saliva determined buhlmann direct saliva melatonin elisa competitive immunoassay using capture antibody ab technique according manufacturer instructions after first 1620 h overnight incubation melatonin present cases controls well calibrators competed biotinylated melatonin second 3-h incubation binding sites highly specific ab after washing enzyme label streptavidin conjugated horseradish peroxidase added binds third incubation step 1 h melatonin biotin ab complexes captured coated wells the unbound enzyme label removed second washing step tetramethylbenzidine substrate added wells fourth 30-min incubation step a chromophore formed inverse proportion amount melatonin present sample the concentration melatonin determined picograms milliliter pg ml due small sample size heterogeneous variance skewed nature data wallis h one way analysis variance anova multiple comparisons mean ranks groups done z test spearman rank order correlation rs method used assess relative association among variables two tailed 2 p 0.05 considered statistically significant p 0.01 highly significant p 0.05 significant beverages containing artificial colorants well alcohol coffee bananas avoided sampling period salivary flow stimulation chewing gums eating lemons also avoided prevent possible interference cotton swab provided device kept patient mouth tongue frozen samples thawed centrifuged 1000 g 2c8c 5 min assay the amount melatonin saliva determined buhlmann direct saliva melatonin elisa competitive immunoassay using capture antibody ab technique according manufacturer instructions after first 1620 h overnight incubation melatonin present cases controls well calibrators competed biotinylated melatonin second 3-h incubation binding sites highly specific ab after washing enzyme label streptavidin conjugated horseradish peroxidase added binds third incubation step 1 h melatonin biotin ab complexes captured coated wells the unbound enzyme label removed second washing step tetramethylbenzidine substrate added wells fourth 30-min incubation step a chromophore formed inverse proportion amount melatonin present sample the concentration melatonin determined picograms milliliter pg ml due small sample size heterogeneous variance skewed nature data studied variables analyzed using nonparametric tests wallis h one way analysis variance anova multiple comparisons mean ranks groups done z test spearman rank order correlation rs method used assess relative association among variables two tailed 2 ) p 0.05 considered statistically significant p 0.01 highly significant p 0.05 significant the salivary melatonin level gingival index probing depth three groups participants shown graphs 1 2 summarized tables 1 2 clinically correlating photographs given figures 13 the salivary melatonin levels control group ranged 0.80 pg ml 6.80 pg ml average standard error se 3.92 0.58 pg ml ranged 3.30 pg ml 10.90 pg ml average se 6.87 0.82 pg ml gingivitis group 5.20 pg ml 14.80 pg ml average se 10.20 0.98 pg ml periodontitis group mean salivary melatonin levels pg ml participants control group gingivitis group periodontitis group box whiskers plot showing distribution melatonin level pg ml gingival index probing depth mm three groups participants summary melatonin level pg ml control group gingivitis group periodontitis group participants one way analysis variance salivary melatonin levels control group gingivitis group periodontitis group participants clinical photograph control group participant salivary melatonin levels pg ml lesser two groups mean 3.92 clinical photograph gingivitis group participant salivary melatonin levels pg ml greater control group lesser periodontitis group mean 6.87 clinical photograph periodontitis group highest levels salivary melatonin pg ml found mean 10.20 comparing levels salivary melatonin three groups together anova table 2 revealed mean levels salivary melatonin among groups differed significantly f 14.93 p 0.01 the correlation severity severity disease control group ranked 1 gingivitis 2 periodontitis 3 melatonin level gingival index probing depth three groups participants summarized table 3 correlation n=30 variables three groups participants estimation melatonin level gingival index probing depth also done separately simple linear regression analysis considering melatonin level dependent variable gingival index probing depth independent variables graph 3 the regression analysis showed significant effect gingival index f 33.24 p 0.01 probing depth f 23.35 p 0.01 melatonin level account estimate 54.3% 45.5% total variations i.e. coefficient determination r melatonin level respectively the best fit regression equation estimate melatonin level gingival index probing depth follows melatonin level pg ml 3.37 2.79 gingival index score i)melatonin level pg ml 0.92 2.10 probing depth mm ( ii melatonin level pg ml 3.37 2.79 gingival index score melatonin level pg ml 0.92 2.10 probing depth mm ( ii best fit regression equation estimate melatonin level pg ml gingival index scores probing depth mm b 95% confidence interval broken lines ) periodontal diseases known exacerbated free radicals altered host immune response microorganisms present plaque periodontitis in addition considerable migration neutrophil gingiva gingival fluid periodontitis leads excessive production ros hence increase free radical production periodontal diseases lead rise melatonin level due free radical scavenging antioxidant properties melatonin alter development periodontal disease act pge2 thereby inhibiting differentiation osteoclasts induced cell cell contact osteoclasts osteoblasts melatonin also modulate proteins regulate resorption process periodontal disease interact biologic agents calcitonin parathormone 1 25(oh)2d3 interleukin il)-2 il-1 il-6 osteoprotegerin receptor activator nuclear factor-b ligand system in contrast previous studies reported decreased salivary serum melatonin levels periodontitis present study authors reported increased salivary melatonin levels increased severity periodontal disease suggested increase may result signal(s derived periodontal inflammation oral cavity further research required make clear role melatonin pathogenesis periodontal disease understand clinical relevance	objective : to evaluate the melatonin levels in saliva in gingivitis and periodontitis cases.background:melatonin has strong antioxidant , free radical scavenging , and immunomodulating properties , acts on osteoblasts directly to stimulate cell proliferation and synthesis of type i collagen , and promotes bone formation.materials and methods : a total of thirty participants were selected and divided into three groups ( control group , gingivitis group , and periodontitis group ) . in each group , ten participants were taken . salivary melatonin was estimated in each of the three groups.results:results from this study showed that the mean levels of salivary melatonin increased as severity increased from control to periodontitis , i.e. , the mean levels were highest in periodontitis followed by gingivitis and least in control group . the melatonin level of all participants was positively and significantly ( p < 0.01 ) correlated with their gingival index ( r = 0.85 , p < 0.01 ) and probing depth ( r = 0.72 , p < 0.01).conclusion : salivary melatonin level varied with the severity of gingivitis and periodontitis . with increased severity of periodontal disease , the level of salivary melatonin also increased suggesting that salivary melatonin may act as a diagnostic biomarker for periodontal diseases .
success periapical surgery dictated elimination infected tissues adequate apical seal ideal apical seal prevents ingress residual irritants periapical region percolation periapical tissue fluid canal system various root end filling materials tested sealing ability newer materials still research the root end filling material possess ideal properties bio compatibility dimensional stability radiopacity ability set wet environment antibacterial properties easy handling adequate compressive strength hardness osteoinductive osteoconductive properties adherence canal walls provide good apical seal among various root end filling materials tested mineral trioxide aggregate mta shown good sealing ability biocompatibility previous vitro vivo studies recent years various materials like biodentine cer cemento endodontico rapido fast endodontic cement errm endosequence root repair material endocem mta derived pozzolan cement introduced aim overcoming disadvantages mta difficulties handling long setting time 10 11 12 biodentine powder mainly composed highly pure tricalcium silicate regulates setting reaction liquid contains calcium chloride setting accelerator water reducing agent super plasticizer water the manufacturer claims material used pulp capping pulpotomy apexification root perforation internal external resorption also root end filling material periapical surgery previous studies biodentine showed biocompatibility ability induce odontoblast differentiation mineralization cultured pulp cells the main benefits biodentine calcium silicate based materials reduced setting time better handling mechanical properties the importance marginal adaptation may indirect correlation sealing ability retro filling materials there previous study assessing marginal adaptation biodentine used root end filling material hence aim study evaluate marginal adaptation biodentine comparison mta irm root end filling material using scanning electron microscopy sem all teeth cleaned autoclaved stored 0.2% thymol solution used access cavity preparation done using 2 round diamond point nsk japan coronal preflaring done using gates glidden drills mani inc japan size 10 k file mani inc japan introduced root canal visible apex 1 mm subtracted point establish working length biomechanical preparation done using step back technique apical enlargement 60 size k file mani inc japan copious irrigation 3% sodium hypochlorite vensons india done procedure final irrigation done 17% edta prime dental products india followed 3% sodium hypochlorite 1 minute rinsing saline the canals dried using absorbent points obturation done 2% gutta percha points dentsply maillefer china zinc oxide eugenol sealer bombay burmah trading corp mumbai india using lateral condensation technique 24 hrs obturation the root ends resected 3 mm apex using no.1557 fissure bur retrograde cavity prepared depth 3 mm coaxially using surgical ultrasonic retro preparation tips satelec as6d france then teeth randomly divided 3 groups group containing 10 teeth group 1- mta dentsply tulsa dental tulsa ok group 2- biodentine septodont saint maurdes fosss france group 3- irm dentsply international inc u.s.a all root end filling materials placed incrementally following radiographs taken labio palatally mesio distally confirm proper filling material root end filling moist cotton pellet placed mta setting material samples stored relative humidity 95% 37c 5 days the samples mounted resin block create platform sectioning hard tissue microtome sectioned apically 1 mm 2 mm levels apex the samples gold sputtered viewed scanning electron microscopy 1000x magnification evaluating adaptation material canal walls the largest gap present material canal wall measured four quadrants fig 1 fig 2 mean gap calculated sample one way anova tukey hsd post hoc test done intergroup analysis compare 1 mm 2 mm overall values three groups paired test used intragroup analysis compare 1 mm 2 mm values within group significance level 0.05 using spss version 17.0 software one way anova tukey hsd post hoc test done intergroup analysis compare 1 mm 2 mm overall values three groups paired test used intragroup analysis compare 1 mm 2 mm values within group significance level 0.05 using spss version 17.0 software the overall results showed mean gap dentin retrograde filling material interface maximum biodentine 1 intra group inter group comparison 1 mm level 2 mm level shown table 1 1 mm level a successful periapical surgery requires appropriate root end resection preparation adequate apical seal root end resection least 3 mm root end must eliminated reduce 98% apical ramifications 93% lateral canals might responsible endodontic failure hence 3 mm root end resected perpendicular long axis tooth study ultrasonic tips reported better control ability stay centered canal reduce perforation risk since diamond coated ultrasonic tips reduce chance microcrack formation diamond coated ultrasonic tips used prepare 3 mm retrograde cavity coaxially incremental placement retrograde filling material done minimize voids enhance quality filling numerous materials used retrograde filling material namely mta gic irm super eba composite resins biodentine relatively new tricalcium silicate based material forms hydrated calcium silicate gel csh calcium hydroxide hydration sem aids assessing marginal adaptation filling material tooth interface higher magnification claimed longitudinal type sectioning might create false gaps interface dentin root end filling material thereby affecting evaluation marginal adaptation a previous studies evaluated marginal adaptation root end filling material canal wall using resin replicas orosco et al stated evaluation marginal adaptation retrofilling material samples directly viewed sem gold sputtering need creation resin replicas direct sem evaluation samples result artificial gap formation marginal adaptation evaluated 1 mm 2 mm levels 3 mm level section avoided would encroach upon junction retrograde filling material gutta percha it clear 1 mm level difference marginal adaptation among three tested materials but 2 mm level mta superior irm biodentine superiority mta irm marginal adaptation accordance previous report torabinejad et al in recent study fast setting mta derived pozzolan cement endocem showed tight sealing mould comparable mta but study biodentine fast setting tricalcium silicate based material showed inferior marginal adaptation compared mta irm previous clinical trials comparable surgical success rates reported mta irm randomized controlled trial surgical success rate showed mta irm similar clinical results used root end filling material another clinical study zuolo et al showed surgical success rate irm root end filling material 91.2% clinically radiographically follow period 4 years the inadequacy marginal adaptation may influence sealing ability clinical success rate a properties biocompatibility ability induce mineralization studied earlier these properties need investigated since biodentine limited published literature supporting use as far vitro study discern may concluded marginal adaptation 1 mm level similar among mta irm biodentine 2 mm level mta superior irm biodentine overall comparison	objectivethe aim of this study was to evaluate the marginal adaptation of biodentine in comparison with mineral trioxide aggregate ( mta ) and intermediate restorative material ( irm ) , as a root end filling material , using scanning electron microscopy ( sem).materials and methods : thirty permanent maxillary central incisors were chemo - mechanically prepared and obturated . three millimetres of the root end were resected and 3 mm retro cavity preparation was done using ultrasonic retrotips . the samples were randomly divided into three groups ( n=10 ) and were restored with root end filling materials : group i mta , group ii biodentine , group iii irm . the root ends were sectioned transversely at 1 mm and 2 mm levels and evaluated for marginal adaptation using sem . the gap between dentin and retro filling material was measured at four quadrants . the mean gap at 1 mm level and 2 mm level from the resected root tip and combined mean were calculated . the data were statistically analyzed , using one - way anova and tukey s hsd post hoc test for intergroup analysis and paired t - test for intragroup analysis.results:the overall results showed no statistically significant difference between mta and irm but both were superior when compared to biodentine . at 1 mm level there was no statistically significant difference among any of the tested materials . at 2 mm level mta was superior to both irm and biodentine.conclusion:in overall comparison , mta and irm were significantly superior when compared to biodentine in terms of marginal adaptation , when used as retrograde filling material .
report case cauda equina syndrome ces spinal anaesthesia patient underlying asymptomatic tubercular arachnoiditis case disease pathology may contributed maldistribution intrathecally administered local anaesthetic leading ces after informed consent patient parents resident anaesthesiologist elected give spinal anaesthesia surgery routine monitors attached patient sitting position lumbar puncture done single attempt 25 g spinal needle l3 4 interspace there bloody tap cerebrospinal fluid csf drawn clear colourless thereafter 50 mg 5% hyperbaric lignocaine injected subarachnoid space barbotage dilution 2% concentration total volume 2.5 ml paresthesias pain time lumbar puncture injection drug absent the surgery lasting 45 minutes completed uneventfully haemodynamic parameters remaining stable the patient shifted recovery room four hours recovery there regression sensory block remained t10 similarly recovery motor power lower limbs deep tendon reflexes absent patient clinical features suggestive ces started intravenous methylprednisolone 500 mg day shifted intensive care unit icu management a neurologist opinion sought confirmed finding ces advised urgent magnetic resonance imaging mri spinal cord the mri imaging lumbosacral region spinal cord revealed arachnoiditis dural ectasia myelitis intradural granulomas clumping cauda equina nerve roots fluid collection close right posterior paraspinal muscle figure 1 as mri findings indicative tubercular arachnoiditis antitubercular drugs isoniazid pyrizinamide ethambutol rifampicin pyridoxine started continuing intravenous methylprednisolone 500 mg day a serum sample polymerase chain reaction pcr test tuberculosis sent later reported positive sagittal t2-weighted mr image dorsolumbar spine shows csf loculation asterix clumped cauda equine nerve roots arrow icu postoperative day 2 patient showed gradual recovery sensations lower limb return motor power seen postoperative day 6 recovery bladder functions day 8 repeat mri scan done second week showed significant reduction size number intradural granulomas resolution arachnoiditis normal cauda equina nerve roots on postoperative day 15 patient transferred ward complete recovery motor power lower limbs bladder functions residual sensory deficits he discharged hospital week later advice continue antitubercular treatment follow neurology clinic we describe case ces occurred patient previously undiagnosed tubercular arachnoiditis underwent uneventful surgery debridement right foot spinal anaesthesia hyperbaric lignocaine postoperative mri suggesting diagnoses tubercular arachnoiditis later confirmed pcr test tuberculosis patient put high dose steroid therapy antitubercular drugs responded well gaining complete neurological recovery 2 weeks review literature find previous reports diagnosed undiagnosed tubercular arachnoiditis complicating spinal anaesthesia although tubercular arachnoiditis common type infectious arachnoiditis india increasing incidence disease seen developed nations conjunction acquired immunodeficiency syndrome aids frequent involvement nerve root spinal cord subarachnoid space differentiates tubercular arachnoiditis arachnoiditis due causes like intrathecal administration contrast agents antibiotics local anaesthetics traumatic punctures bloody taps occurring neuraxial block trauma surgery disc disease etc tubercular radiculomyelitis. tubercular arachnoiditis may occur primary lesion secondary tubercular meningitis vertebral tuberculosis most patients present backache 86% fever 67% smaller numbers radicular pain paraesthesias subacute paraparesis bladder bowel disturbances vertebral kyphosis cases in early stages disease inflammation leads clumping cauda equine nerve roots granulomas formation the later stages marked irregular csf loculations blockage csf flow due formation arachnoid bands it seen patients receiving central neuraxial block undetected underlying spinal pathologies spinal canal stenosis spinal metastatic lesion subarachnoid cyst cause ces due local anaesthetic drug maldistributed compromised subarachnoid space maldistribution turn causes high concentrations local anaesthetic drug csf leading structural functional changes neural tissue the mechanism responsible ces use spinal microcatheter repeat spinal injections event failed patchy blocks although ces reported several local anaesthetics frequently associated lignocaine yet lignocaine remains useful drug procedure short ambulatory surgery due fast onset intense sensory motor blocks rapid recovery dosage 60 mg considered safe subarachnoid block other identified causes ces spinal anaesthesia include direct needle trauma spinal cord ischaemia abscess spinal haematomas cases ces complicating spinal block typically seen immediate postoperative period may occur later well documented two cases reports ces due subdural haematoma epidural haematoma seen 96 hours 3 months respectively uneventful spinal anaesthesia present case we presume underlying disease pathology tubercular arachnoiditis may caused neurotoxicity lignocaine restricting spread drug subarachnoid space eventually resulting ces even though safe dosage 50 mg lignocaine used besides use small bore spinal needle hyperbaric drug sitting position could additional contributory factors ces however direct damage spinal cord dural puncture seem likely factor neurological pain dysethesia time needle insertion conclusion case highlights like undetected pre existing spinal pathology asymptomatic tubercular arachnoiditis contribute ces even carefully administered spinal anaesthesia therefore surgery spinal anaesthesia careful monitoring recovery sensory motor functions important early detection neurological complication ces case ces suspected 1 patient should investigated thoroughly mri done identify suitably address underlying contributory spinal pathology 2 appropriate treatment immediately instituted	a 14-year - old boy underwent emergency debridement surgery of right foot under spinal anaesthesia . four hours after the surgery , the patient developed symptoms of cauda equina syndrome ( ces ) . postoperative magnetic resonance imaging of the patient 's spine suggested underlying tubercular arachnoiditis . the boy was started on intravenous methylprednisolone and antitubercular therapy . he responded to the therapy and recovered completely in 2 weeks without any residual neurological deficits . we suggest that underlying pathological changes in the subarachnoid space due to tubercular arachnoiditis contributed to maldistribution of the local anaesthetic drug leading to ces .
two main reasons wanting simulate genetic data first gain insight effects underlying demographic mutational parameters may genetic data one sees secondly create test datasets assessing power alternative genetic analysis methods ways tackling first goal range informal approaches aim getting feel altering different parameters affects output data formal methods based matching many simulated datasets observed dataset eg approximate bayesian computation tackle second goal particularly genetic epidemiology methods additional ascertainment modelling element often required allow simulation disease affecting loci within context given study design case control study the key challenges simulation algorithms face 1 speed -- typically one wants lots simulations need fast 2 scalability -- advent genome wide genotyping large scale sequencing need simulation programs match 3 flexibility -- program cope different demographic histories population structure recombination selection mutation models disease models ? three main approaches dealing challenges termed backwards forwards sideways backwards coalescent simulations start sample individuals form simulated dataset work backwards time construct ancestral tree graph genealogical relationships connects the simulation algorithm actually work backwards time achieve technical detail the important point restricting attention genealogical structure relevant sample question large computational saving generally achieved relative forwards time approach still greater efficiency afforded classic coalescent approach employs continuous time approximation effectively skip intermediate generations important tree generating events forwards simulations start entire population individuals -- typically many thousands -- follow genetic data question passed one generation next one usually needs simulate many thousands generations order arrive equilibrium genetic characteristics population independent original starting conditions finally sideways simulations start collection real present day genetic data use template generating new simulated data similar properties sideways algorithms also coalescent based thus fit backwards sideways categories adopt simpler resampling strategies explicitly consider changes generational time either direction table 1 lists programs authors able source via pubmed internet based searches ( coalescent approaches formthe largest part table 1 reflecting inherent attractiveness computational efficiency simulating part genealogy needed produce data simulated sample mshot snpsim cosi extend algorithm allow variable recombination rates along dna sequence mshot cosi coasim newgenecoal also allow allelic gene conversion addition crossovers recombination events simcoal introduces complex demographic models simcoal2 extends variable recombination serial simcoal allows sampling multiple time points modeler4simcoal provides handy graphical user interface flexible necessarily easy implement coalescent simulators provided coasim mlcoalsim sarg geneartisan neutral loci tree graph generating step conveniently decoupled mutation generating step latter run via separate program andy rambaut seqgen program produce wide range different types genetic data range different mutational models it also possible decouple sampling ascertainment process eg get case control data applying additional step unascertained simulated data currently however easy ways additional user coding would needed adapt sampling algorithms available example coasim simupop[28 30 fregene furthermore yet completely flexible ascertainment options would allow example simulation cases models one partially linked disease locus general causal models incorporated additional covariates this recombination gives rise complex ancestral recombination graphs args rather simple binary genealogical trees recombination leads ever larger complex args the fastcoal genome simulators employ approximations real coalescent recombination lead simpler args thence feasible genome wide simulations macs recent update fastcoal uses improved approximation coalescent recombination available request jeff wall http://wallj@humgen.ucsf.edu fastcoal reported able generate 2,000 50-megabase mb diploid samples two minutes standard workstation genome generate 600 150 mb diploid samples 66 minutes forwards time simulators naturally capable coping complex modelling scenarios expense decreased computational efficiency the fregene genomepop programs make biggest effort maintaining speed fregene allows ascertained disease gene sampling a useful scaling option programs allows one simulate smaller population smaller number generations use results approximate larger population generations unfortunately diallelic snp data simulated fast enough cover large genomic regions smaller genomic scales complex nucleotide codon models simulated genomepop copy number variation cnv microsatellite data simulated simupop 28 30 nemo genomesim claims able generate genome wide snp data forwards simulation achieves simulating limited ten generations far fewer needed achieve proper genetic equilibrium indeed fregene genomepop could also generate genome wide datasets way presumably could greater computational efficiency sideways simulators extent side step whole issue model complexity relying real data guide simulation process simple bootstrap resampling breaks longer regions genetic diversity seen reference sample usually 270 individuals hapmap adequate capture full diversity among humans the situation improve 1,000 genomes project also steady increase publically available genome wide snp data still seems sensible apply additional method perturb simulated data away narrow range seen real data dudbridge proposed forming random diploid chromosomes phased hapmap data followed single round artificial meiosis governed empirical recombination rates also estimated hapmap this idea put use hap sample software additional option boost baseline recombination rate x100 recommended reduce long range linkage disequilibrium durrant et al proposed alternative idea based sliding windows introducing new variations simulated data this method implemented gwa simulator software improved extension idea allows variable sliding window size implemented gs software jonathan marchini hapgen software based underlying principles genotype imputation software impute applies approximation coalescent recombination generate new simulated data existing phased hapmap data slower two sideways simulators hap sample reported able generate 2,000 samples 100,000 genome wide snp chip minutes standard workstation gs generate 2,000 samples chromosome 6 36,000 snps 140 minutes in summary one program capable everything exist useful applications three main simulation approaches genome wide snp data the main contenders fastcoal genome hap sample gs high model flexibility sampling ascertainment 10 mb scale less whole genome still enough many purposes fregene recommended simulation copy number variation and/or microsatellite data larger genomic scales complex disease models allowing covariates linked loci remain areas future program development	a number of programs have been developed for simulating population genetic and genetic epidemiological data conforming to one of three main algorithmic approaches : ' forwards ' , ' backwards ' and ' sideways ' . this review aims to make the reader aware of the range of options currently available to them . while no one program emerges as the best choice in all circumstances , we nominate a set of those which currently appear most promising .
traumatic brain injury tbi major public health problem evidenced clinicians epidemiologist india disability due neurological illness ranks third india major contributor tbi rapid increase population motorization industrialization country contributed significant increase tbi tbi results deaths injuries disabilities age groups especially young productive people gender significant effect tbi although men women experience brain injury difference epidemiological clinical imaging outcome majority studies tbi emphasize male population incidence tbi male population if stated variables related female population highlighted literature characteristics differences unique female patients tbi explored great detail the present study scrutinizes epidemiological clinical imaging treatment mortality variables exclusively among female tbi patients the study also intends identify variable differs female male population this study conducted national institute mental health neurosciences tertiary level referral center neuroscience exclusive trauma care facility tbi patients the patients brain injury evaluated neurosurgery residents patients details entered structured head injury pro forma data patients tbi presented casualty period january 1 2010 march 15 2010 retrospectively reviewed the following variables analyzed demographic details age gender cause injury clinical data like time since injury injury severity symptoms manifestation computed tomography ct scan findings intracranial bleed skull fractures treatment like medical surgical management mortality discharge the data categorized pediatric 18 years middle age 1960 years elderly age 61 years the statistical analysis performed r statistics r.3.2.0 institute statistics mathematics wu wirtschaftsuniversitt wien data expressed using descriptive statistics mean standard deviation continuous variables frequency percentage categorical variables chi square test used among categorical data p 0.05 significance the statistical analysis performed r statistics r.3.2.0 institute statistics mathematics wu wirtschaftsuniversitt wien data expressed using descriptive statistics mean standard deviation continuous variables frequency percentage categorical variables chi square test used among categorical data p 0.05 significance during study period 1627 patients head injuries 293/1627 18% female patients the incidence tbi higher first fifth sixth decade among female patients compared males figure 1 mean duration female patients reach hospital 18 h 27 min lesser male patients 19 h 29 min percentage female male brain injuries decade wise severity brain injuries assessed glasgow coma scale gcs among female patients revealed 225 76.8% mild injuries 37 12.6% moderate 31 10.6% severe injuries the manifesting symptoms among female tbis loss consciousness 152 51.9% vomiting 154 52.6% ear nose bleeding 71 24.2% seizures 20 6.8% headache 4 1.4% limb weakness 2 0.7% road traffic accidents major cause injury 168 57.3% followed falls 94 32.1% assaults 26 8.9% others 5 1.66% among female patients head the abnormal ct findings included parenchymal contusion 70 23.9% extradural hematoma 23 7.8% subdural hematoma subdural hemorrhage 14% subarachnoid hemorrhage 4.4% cerebral edema 72 24.6% petechial hemorrhage 5 1.7% ventricular hemorrhage 4 1.4% infarct 4 1.4% skull fracture 61 20.8% pneumocephalus 10 3.4% majority patients managed medically however 34 11.6% patients required surgery emergency hematoma evacuation nearly 33% patients severe tbi underwent surgery tables 1a b depict details gcs cause symptoms image findings treatment outcome genders different age groups female male pediatric middle elderly patients mode injury clinical symptoms emergency evaluation image findings outcome female male number percentages mode injury clinical symptoms emergency evaluation image findings outcome during study period 1627 patients head injuries 293/1627 18% female patients the incidence tbi higher first fifth sixth decade among female patients compared males figure 1 mean duration female patients reach hospital 18 h 27 min lesser male patients 19 h 29 min percentage female male brain injuries decade wise severity brain injuries assessed glasgow coma scale gcs among female patients revealed 225 76.8% mild injuries 37 12.6% moderate 31 10.6% severe injuries the manifesting symptoms among female tbis loss consciousness 152 51.9% vomiting 154 52.6% ear nose bleeding 71 24.2% seizures 20 6.8% headache 4 1.4% limb weakness 2 0.7% road traffic accidents major cause injury 168 57.3% followed falls 94 32.1% assaults 26 8.9% others 5 1.66% the abnormal ct findings included parenchymal contusion 70 23.9% extradural hematoma 23 7.8% subdural hematoma subdural hemorrhage 14% subarachnoid hemorrhage 4.4% cerebral edema 72 24.6% petechial hemorrhage 5 1.7% ventricular hemorrhage 4 1.4% infarct 4 1.4% skull fracture 61 20.8% pneumocephalus 10 3.4% majority patients managed medically however 34 11.6% patients required surgery emergency hematoma evacuation nearly 33% patients severe tbi underwent surgery tables 1a b depict details gcs cause symptoms image findings treatment outcome genders different age groups female male pediatric middle elderly patients mode injury clinical symptoms emergency evaluation image findings outcome female male number percentages mode injury clinical symptoms emergency evaluation image findings outcome our study summarizes female population contributes nearly one fifth 18% total brain injuries highest percentage brain injuries appreciated third decade 19.8% followed fifth 17.5% first decade 17% figure 1 there significant difference mortality female 3.4% male 1.6% we found larger proportion females age group 18 years patients middle age manifest higher percent whereas pediatric elderly age report lesser percent symptoms compared males pediatric elderly age group the road traffic injuries lesser falls females compared males among females elderly age group showed higher percent abnormal image findings the mortality age groups females table 1a the present study reports high male female ratio 4.5:1 males common road users predominantly affected road traffic injuries also commonly involved disputes the high ratio male female injury difficult explain based place data acquisition gender ratio nearly male female 1.1:1 high male female 4:1 ratio reported south african study study revealed higher proportion females third decade followed fifth first decade we found nearly two third female patients third sixth decade the reason might age groups vulnerable road injuries disputes studies usa france eritrean shown higher incidence brain injuries female first second third decade age group 18 years contributes one fourth percent total injuries male pediatric group high percent mild head injuries noted pediatric tbi importantly genders current study proportion females tbi higher 77% male mild injury category significance severity injury female male documented respect specific risk factors a meta analysis observed female patients tbi report higher number trauma symptoms compared males our study reports female third sixth decade reports higher percentages posttraumatic symptoms males the females reproductive age group effect hormonal influences reported inconsistent posttraumatic symptoms studies reported among pediatric elderly age groups falls common mode tbis we could appreciate results percentage female patients male group a study eritrean reported abnormal ct finding 54.5% severities brain injuries gender our study reports higher percent abnormal ct findings 71.6% severities gender elderly female category higher percentage abnormal ct findings elderly male group study found female patients severe tbi higher requirement neurosurgical intervention male counterparts similar findings sweden study the mortality report study demonstrates percentage female group significantly male group tbi induced death 1 year follow study scotland reports percentage deaths female 13.5% 21/156 male 8.5% 52/611 proper plan prospective study detailed variables provide insight however present study provides basic details tbi a follow study documenting serial posttraumatic symptoms quality life would effective the present study comprises 293 female tbi patients period 2 months institute study asmara eritrea reports 28 female injury patients 5 months duration a female domestic violence based study three metropolitan cities report 169 patients period 79 months even though sample size planned present study number patients reported single institute female tbi seems good mentioned duration compared existing literature the present study highlights even though incidence tbi lesser female population higher percentage abnormal image findings elderly group needs higher neurosurgical intervention reports high number deaths	background : traumatic brain injury ( tbi ) is a major public health problem . both genders are affected , but little is known about female tbi . the present study exclusively explores epidemiological , clinical , imaging , and death aspects of female tbi , and how it differs from males.methods:it is a retrospective study . data were documented from a tertiary institute during january 2010 to march 2010 . all variables were documented on standard proforma . the data were analyzed using r statistics software . age group was categorized into pediatric ( < 18 years ) , middle ( 1960 years ) and elderly ( > 61 years ) . significance was tested using chi - square test at the significance level of p < 0.05.results:data of 1627 tbi patients were recorded . of the total , female tbis contributed nearly 20% . compared to males , female patients reported higher percentages in manifesting symptoms ( 84.3% vs. 82.6% ) , injuries due to fall ( 32.1% vs. 24.4% ) , and surgical interventions ( 11.6% vs. 10.4% ) . female patients were significantly higher in mild head injury group ( 76.8% vs. 69.5% , p - 0.016 ) and mortality ( 3.4% vs. 1.6% , p - 0.048 ) . number of patients and deaths was more among females than males in pediatric and elderly age group . severities of injuries were more among female patients than male patients in middle and elder age groups.conclusion:the study results observe that female tbi group differ significantly in the severity of injury and mortality .
alloderm lifecell corp branchburg nj acellular dermal matrix originating cadaveric dermis processed remove antigenic epitopes cells creating immunologically inert scaffold the matrix figure 1 contains collagen elastin hyaluronic acid fibronectin proteoglycans growth factor receptors vascular channels allow host cell migration angiogenesis current practice the pectoralis major muscle provides inadequate coverage tissue expander implant alloderm sling described breuing warren created sewing inferior edge pectoralis major muscle along chest wall location inframammary fold construct subpectoral sub allodermpocket united states 75% implant based reconstruction is done using dermal matrices name brands group 75% specifically alloderm complications associated alloderm including infection hematoma formation flap necrosis similar seen standard submuscular reconstruction a systematic review sbitany serletti found higher rate postoperative seromas patients undergoing reconstruction acellular dermal matrix compared without colwell et al found significant difference total overall costs single stage implant reconstruction alloderm tissue expander reconstruction without alloderm breast imaging reconstruction alloderm typically obtained diagnostic evaluation concern postoperative complication clinical area concern palpable abnormality pain reported case patient new palpable fixed mass breast mastectomy surgical excision mass demonstrated foreign body giant cell infiltrate secondary acellular dermal matrix without evidence recurrent tumor literature search yielded single preliminary report describing radiologic appearances alloderm breast conservation therapy patients where a brief description imaging appearance postmastectomy alloderm sling described dialani isointense glandular tissue t1w imaging lacking enhancement gadolinium the objective manuscript provide imaging features alloderm primary reconstructive breast surgeries particularly postmastectomy patient ex vivo imaging alloderm hydrating normal saline 30 min per usage instructions performed mammography figure 2 ultrasound figure 3 magnetic resonance imaging mri figure 4 illustrate imaging features prior host cell migration angiogenesis ( single sheet alloderm asterisk placed medial aspect breast phantom b right craniocaudal view obtained shows alloderm isodense . simulated calcifications arrows two biopsy tracts arrowheads phantom ( transverse view shows single sheet alloderm overlying skin field view entirely ( b transverse view partially visualized alloderm adjacent normal breast parenchyma shows alloderm hyperechoic normal breast parenchyma demonstrated posterior acoustic shadowing ( c additional transverse view normal breast without alloderm top breast junction denoted arrow performed using standoff gel pad reveals hyperechoic surface alloderm artifacts presumably caused microairbubbles within acellular alloderm seen deep alloderm noncontrast mri imaging technique meeting acr accreditation standards performed ge signa hd 1.5 magnet waukesha wi a folded sheet alloderm taped inferomedial aspect left breast arrows fat saturated t1-weighted 3d spoiled gradient recalled echo spgr axial b sagittal reformatted images show alloderm exhibiting hypointense isointense t1 signal compared glandular breast tissue fat suppressed t2-weighted c axial sagittal images alloderm demonstrate hyperintense t2 signal heterogeneity likely related folded configuration alloderm e sagittal diffusion weighted imaging dwi f apparent diffusion coefficient adc images alloderm show restricted diffusion intraoperative photos illustrate alloderm used reconstruction breast figure 5 table 1 summarizes imaging features alloderm patients compared study tran cao et al intraoperative photos alloderm asterisk placement suturing initially e h 4 -months later ( b tissue expander place alloderm shown sewn pectoralis major muscle inframammary fold ( c alloderm checked contour hand glove fit overlying skin envelope ( e h four months later second stage patient undergoes implant exchange removal tissue expander deep subcutaneous fat bleeding incising alloderm demonstrates host incorporation vascularization e f arrow the tissue expander g h arrow exposed undersurface incorporated alloderm visualized h asterisk mammogram right mediolateral oblique mlo b right craniocaudal cc implant displaced views demonstrate multiple variable sized circumscribed masses arrows isodense normal glandular tissue prominent along lateral aspect implant axillary tail targeted ultrasound c without color flow right axilla palpable area concern demonstrate multiple isoechoic vague parallel hypoechoic isoechoic masses smooth margins c arrows ( e f transverse longitudinal sonographic views right breast demonstrate masses resembling fatty lobules extending approximately 6 cm inferior lateral edge mastectomy scar 7 cm superior lateral edge scar e f arrow similar findings continue extend toward axilla adjacent implant images shown mri fat suppressed t2-weighted images g three different axial slice locations superior inferior show elongated slightly lobulated area increased t2 signal g arrows right breast j l postgadolinium images locations show appreciable enhancement j l arrows corresponding location alloderm sling adjacent intact silicone implant post gadolinium cad overlay show kinetic enhancement associated alloderm ( p diffusion weighted image q apparent diffusion coefficient map demonstrate mildly increased signal without evidence restricted diffusion arrows the mri findings related alloderm extended hammock sling axilla palpable case 2 46-year old female bilateral prophylactic mastectomies bilateral subpectoral implants mri contrast enhanced axial b reformatted sagittal c postgadolinium cad overlay images demonstrate mildly increased prominence enhancement arrows posterior lateral intact right implant prior mri contrast enhanced axial b reformatted sagittal left breast c postgadolinium cad overlay mr images demonstrate area minimal non mass enhancement location alloderm arrows inframammary fold posterior lateral implant follow mri 16 months later intact implants less conspicuity prominence non mass enhancement f arrows ) comparison imaging features alloderm study tran cao et al study 36-year old female 2 years prior underwent bilateral skin sparing mastectomies implants left breast invasive ductal carcinoma presented palpable nodularity along upper outer aspects reconstructed right breast a diagnostic mammogram targeted ultrasound demonstrated multiple masses corresponding area palpable concern right mediolateral oblique mlo right cranial caudal cc implant displaced views demonstrated multiple variable sized circumscribed masses isodense normal glandular tissue prominent along lateral aspect implant axillary tail figure 6a b ultrasound without color flow palpable area concern right axilla demonstrated multiple vague parallel hypoechoic isoechoic masses smooth margins figure 6c in right breast masses resembled fatty lobules extending approximately 6 cm inferior lateral edge mastectomy scar 7 cm superior lateral edge scar figure 6e f subsequent breast mri characterize masses right breast axilla performed fat suppressed t2-weighted images three different axial slice locations superior inferior showed elongated area increased t2 signal reconstructed right breast figure 6g postgadolinium images locations showed appreciable enhancement corresponding location alloderm sling adjacent intact silicone implant figure 6j l postgadolinium computer aided detection cad overlay figure 6m images also showed areas kinetic enhancement corresponding areas alloderm diffusion weighted image figure 6p apparent diffusion coefficient map figure 6q demonstrated mildly increased signal without evidence restricted diffusion the mri findings related alloderm extending hammock sling axilla palpable review plastic surgeon confirmed location configuration corresponded alloderm sling therefore given birads 2 breast imaging reporting data system benign finding patient currently well without evidence recurrent breast cancer a 46-year old female bilateral prophylactic mastectomies bilateral subpectoral implants presented plastic surgeon 9-months surgery pain left breast breast mri ordered diagnostic evaluation targeted ultrasound revealed correlative finding contrast enhanced axial figure 7a reformatted sagittal figure 7b postgadolinium cad overlay figure 7c mri demonstrated mildly increased prominence enhancement posterior lateral intact right implant no abnormality noted left breast correspond patient area pain the pain nodularity resolved patient currently well complaints regarding reconstruction 58-year old female underwent right mastectomy invasive ductal carcinoma 8 years prior left mastectomy high grade ductal carcinoma situ 2 years prior subsequent bilateral implants presented area cellulitis clinically presumed fat necrosis right breast breast mri done 16 months earlier demonstrated intact implants mild enhancement along left inframammary fold location alloderm areas suspicious malignancy either breast contrast enhanced axial figure 8a reformatted sagittal image left breast figure 8b postgadolinium cad overlay figure 8c mri demonstrated area minimal non mass enhancement location alloderm arrows inframammary fold posterior lateral implant left the patient continued mild tenderness medial aspect left breast follow mri 16 months later images showed intact implants less conspicuity prominence non mass enhancement figure 8d f arrows ex vivo imaging alloderm hydrating normal saline 30 min per usage instructions performed mammography figure 2 ultrasound figure 3 magnetic resonance imaging mri figure 4 illustrate imaging features prior host cell migration angiogenesis ( single sheet alloderm asterisk placed medial aspect breast phantom b right craniocaudal view obtained shows alloderm isodense . simulated calcifications arrows two biopsy tracts arrowheads phantom ( transverse view shows single sheet alloderm overlying skin field view entirely ( b transverse view partially visualized alloderm adjacent normal breast parenchyma shows alloderm hyperechoic normal breast parenchyma demonstrated posterior acoustic shadowing ( c additional transverse view normal breast without alloderm top breast junction denoted arrow performed using standoff gel pad reveals hyperechoic surface alloderm artifacts presumably caused microairbubbles within acellular alloderm seen deep alloderm noncontrast mri imaging technique meeting acr accreditation standards performed ge signa hd 1.5 magnet waukesha wi a folded sheet alloderm taped inferomedial aspect left breast arrows fat saturated t1-weighted 3d spoiled gradient recalled echo spgr axial b sagittal reformatted images show alloderm exhibiting hypointense isointense t1 signal compared glandular breast tissue fat suppressed t2-weighted c axial sagittal images alloderm demonstrate hyperintense t2 signal heterogeneity likely related folded configuration alloderm e sagittal diffusion weighted imaging dwi f apparent diffusion coefficient adc images alloderm show restricted diffusion intraoperative photos illustrate alloderm used reconstruction breast figure 5 table 1 summarizes imaging features alloderm patients compared study tran cao et al intraoperative photos alloderm asterisk placement suturing initially e h 4 -months later ( b tissue expander place alloderm shown sewn pectoralis major muscle inframammary fold ( c alloderm checked contour hand glove fit overlying skin envelope ( e h four months later second stage patient undergoes implant exchange removal tissue expander deep subcutaneous fat the incorporated alloderm seen e asterisk bleeding incising alloderm demonstrates host incorporation vascularization e f arrow the tissue expander g h arrow exposed undersurface incorporated alloderm visualized h asterisk mammogram right mediolateral oblique mlo b right craniocaudal cc implant displaced views demonstrate multiple variable sized circumscribed masses arrows isodense normal glandular tissue prominent along lateral aspect implant axillary tail targeted ultrasound c without color flow right axilla palpable area concern demonstrate multiple isoechoic vague parallel hypoechoic isoechoic masses smooth margins c arrows ( e f transverse longitudinal sonographic views right breast demonstrate masses resembling fatty lobules extending approximately 6 cm inferior lateral edge mastectomy scar 7 cm superior lateral edge scar e f arrow similar findings continue extend toward axilla adjacent implant images shown mri fat suppressed t2-weighted images g three different axial slice locations superior inferior show elongated slightly lobulated area increased t2 signal g arrows right breast j l postgadolinium images locations show appreciable enhancement j l arrows corresponding location alloderm sling adjacent intact silicone implant post gadolinium cad overlay show kinetic enhancement associated alloderm ( p diffusion weighted image q apparent diffusion coefficient map demonstrate mildly increased signal without evidence restricted diffusion arrows the mri findings related alloderm extended hammock sling axilla palpable case 2 46-year old female bilateral prophylactic mastectomies bilateral subpectoral implants mri contrast enhanced axial b reformatted sagittal c postgadolinium cad overlay images demonstrate mildly increased prominence enhancement arrows posterior lateral intact right implant prior mri contrast enhanced axial b reformatted sagittal left breast c postgadolinium cad overlay mr images demonstrate area minimal non mass enhancement location alloderm arrows inframammary fold posterior lateral implant follow mri 16 months later intact implants less conspicuity prominence non mass enhancement f arrows ) comparison imaging features alloderm study tran cao et al study 36-year old female 2 years prior underwent bilateral skin sparing mastectomies implants left breast invasive ductal carcinoma presented palpable nodularity along upper outer aspects reconstructed right breast diagnostic mammogram and right mediolateral oblique mlo right cranial caudal cc implant displaced views demonstrated multiple variable sized circumscribed masses isodense normal glandular tissue prominent along lateral aspect implant axillary tail figure 6a b ultrasound without color flow palpable area concern right axilla demonstrated multiple vague parallel hypoechoic isoechoic masses smooth margins figure 6c in right breast masses resembled fatty lobules extending approximately 6 cm inferior lateral edge mastectomy scar 7 cm superior lateral edge scar figure 6e f subsequent breast mri characterize masses right breast axilla performed fat suppressed t2-weighted images three different axial slice locations superior inferior showed elongated area increased t2 signal reconstructed right breast figure 6g postgadolinium images locations showed appreciable enhancement corresponding location alloderm sling adjacent intact silicone implant figure 6j l postgadolinium computer aided detection cad overlay figure 6m images also showed areas kinetic enhancement corresponding areas alloderm diffusion weighted image figure 6p apparent diffusion coefficient map figure 6q demonstrated mildly increased signal without evidence restricted diffusion the mri findings related alloderm extending hammock sling axilla palpable review plastic surgeon confirmed location configuration corresponded alloderm sling therefore given birads 2 breast imaging reporting data system benign finding patient currently well without evidence recurrent breast cancer 46-year old female bilateral prophylactic mastectomies bilateral subpectoral implants presented plastic surgeon 9-months surgery pain left breast breast mri ordered diagnostic evaluation targeted ultrasound revealed correlative finding contrast enhanced axial figure 7a reformatted sagittal figure 7b postgadolinium cad overlay figure 7c mri demonstrated mildly increased prominence enhancement posterior lateral intact right implant no abnormality noted left breast correspond patient area pain the pain nodularity resolved patient currently well complaints regarding reconstruction 58-year old female underwent right mastectomy invasive ductal carcinoma 8 years prior left mastectomy high grade ductal carcinoma situ 2 years prior subsequent bilateral implants presented area cellulitis clinically presumed fat necrosis right breast breast mri done 16 months earlier demonstrated intact implants mild enhancement along left inframammary fold location alloderm areas suspicious malignancy either breast contrast enhanced axial figure 8a reformatted sagittal image left breast figure 8b postgadolinium cad overlay figure 8c mri demonstrated area minimal non mass enhancement location alloderm arrows inframammary fold posterior lateral implant left patient continued mild tenderness medial aspect left breast follow mri 16 months later images showed intact implants less conspicuity prominence non mass enhancement figure 8d f arrows a 36-year old female 2 years prior underwent bilateral skin sparing mastectomies implants left breast invasive ductal carcinoma presented palpable nodularity along upper outer aspects reconstructed right breast diagnostic mammogram and right mediolateral oblique mlo right cranial caudal cc implant displaced views demonstrated multiple variable sized circumscribed masses isodense normal glandular tissue prominent along lateral aspect implant axillary tail figure 6a b ultrasound without color flow palpable area concern right axilla demonstrated multiple vague parallel hypoechoic isoechoic masses smooth margins figure 6c in right breast masses resembled fatty lobules extending approximately 6 cm inferior lateral edge mastectomy scar 7 cm superior lateral edge scar figure 6e f subsequent breast mri characterize masses right breast axilla performed fat suppressed t2-weighted images three different axial slice locations superior inferior showed elongated area increased t2 signal reconstructed right breast figure 6g postgadolinium images locations showed appreciable enhancement corresponding location alloderm sling adjacent intact silicone implant figure 6j l postgadolinium computer aided detection cad overlay figure 6m images also showed areas kinetic enhancement corresponding areas alloderm diffusion weighted image figure 6p apparent diffusion coefficient map figure 6q demonstrated mildly increased signal without evidence restricted diffusion the mri findings related alloderm extending hammock sling axilla palpable review plastic surgeon confirmed location configuration corresponded alloderm sling therefore given birads 2 breast imaging reporting data system benign finding patient currently well without evidence recurrent breast cancer a 46-year old female bilateral prophylactic mastectomies bilateral subpectoral implants presented plastic surgeon 9-months surgery pain left breast breast mri ordered diagnostic evaluation targeted ultrasound revealed correlative finding contrast enhanced axial figure 7a reformatted sagittal figure 7b postgadolinium cad overlay figure 7c mri demonstrated mildly increased prominence enhancement posterior lateral intact right implant no abnormality noted left breast correspond patient area pain the pain nodularity resolved patient currently well complaints regarding reconstruction a 58-year old female underwent right mastectomy invasive ductal carcinoma 8 years prior left mastectomy high grade ductal carcinoma situ 2 years prior subsequent bilateral implants presented area cellulitis clinically presumed fat necrosis right breast breast mri done 16 months earlier demonstrated intact implants mild enhancement along left inframammary fold location alloderm areas suspicious malignancy either breast contrast enhanced axial figure 8a reformatted sagittal image left breast figure 8b postgadolinium cad overlay figure 8c mri demonstrated area minimal non mass enhancement location alloderm arrows inframammary fold posterior lateral implant left patient continued mild tenderness medial aspect left breast follow mri 16 months later images showed intact implants less conspicuity prominence non mass enhancement figure 8d f arrows given differences alloderm usage study one tran cao et al the earlier manuscript described alloderm folded roll fill large lumpectomy defects manuscript describes alloderm used hammock sling postmastectomy patients the variability sonographic features alloderm two manuscripts ex vivo vivo cases probably reflects continuum vascularization incorporation alloderm host in particular distinct contrast vivo ex vivo sonographic features suggests posterior acoustic shadowing less incorporation host similarly varying enhancing mri features shown patients compared tran cao et al attributed differences alloderm use elapsed time incorporation host we believe mri enhancement alloder varies time little enhancement matrix initially demonstrated tran cao et al differentiating alloderm abscess recurrence postoperative seroma hematoma fat necrosis capsular contraction even extracapsular implant rupture always straightforward settings the imaging features alloderm nonspecific alloderm considered differential corroborated operative notes practice postmastectomy postreconstructed breast concerns addressed case case basis almost always targeted ultrasound initial imaging modality choice cases fat necrosis differential consideration mammograms may also obtained look expected calcifications fat density masses breast reconstructions transverse rectus abdominus myocutaneous flap deep inferior epigastric perforator flap an initial mammographic approach used patients present clinical area concern ultrasound mammograms certainly cost effective way evaluation instances many bilateral postmastectomy patients initially referred mri lack breast parenchyma exquisite soft tissue characterization afforded mri ability simultaneously evaluate implant integrity cases conventional diagnostic workup mammogram ultrasound remains equivocal mri often performed mainly conformation configuration alloderm relative rest reconstructed breast better assessed cases found helpful information comes clinical history correlation operative note direct discussion clinician surgeon cases if strong clinical suspicion patient able return short term follow biopsy thus obviated we suspect continuum imaging features alloderm incorporated host prospective longitudinal study various time points alloderm integration would helpful the variation appearances confounded extent incorporation alloderm host time imaging familiarity appearances alloderm postmastectomy reconstructed breast may help obviate need immediate biopsy	the purpose of this pictorial essay is to demonstrate the imaging features ( ultrasound , mammogram , and magnetic resonance imaging ( mri ) ) of alloderm(lifecell corp . ; branchburg , nj ) , an acellular dermal matrix sometimes used in both primary and reconstructive breast surgeries . alloderm is derived from cadaveric dermis and provides an immunologically inert scaffold in tissue reconstruction . since there is little literature on the imaging of this substance , radiologists may be unfamiliar with its appearance in breast imaging . for this manuscript , ex vivo and in vivo images of alloderm in postmastectomy patients were evaluated using different imaging modalities . the appearance of alloderm can vary based on length of time postsurgery and incorporation into the host . alloderm appears as an isodense to glandular tissue on a mammogram and isoechoic to glandular tissue on ultrasound imaging . on mri , in comparison with normal breast parenchyma , alloderm is hyperintense on t2-weighted imaging and isointense on t1-weighted imaging and demonstrates mild enhancement . to the best of the authors knowledge , this is the first multimodality imaging description of alloderm used in postmastectomy patients . the conformation of alloderm at surgical placement and the degree of host cell migration and neoangiogenesis are factors to take into consideration when performing diagnostic evaluations ; and , familiarity with the various imaging appearances of alloderm can be helpful to exclude residual or recurrent disease .
lack adequate bone common complication periodontally compromised teeth implant dentistry autogenous bone still gold standard bone augmentation procedures low availability donor site morbidity necessitates development alternative products many bone substitutes introduced every day allografts xenografts synthetically produced ones one commonly used substitute allogenic bone graft use demineralized freeze dried bone allograft dfdba whether alone combination bone substitute showed significant improvements bone augmentation procedures in fact presence bone morphogenic proteins bmp dfdba facilitates new bone formation allowing undifferentiated mesenchymal progenitor cells undergo phenotypic conversion osteoblasts the main advantage allografts eliminate need donor site besides used large quantities necessary but controversy effectiveness bone allografts bone regeneration studies becker et al find dfdba beneficial periodontal regeneration study use dfdba improve repair periodontal lesions there different batches allografts commercially available might different bone inductive activity bmp concentration depends biological properties graft criteria selecting donors methods allograft processing schwartz colleagues stated many differences exist bone bank preparations dfdba induce bone formation variously however dental practitioners need select efficient cost effective ones routine dental practice fact effective products maintain porous structure anatomy mineralized bone scrutinized sterilization adhere american association tissue banks aatb guidelines the aim study evaluate ability three different commercial dfdba induce new bone formation rabbit calvaria sixteen new zealand white male rabbits weighing 2.0 3.0 kg selected study mature skeletally rabbits allowed acclimatize 14 days experimental study the animals housed separate cages standard laboratory conditions fed standard diet animal selection management surgical protocol preparation approved institutional animal care use committee torabinejad dental research center school dentistry isfahan university medical sciences isfahan iran the animals anesthetized intramascular injection 50 mg kg ketamine hydrochloride ketamine alfasan woerden holland 1 mg kg acepromazine neurotranq alfasan woerden holland the surgical sites shaved disinfected alcohol povidone iodine followed local anesthesia 2% lidocaine hcl epinephrine dilution 1:100,000 persocaine e darou pakhsh pharmaceutical mfg.co tehran iran incision made along midsagittal suture frontal bone occipital bone one standardized circular bicortical defect 11 mm diameter created using trephine bur constant cool saline irrigation side midsagittal suture figure 1 thirty two critical size defects randomly filled three dfdba photograph two standardized circular defects created diameter 11 mm dfdba 1(dbm iranian tissue bank research preparation center tehran iran particle size 420 840 dfdba 2 cenobone tissue regeneration corporation kish iran particle size 500 1000 dfdba 3(dembone pacific coast tissue bank los angeles usa particle size 250 850 control group periosteum sutured resorbable suture material 4 0 polyglycolate hur teb medical devices ghazvin iran skin silk 3 0 supasil supa medical devices tehran iran postoperative cares included intramascular administration antibiotic ceftriaxone 5 mg kg ceftrax jaberebne haian pharmaceutical mfg co tehran iran careful clinical observation animals throughout healing period the animals sacrificed 6 12 weeks postoperatively using intracardial injection magnesium sulfate deep anesthesia the area surgical defects surrounding tissues removed en bloc sacrifice the sections decalcified 10% formic acid solution 20 days dehydrated grated alcohols embedded paraffin the central sections greatest diameter circle block stained hematoxylin eosin h e examined using light microscopy nicon e400 japan figure 2 ( dbm 6 weeks b dbm 12 weeks c cenobone 6 weeks cenobone 12 weeks e dembone 6 weeks f dembone 12 weeks g control 6 weeks h control 12 weeks central sections chosen histomorphometric analysis computer assisted histomorphometric measurements newly formed bone obtained using automated image analysis software the new bone formation values percentile ratio newly formed bone area total defect area remained particles percentage type inflammation type bone connective tissue assessed blinded pathologist significant differences among groups identified one way anova tukey ad hoc test significant differences among two healing times determined test p 0.05 considered statistically significant the animals anesthetized intramascular injection 50 mg kg ketamine hydrochloride ketamine alfasan woerden holland 1 mg kg acepromazine neurotranq alfasan woerden holland the surgical sites shaved disinfected alcohol povidone iodine followed local anesthesia 2% lidocaine hcl epinephrine dilution 1:100,000 persocaine e darou pakhsh pharmaceutical mfg.co tehran iran an incision made along midsagittal suture frontal bone occipital bone one standardized circular bicortical defect 11 mm diameter created using trephine bur constant cool saline irrigation side midsagittal suture figure 1 thirty two critical size defects randomly filled three dfdba photograph two standardized circular defects created diameter 11 mm dfdba 1(dbm iranian tissue bank research preparation center tehran iran particle size 420 840 dfdba 2 cenobone tissue regeneration corporation kish iran particle size 500 1000 dfdba 3(dembone pacific coast tissue bank los angeles usa particle size 250 850 control group defects filled bone material periosteum sutured resorbable suture material 4 0 polyglycolate hur teb medical devices ghazvin iran skin silk 3 0 supasil supa medical devices tehran iran postoperative cares included intramascular administration antibiotic ceftriaxone 5 mg kg ceftrax jaberebne haian pharmaceutical mfg co tehran iran careful clinical observation animals throughout healing period the animals sacrificed 6 12 weeks postoperatively using intracardial injection magnesium sulfate deep anesthesia the area surgical defects surrounding tissues removed en bloc sacrifice the sections decalcified 10% formic acid solution 20 days dehydrated grated alcohols embedded paraffin the central sections greatest diameter circle block stained hematoxylin eosin h e examined using light microscopy nicon e400 japan figure 2 ( dbm 6 weeks b dbm 12 weeks c cenobone 6 weeks cenobone 12 weeks e dembone 6 weeks f dembone 12 weeks g control 6 weeks h control 12 weeks computer assisted histomorphometric measurements newly formed bone obtained using automated image analysis software the new bone formation values percentile ratio newly formed bone area total defect area remained particles percentage type inflammation type bone connective tissue assessed blinded pathologist significant differences among groups identified one way anova tukey ad hoc test significant differences among two healing times determined test p 0.05 considered statistically significant mean regenerated bone remained particles study samples mentioned table 1 mean sds percentage regenerated bone remaining material study sample study groups regenerated bone consisted woven lamellar bone produced 6 12 weeks bone formation seen margin defects fibrous connective tissue center defects dbm control groups there bone formation margin center defect fibrous connective tissue background healing times cenobone 12 weeks dembone allograft there foreign body reaction chronic inflammatory cells dbm samples healing times diminished cenobone dembone groups 6 12 weeks inflammatory aggregations seen around remained particles chronic inflammatory cell aggregations could seen around remained particles tested allografts mean regenerated bone increased dembone p 0.40 cenobone p 0.12 control p 0.05 groups significantly decreased dbm p 0.04 6 12 weeks there reduction mean remained particles 12 weeks allografts statistically significant dbm p 0.53 cenobone p 0.22 dembone p 0.009 chronic inflammatory cells significantly decreased study period groups cenobone p 0.01 dembone p 0.04 control p 0.01 except dbm inflammatory cells 12 weeks allografts spearman rank correlation coefficient showed significant reverse relation bone formation remained particles groups p 0.001 r 0.624 comparison mean percentage bone formation remained particles study groups healing times shown figures 3 4 comparison bone formation study groups two healing times comparison remained particles study groups two healing times 6 weeks cenobone least bone formation even significantly less control group p 0.04 statistically significant differences three allografts remained particles bone formation after 12 weeks bone grafts bone formation 6 weeks except dbm demonstrated significantly less bone formation control group p 0.02 besides remained particles allografts 3 months there statistically significant differences three allografts remained particles bone formation healing time in study groups regenerated bone consisted woven lamellar bone produced 6 12 weeks bone formation seen margin defects fibrous connective tissue center defects dbm control groups there bone formation margin center defect fibrous connective tissue background healing times cenobone 12 weeks dembone allograft there foreign body reaction chronic inflammatory cells dbm samples healing times diminished cenobone dembone groups 6 12 weeks inflammatory aggregations seen around remained particles chronic inflammatory cell aggregations could seen around remained particles tested allografts mean regenerated bone increased dembone p 0.40 cenobone p 0.12 control p 0.05 groups significantly decreased dbm p 0.04 6 12 weeks there reduction mean remained particles 12 weeks allografts statistically significant dbm p 0.53 cenobone p 0.22 dembone p 0.009 chronic inflammatory cells significantly decreased study period groups cenobone p 0.01 dembone p 0.04 control p 0.01 except dbm inflammatory cells 12 weeks allografts spearman rank correlation coefficient showed significant reverse relation bone formation remained particles groups p 0.001 r 0.624 comparison mean percentage bone formation remained particles study groups healing times shown figures 3 4 comparison bone formation study groups two healing times comparison remained particles study groups two healing times 6 weeks cenobone least bone formation even significantly less control group p 0.04 statistically significant differences three allografts remained particles bone formation after 12 weeks bone grafts bone formation 6 weeks except dbm demonstrated significantly less bone formation control group p 0.02 besides remained particles allografts 3 months there statistically significant differences three allografts remained particles bone formation healing time using enough information capacity bone regeneration materials could help select efficient cost effective ones double blind randomized experimental animal study amounts regenerated bone remaining graft material along severity inflammation foreign body reactions compared groups critical size defects grafted three common allografts and it recommended healing period 8 weeks critical size defects 11 mm used evaluation late healing resorption materials amount bone regeneration rabbit calvaria there statistically significant differences 3 allografts remained particles bone formation two healing times could induce bone formation significantly control group found dfdba showed higher bone formation control group 4 8 12 weeks defects created trephine 8 rat calvaria different study becker colleagues find dfdba beneficial periodontal regeneration bone regeneration around implants abolfazli colleagues found use dfdba improve repair periodontal lesions two three walls alveolar bone defects reported similar effect like autogenous bone bone formation studies schwartz colleagues stated many differences exist bone bank preparations dfdba induce bone formation variously study dfdba two banks caused new bone formation 2 months dfdba one tissue bank induce bone formation study defect closure new bone area ratio gradually increased healing time parameters differ significantly 6 12 weeks groups except dbm mean percentage bone formation significantly decreased p 0.04 2 healing times this may due chronic inflammation presented around remained particles remained allografts 3 months know the presence inflammation mandatory bone healing persistence inflammatory mediators may lead suboptimal bone formation stated inflammation reduced healing time agreement result study dembone least inflammation allografts 6 weeks statistically significant differences control group control group minute inflammation healing times although hydrochloric acid needed removal masking effect mineralized matrix bmps putting allografts long time 90 min acid bath affect bmp concentration reversely in fact studies shown 2% residual calcium level necessary bone induction allografts words level calcium optimal osteoclastic resorption following osteoblastic activity besides herold et al stated find highest alkaline phosphatase activity cultured human periosteal cells 2% residual calcium optimal bone regeneration the time acid demineralization may variant different tissue banks may affect osteoinductive osteoconductive properties origination healing defect margin constant independent using bone graft could see control group although cenobone least bone formation 6 weeks bone islets centre defects could seen defects grafted dembone 12 weeks presence bony islets center defect might present particles far margin lined osteoblasts actively secret osteoid probably point osteoconductive property allografts dbm specimens could see marginal bone formation means graft particles near host bone involved bone regeneration speed bone regeneration important treatment modalities immediate loading study we could see differences bone formation allografts 6 weeks allograft could faster bone formation remained particles decreased increasing bone formation dembone least remained particles 12 weeks attributed nearly smaller size graft particles could justify least inflammation samples allografts 12 weeks according study done shwartz et al mentioned ability dfdba induce bone formation age dependant affect ability bone formation various tissue banks different donor selection criteria study the mean cadaver ages 35 years allografts difference aspect the graft materials used study considered xenograft human bone used rabbit calvaria one supposed may negative effect total bone formation studies pointed allogenic bone grafts may effective xenogenic ones.[2426 hand stated homology bmps human monkey bovine rabbit rat extracellular bone matrices study hollinger et al use allogenic human bone primates significantly increase new bone formation csds absence statistically significant differences allogenic bone materials attributed low number study population author recommended compare different allografts studies sample size human controlled trials no difference noted bone formation remained particles three commercial bone allografts	background : it has been stated that the bone allografts from different tissue banks may lead to various amount of bone induction , so the aim of this study was to evaluate bone regeneration of three demineralized allografts both histologically and histomorphometrically in rabbits calvaria bone defects.materials and methods : in this double - blind randomized experimental animal study , 32 critical size defects ( 11-mm diameter ) in the calvaria of 16 male new zealand white rabbits were randomly filled with three demineralized freeze - dried bone allografts ( dbm , cenobone , dembone ) , while the nongrafted defect was regarded as control group . after 6 and 12 weeks of healing , the experimental animals were euthanized for specimen preparation . after histological evaluation , histomorphometric analysis was performed to quantify new bone formation and remained graft particles . the data were analyzed by one - way anova with tukey 's ad - hoc test and t - test . ( p < 0.05 was considered to be statistically significant).results : mean percentage of bone formation increased between two healing time , but it was not statistically significant in all groups except dbm which the bone formation significantly decreased ( p = 0.04 ) . there were not statistically significant differences between three allografts in remained particles and bone formation in both healing times and they could not induce significantly more bone formation than control group.conclusion:both test and control groups resulted in successful new bone formation . no difference was noted in bone formation and remained particles between three commercial bone allografts . further studies in this issue may be needed .
current published estimates worldwide prevalence psoriasis range approximately 13%.1 2 3 4 5 6 psoriatic arthritis psa occurs approximately 1030% psoriasis patients vast majority cases joint involvement follows skin involvement often 10 years.7 8 patients psoriasis psa experience significant burden disease including reduced quality life decreased physical function increased comorbidities.7 9 10 available evidence suggests numerous unmet needs exist care patients including underdiagnosis2 7 suboptimal treatment.11 12 13 available surveys offer insight psoriasis psa disease burden treatment however limited specific geographic region patients currently care physician and/or treated specific healthcare setting and/or members patient association lack patient physician survey component moreover many surveys provide limited information patient physicianrelated factors influencing treatment decisions better understand unmet needs patient physician perspective gain deeper insight impact psoriasis psa patients lives populationbased survey 4400 patients 800 physicians north america europe the multinational assessment psoriasis psoriatic arthritis mapp survey firstofitskind largescale multinational survey conducted the survey explores diagnosis impact psoriasis psa healthrelated quality life well attitudes towards current therapies the mapp survey developed patient physician input aims provide better reflection psoriasis psa severity including impact disease treatment patients daily lives physician perspective results multinational patient survey published separately identified unmet needs related assessment disease severity psa screening diagnosis treatment options.8 current report includes results multinational physician survey the survey conducted abt srbi inc new york ny usa methodology results patient survey reported.8 dermatologists rheumatologists identified national databases country physicians contacted list random sampling methods offered participation survey screening criteria dermatologists required 50% practice devoted medical dermatology a total 6530 dermatologists 5445 rheumatologists screened 391 dermatologists 390 rheumatologists completed interviews north american results combine findings canada united states european results combine findings france germany italy spain united kingdom report results reflect overall global findings except notable differences responses observed north america europe the survey conducted abt srbi inc new york ny usa methodology results patient survey reported.8 dermatologists rheumatologists identified national databases country physicians contacted list random sampling methods offered participation survey screening criteria dermatologists required 50% practice devoted medical dermatology a total 6530 dermatologists 5445 rheumatologists screened 391 dermatologists 390 rheumatologists completed interviews north american results combine findings canada united states european results combine findings france germany italy spain united kingdom report results reflect overall global findings except notable differences responses observed north america europe dermatologists reported 86.0% office visits typical month related medical dermatology 16.1% specifically related psoriasis 4.1% psa overall north american rheumatologists twice many psa patients european rheumatologists physician practice demographics psa psoriatic arthritis psoriasis patients often referred participating dermatologist primary care physician 63.9% another specialist 16.2% another dermatologist 7.9% psa patients often referred primary care physician 51.2% another specialist 21.0% another dermatologist 7.0% psa patients often referred participating rheumatologist primary care physician 51.7% dermatologist 22.9% another specialist 18.4% dermatologists classified 20.3% psoriasis patients 25.7% psa patients severe disease 38.1% 38.3% moderate 40.5% 32.9% mild respectively psoriasis patients dermatologists most commonly considered location size skin lesions important factor contributing disease severity fig most commonly considered pain swelling joints important factor contributing disease severity fig top five important factors contributing psoriasis psoriatic arthritis b disease severity most dermatologists 62.6% reported psoriasis impacted patients daily activities and/or work 79.3% reported affected patients socially and/or emotionally 92.1% agreed disease burden psoriasis frequently underestimated dermatologists recognized higher proportion psa patients 73.7% impacted daily activities and/or work 76.8% affected socially and/or emotionally fewer rheumatologists recognized effect psa daily activities and/or work 57.2% social and/or emotional toll 64.9% however proactively discuss effect psa daily activities 85.3% social and/or emotional toll 67.2% dermatologists reported discussing possibility developing joint disease 43.5% 46.5% psoriasis patients however dermatologists rheumatologists 75% acknowledged psa likely underdiagnosed failure connect skin joint symptoms according dermatologists 20.0% psoriasis patients complain joint symptoms 33.0% patients confirmed diagnosis psa often made another physician 48.7% participating dermatologist 39.1% collaborative rheumatologist dermatologist care psa patients reported 75.6% dermatologists 42.9% rheumatologists dermatologists indicated solely responsible prescribing decisions 23.6% psa patients 30.8% primarily responsible prescribing decisions patients monitored rheumatologist joint symptoms 44.8% rheumatologists made prescribing decisions responding dermatologist monitored skin symptoms rheumatologists indicated solely responsible prescribing decisions 66.1% psa patients 34.2% might also monitored dermatologist skin symptoms 8.7% patients dermatologist made primary prescribing decisions whereas joint symptoms monitored rheumatologist table 2 summarizes physician estimates current treatment utilization patients moderatetosevere psoriasis psa practice dermatologists reported 74.9% psoriasis patients receiving topical therapy 19.5% receiving conventional oral diseasemodifying antirheumatic drug dmard therapy 19.6% receiving biologics psa patients often receiving oral therapy treated rheumatologists 63.4% vs. dermatologists 35.2% whereas dermatologists rheumatologists reported approximately 30% psa patients receiving biologics current treatment utilization patients psoriasis psa psa psoriatic arthritis uvb puva ultraviolet b psoralen+ultraviolet a. top goal dermatologists treating psoriasis patients keeping signs symptoms bay 52.5% followed improving normal functional activities 22.3% improving patient selfesteem 10.7% dermatologists reported feeling optimistic 45.2% and/or hopeful 35.3% managing new patient moderatetosevere psoriasis however approximately one five felt managing patient timeconsuming 19.8% complicated 18.6% approximately 60% dermatologists felt psoriasis patients require time support patients current structure healthcare system allow adequate time care dermatologists cited affordability longterm safety risks current medications greatest challenges managing psoriasis patients fig greatest challenge managing psoriasis psoriatic arthritis b patients when treating psa patients dermatologists rheumatologists reported top goals reduce joint pain stiffness 33.8% 36.2% respectively improve normal functional activities 28.4% 23.6% keep symptoms bay 25.3% 23.6% dermatologists reported feeling optimistic 30.9% hopeful 29.7% managing psa patients active disease 26.5% felt would complicated 15.4% said timeconsuming 17.4% thought would need refer involve specialists rheumatologists reported feeling optimistic 61.3% hopeful 37.2% managing psa patient active disease 29.5% agreed psa patients require time support patients dermatologists often cited differentiating psa arthritic diseases greatest challenge 24.6% whereas rheumatologists often cited delayed referral 31.0% fig , 53.5% dermatologists said would prescribe topical therapies monotherapy moderatetosevere psoriasis patients dermatologists commonly identified primary challenge topical therapies lack partial waning response 25.1% compliance 18.4% patient complaints inconvenience mess 18.2% inability cover entire surface area 17.9% dermatologists 47.6% ) most commonly felt comfortable conservative use conventional oral dmard therapy reported using sparingly 20.5% whereas rheumatologists 68.5% reported felt conventional oral therapy provided benefit used broadly 9.0% used sparingly in addition 18.7% dermatologists 16.1% rheumatologists said patient contraindications main factor preventing greater use conventional oral therapies rheumatologists commonly cited lack response limitation continuing therapy 35.4% dermatologists rheumatologists held back prescribing oral therapy patient refusal concerns the common reasons related tolerability longterm safety lifestyle modifications lack loss response fig top five commonly cited limitations initiating conventional oral therapy continuing conventional oral therapy b patient concerns regarding use conventional oral therapy c approximately 40% dermatologists rheumatologists comfortable conservative use biologic therapy more rheumatologists 41.5% reported aggressive use compared dermatologists 19.9% greater proportion dermatologists 10.5% reported prescribing biologics compared rheumatologists 1.8% among dermatologists 65.5% said would initiate manage biologic therapy compared 90.3% rheumatologists the main reasons initiating biologics related cost longterm safety tolerability concerns fig 4a rheumatologists commonly cited lack loss response limitation continuing therapy fig longterm safety commonly reported limitation initiating biologics dermatologists rheumatologists north america 32.6% 54.5% respectively compared europe 13.6% 17.0% respectively biologic therapyrelated tasks commonly considered burdensome included prior authorization paperwork ensuring patients comply laboratory results handling patient calls regarding questions possible sideeffects teaching selfinjection discussing patients use risks associated injectable biologic therapy fig top five commonly cited limitations initiating continuing b patients biologic therapy burdensome tasks steps associated biologic therapy c dermatologists somewhat satisfied effectiveness conventional oral 84.2% biologic therapy 95.9% 27.8% 25.6% somewhat dissatisfied longterm safety respectively 75.4% 83.4% expressed concern health risks longterm use likewise rheumatologists somewhat satisfied efficacy currently available therapies conventional oral therapy 81.8% biologics 97.9% concern regarding longterm safety oral biologic therapies reported 11.3% 15.4% rheumatologists respectively however 53.6% 68.5% rheumatologists reported somewhat concerned health risks longterm use oral biologic therapies respectively when prescribing topical therapy psoriasis patients eligible oral biologic therapy 7.9% rheumatologists stated hesitation prescribe systemic therapy related tolerability longterm safety concerns among respondents 53.0% dermatologists 30.5% rheumatologists agreed keeping patient symptoms bay best patients could expect conventional oral therapy 49.6% 27.7% respectively felt patients leaving practice due frustration dissatisfaction currently available therapies important issue 26.3% 13.3% respectively felt treatment options could worse condition the important attributes ideal therapy identified respondents largely related efficacy safety generally mirrored considered greatest unmet therapeutic needs table 3 in addition improved access therapy oral administration among five commonly selected attributes another oral option new mechanism action among five commonly noted unmet therapeutic needs top five attributes ideal therapy greatest unmet therapeutic needs psa psoriatic arthritis dermatologists classified 20.3% psoriasis patients 25.7% psa patients severe disease 38.1% 38.3% moderate 40.5% 32.9% mild respectively psoriasis patients dermatologists most commonly considered location size skin lesions important factor contributing disease severity fig most commonly considered pain swelling joints important factor contributing disease severity fig top five important factors contributing psoriasis psoriatic arthritis b disease severity most dermatologists 62.6% reported psoriasis impacted patients daily activities and/or work 79.3% reported affected patients socially and/or emotionally 92.1% agreed disease burden psoriasis frequently underestimated dermatologists recognized higher proportion psa patients 73.7% impacted daily activities and/or work 76.8% affected socially and/or emotionally fewer rheumatologists recognized effect psa daily activities and/or work 57.2% social and/or emotional toll 64.9% however proactively discuss effect psa daily activities 85.3% social and/or emotional toll 67.2% dermatologists reported discussing possibility developing joint disease 43.5% 46.5% psoriasis patients however dermatologists rheumatologists 75% acknowledged psa likely underdiagnosed failure connect skin joint symptoms according dermatologists 20.0% psoriasis patients complain joint symptoms 33.0% patients confirmed diagnosis psa often made another physician 48.7% participating dermatologist 39.1% collaborative rheumatologist dermatologist care psa patients reported 75.6% dermatologists 42.9% rheumatologists dermatologists indicated solely responsible prescribing decisions 23.6% psa patients 30.8% primarily responsible prescribing decisions patients monitored rheumatologist joint symptoms 44.8% rheumatologists made prescribing decisions responding dermatologist monitored skin symptoms rheumatologists indicated solely responsible prescribing decisions 66.1% psa patients 34.2% might also monitored dermatologist skin symptoms 8.7% patients dermatologist made primary prescribing decisions whereas joint symptoms monitored rheumatologist table 2 summarizes physician estimates current treatment utilization patients moderatetosevere psoriasis psa practice dermatologists reported 74.9% psoriasis patients receiving topical therapy 19.5% receiving conventional oral diseasemodifying antirheumatic drug dmard therapy 19.6% receiving biologics psa patients often receiving oral therapy treated rheumatologists 63.4% vs. dermatologists 35.2% whereas dermatologists rheumatologists reported approximately 30% psa patients receiving biologics current treatment utilization patients psoriasis psa psa psoriatic arthritis uvb puva ultraviolet b psoralen+ultraviolet a. the top goal dermatologists treating psoriasis patients keeping signs symptoms bay 52.5% followed improving normal functional activities 22.3% improving patient selfesteem 10.7% dermatologists reported feeling optimistic 45.2% and/or hopeful 35.3% managing new patient moderatetosevere psoriasis however approximately one five felt managing patient timeconsuming 19.8% complicated 18.6% approximately 60% dermatologists felt psoriasis patients require time support patients current structure healthcare system allow adequate time care dermatologists cited affordability longterm safety risks current medications greatest challenges managing psoriasis patients fig . greatest challenge managing psoriasis psoriatic arthritis b patients when treating psa patients dermatologists rheumatologists reported top goals reduce joint pain stiffness 33.8% 36.2% respectively improve normal functional activities 28.4% 23.6% keep symptoms bay 25.3% 23.6% dermatologists reported feeling optimistic 30.9% hopeful 29.7% managing psa patients active disease 26.5% felt would complicated 15.4% said timeconsuming 17.4% thought would need refer involve specialists rheumatologists reported feeling optimistic 61.3% hopeful 37.2% managing psa patient active disease 29.5% agreed psa patients require time support patients dermatologists often cited differentiating psa arthritic diseases greatest challenge 24.6% whereas rheumatologists often cited delayed referral 31.0% fig in 53.5% dermatologists said would prescribe topical therapies monotherapy moderatetosevere psoriasis patients dermatologists commonly identified primary challenge topical therapies lack partial waning response 25.1% compliance 18.4% patient complaints inconvenience mess 18.2% inability cover entire surface area 17.9% dermatologists 47.6% commonly felt comfortable conservative use conventional oral dmard therapy reported using sparingly 20.5% whereas rheumatologists 68.5% reported felt conventional oral therapy provided benefit used broadly 9.0% used sparingly in addition 18.7% dermatologists 16.1% rheumatologists said patient contraindications main factor preventing greater use conventional oral therapies rheumatologists commonly cited lack response limitation continuing therapy 35.4% dermatologists rheumatologists held back prescribing oral therapy patient refusal concerns the common reasons related tolerability longterm safety lifestyle modifications lack loss response fig top five commonly cited limitations initiating conventional oral therapy continuing conventional oral therapy b patient concerns regarding use conventional oral therapy c approximately 40% dermatologists rheumatologists comfortable conservative use biologic therapy more rheumatologists 41.5% reported aggressive use compared dermatologists 19.9% greater proportion dermatologists 10.5% reported prescribing biologics compared rheumatologists 1.8% among dermatologists 65.5% said would initiate manage biologic therapy compared 90.3% rheumatologists the main reasons initiating biologics related cost longterm safety tolerability concerns fig 4a rheumatologists commonly cited lack loss response limitation continuing therapy fig longterm safety commonly reported limitation initiating biologics dermatologists rheumatologists north america 32.6% 54.5% respectively compared europe 13.6% 17.0% respectively biologic therapyrelated tasks commonly considered burdensome included prior authorization paperwork ensuring patients comply laboratory results handling patient calls regarding questions possible sideeffects teaching selfinjection discussing patients use risks associated injectable biologic therapy fig top five commonly cited limitations initiating continuing b patients biologic therapy burdensome tasks steps associated biologic therapy c dermatologists somewhat satisfied effectiveness conventional oral 84.2% biologic therapy 95.9% 27.8% 25.6% somewhat dissatisfied longterm safety respectively 75.4% 83.4% expressed concern health risks longterm use likewise rheumatologists somewhat satisfied efficacy currently available therapies conventional oral therapy 81.8% biologics 97.9% concern regarding longterm safety oral biologic therapies reported 11.3% 15.4% rheumatologists respectively however 53.6% 68.5% rheumatologists reported somewhat concerned health risks longterm use oral biologic therapies respectively when prescribing topical therapy psoriasis patients eligible oral biologic therapy 7.9% rheumatologists stated hesitation prescribe systemic therapy related tolerability longterm safety concerns among respondents 53.0% dermatologists 30.5% rheumatologists agreed keeping patient symptoms bay best patients could expect conventional oral therapy 49.6% 27.7% respectively felt patients leaving practice due frustration dissatisfaction currently available therapies important issue 26.3% 13.3% respectively felt treatment options could worse condition the important attributes ideal therapy identified respondents largely related efficacy safety generally mirrored considered greatest unmet therapeutic needs table 3 in addition improved access therapy oral administration among five commonly selected attributes another oral option new mechanism action among five commonly noted unmet therapeutic needs top five attributes ideal therapy greatest unmet therapeutic needs psa psoriatic arthritis mapp unique largescale multinational survey containing patient physician component aimed gaining better understanding global perspectives burden psoriasis psa treatment results multinational patient survey showed significant burden disease unmet treatment needs.8 report findings physician portion survey included dermatologists rheumatologists care patients psoriasis and/or psa these findings largely support patient survey including large disease burden underdiagnosis psa differing perceptions disease severity challenges current treatment options while dermatologists rheumatologists recognized emotional social toll psoriasis psa may place patients acknowledged burden disease often underestimated dermatologists estimated 20% psoriasis patients 26% psa patients severe disease patient portion mapp survey slightly psoriasis patients 27% twice many psa patients 53% rated disease severe.8 reasons disconnect may related use standardized tools physicians vs. subjective assessments patients in addition patients physicians matched results directly compared however physicians patients revealed notable differences factors contributing assessment physicians reported important factors contributing disease severity location size skin lesions psoriasis patients pain swelling joints psa patients itching location skin lesions cited important factors patients assessment disease severity.8 current findings show factors notably itching 5a b 7% dermatologists cited itching important factor contributing disease severity compared 38% patients.8 itching captured currently utilized assessment tools indicating potential need examine disease severity assessed educating healthcare providers hcps regarding importance outcome well increased use pruritus assessment tools clinical studies may help bridge disconnect most important factors contributing psoriasis disease severity reported physicians patients.8 dermatologists rheumatologists acknowledged psa likely underdiagnosed failure connect skin joint symptoms however dermatologists indicated always discuss possibility psa psoriasis patients according dermatologists 20.0% psoriasis patients complained joint symptoms lower 44% psoriasis patients mapp survey indicated joint pain.8 addition 16% 26% patients psoriasis alone reported symptoms possibly resembling enthesitis dactylitis respectively.8 according dermatologists 33.0% psoriasis patients complaining joint pain confirmed diagnosis psa consistent previous reports,14 may indicate patients fully assessed diagnosed psa despite presence joint symptoms although joint pain may attributable number conditions psa dermatologists often cited differentiating psa rheumatologic musculoskeletal diseases greatest challenge managing psa whereas rheumatologists often cited delayed referral educating dermatologists importance discussing symptoms pain joint back foot pain psoriasis patients refer patients rheumatologist may helpful increasing psa identification the current findings indicate many patients moderatetosevere disease may undertreated especially dermatology setting.15 39.1% dermatologists reported moderatetosevere psoriasis patients receiving conventional oral 19.5% biologic 19.6% therapy 54% indicated would prescribe topical therapies monotherapy moderatetosevere psoriasis patients treatment rates psa patients higher approximately 65% dermatologists reporting conventional oral 35.2% biologic 30.6% use the main reasons initiating maintaining therapies related concerns longterm safety tolerability efficacy well costs biologics in addition physician responses indicate burdensome aspects biologic therapy related time requirements patient education management prior authorization requirements dermatologists rheumatologists reported higher treatment rates compared patients surveyed mapp.8 may due fact patients could participate mapp survey whether care physician may treated seeing physician disease many dermatologists rheumatologists felt management psoriasis psa complicated timeconsuming challenging approximately half dermatologists one quarter rheumatologists felt patients leaving practice frustration dissatisfaction current therapies important issue in patient survey many patients cited seeing hcp past 12 months think hcp could help frustration low expectations and/or dissatisfaction current therapies.8 furthermore dermatologists rheumatologists often perceive management psa challenging patients typically seen multiple hcps psoriasis psa associated number comorbidities make treatment complex.16 satisfaction current therapies may impact patient management well patients generally expressed lower rates satisfaction current therapies compared dermatologists rheumatologists particularly ease use longterm safety.8 taken together findings patient physician surveys suggest available therapies may initiated longterm safety concerns cost need injections additional time requirements therapies confirm need efficacious less burdensome costeffective therapies improved safety tolerability profiles as survey mapp limited factors accurate recall interpretation questions survey blinded physicians could recontacted clarify answers the mapp survey lacked control group designed capture differences use attitudes towards various agents within class drugs impact healthcare system requirements decisionmaking the findings physician portion mapp survey support findings patient survey highlight importance screening assessing psoriasis patients symptoms psa aligning patient physician severity assessments treatment goals ongoing need safe effective therapies psoriasis psa	abstractbackgroundavailable literature on psoriasis and psoriatic arthritis ( psa ) demonstrates a tremendous burden of disease and suggests underdiagnosis and undertreatment.objectiveto obtain realworld physician perspectives on the impact of psoriasis and psa and its treatment on patients ' daily lives , including perceptions of , and satisfaction with , current therapies.methodsthe multinational assessment of psoriasis and psoriatic arthritis ( mapp ) surveyed dermatologists ( n = 391 ) and rheumatologists ( n = 390 ) in north america ( canada and the united states ) and europe ( france , germany , italy , spain and united kingdom).resultsdermatologists classified 20.3% and 25.7% of their patients as having severe psoriasis and severe psa respectively ; rheumatologists indicated that 48.4% of their psa patients had active disease . of the psoriasis patients complaining of joint pain , only 33.0% had a diagnosis of psa . an impact on daily activities or social / emotional wellbeing was recognized by 57.2% to 79.3% of physicians . in patients with moderatetosevere psoriasis , dermatologists reported 74.9% were receiving topical therapy , 19.5% conventional oral therapy and 19.6% biologics . dermatologists and rheumatologists reported similar rates of topical ( 45% ) and biologic ( 30% ) therapy utilization for their psa patients ; conventional oral therapy was more often prescribed by rheumatologists ( 63.4% ) vs. dermatologists ( 35.2% ) . reasons for not initiating or maintaining systemic therapies were related to concerns about longterm safety , tolerability , efficacy and costs ( biologics).conclusionphysicians in north america and europe caring for patients with psoriasis and psa acknowledge unmet treatment needs , largely concerning longterm safety / tolerability and efficacy of currently available therapies ; evidence suggests underdiagnosis of psa and undertreatment of psoriasis among dermatologists .
hearts isolated wildtype zebrafish embryos 24hpf 72hpf stained transmembrane potential sensitive dye di-8-anepps invitrogen calcium sensitive ratiometric dye fura-2 invitrogen measurements action potentials calcium transients respectively fluorescence intensities recorded high speed ccd camera redshirt imaging propagation velocities depolarizing waves estimated previously described modifications see full description online methods hearts isolated 72hpf zebrafish embryos fixed prefer fixative anatech ltd stained primary antibodies rabbit anti connexin43 sigma 1:50 mouse anti--catenin bd biosciences 1:200 mouse anti zn8 dshb 1:50 secondary antibodies donkey anti rabbit mouse alexa fluor-488 -546 conjugated invitrogen 1:1000 wnt11:cfp fusion protein cloned downstream cmlc2 promoter tol2kit expression system using gateway technology invitrogen 10 g/l 25 g/l dna co injected 25 g/l capped tol2 transposase mrna 1 cell stage embryos scientific added 30hpf old zebrafish embryos egg water buffered 5 mm hepes isolated zebrafish hearts incubated mix thapsigargin 10 sigma caffeine 10 mm sigma tyrode solution 45 min prior optical imaging hearts isolated wildtype zebrafish embryos 24hpf 72hpf stained transmembrane potential sensitive dye di-8-anepps invitrogen calcium sensitive ratiometric dye fura-2 invitrogen measurements action potentials calcium transients respectively fluorescence intensities recorded high speed ccd camera redshirt imaging propagation velocities depolarizing waves estimated previously described modifications see full description online methods hearts isolated 72hpf zebrafish embryos fixed prefer fixative anatech ltd stained primary antibodies rabbit anti connexin43 sigma 1:50 mouse anti--catenin bd biosciences 1:200 mouse anti zn8 dshb 1:50 secondary antibodies donkey anti rabbit mouse alexa fluor-488 -546 conjugated invitrogen 1:1000 wnt11:cfp fusion protein cloned downstream cmlc2 promoter tol2kit expression system using gateway technology invitrogen 10 g/l 25 g/l dna co injected 25 g/l capped tol2 transposase mrna 1 cell stage embryos scientific added 30hpf old zebrafish embryos egg water buffered 5 mm hepes isolated zebrafish hearts incubated mix thapsigargin 10 sigma caffeine 10 mm sigma tyrode solution 45 min prior optical imaging	electrical gradients are critical for many biological processes , including the normal function of excitable tissues , left - right patterning , organogenesis , and wound healing14 . the fundamental mechanisms that regulate the establishment and maintenance of such electrical polarities are poorly understood . using high - speed optical mapping of transmembrane potentials and calcium concentrations in the zebrafish heart , we have identified a gradient of electrical coupling across the developing ventricular myocardium . we excluded a role for cellular excitability , connexin localization , tissue geometry and mechanical inputs , but in contrast we were able to demonstrate that non - canonical wnt11 signals are required for the genesis of this myocardial electrical gradient . importantly , though the traditional planar cell polarity pathway is not involved , we obtained evidence that wnt11 acts to set up this gradient of electrical coupling through effects on transmembrane ca2 + conductance mediated via the l - type calcium channel . these data reveal a previously unrecognized role for wnt / ca2 + signaling in establishing an electrical gradient in the plane of developing cardiac epithelium through modulation of ion channel function . the regulation of cellular coupling through such mechanisms may be a general property of non - canonical wnt signals .
hematopoietic stem cell transplantation hsct potentially curative treatment patients various hematological malignancies bone marrow failure syndromes congenital immune deficiencies stem cells obtained bone marrow peripheral blood umbilical cord blood autologous hsct stem cells derived patient utilized treat chemosensitive malignancies multiple myeloma non hodgkin hodgkin lymphoma its anticancer effect entirely derived high dose myeloablative conditioning regimen whereas subsequent autologous stem cell infusion enables bone marrow recovery allogeneic hsct stem cells originate related unrelated donor often preferred treatment number hematological malignancies acute chronic leukemia relapsed lymphoma graft versus leukemia lymphoma gvl effect immunological response donor derived immune cells malignant cells late 1990s a better understanding gvl biology led preparative regimens involve less intensive conditioning radio chemotherapy thus less directly toxic myeloablative regimens unlike traditional myeloablative conditioning reduced intensity conditioning ric regimens primarily immunosuppressive enable engraftment transplanted donor cells depend graft eradicate cancer ric transplants also conducted patients previously eligible myeloablative protocols older age medical condition gvl responses often accompanied graft versus host disease gvhd complication allogeneic hsct donor derived immune cells including t- b- natural killer nk cells raise immune response normal host tissue oropharynx gut skin eyes liver overall prevalence oral complications patients receiving hsct estimated 80% frequently encountered acute oral complications include mucositis local systemic infections oral dryness taste changes 36 whereas autologous hsct most problems resolved 6 months patients treated allogeneic hsct may also later experience complications associated gvhd inflammatory processes key pathobiology oral complications hsct recipients this review article discuss frequently encountered oral complications associated hsct focusing inflammatory pathways inflammatory mediators involved pathogenesis oral mucositis om inflammatory driven process oral mucosa one best studied oral side effects cancer therapy it induced radiation therapy and/or chemotherapy characterized clinically mucosal damage ranging mild inflammation presenting erythematous atrophic lesions extensive ulcerations penetrating submucosa hsct recipients mucositis limited oral cavity may occur along entire orodigestive tract the mechanisms underpinning pathobiology mucositis thought largely regardless location along tract the incidence om estimated range 75% 100% following myeloablative conditioning regimens reported painful debilitating oral complication significantly impairing quality life qol prospective studies reported conditioning regimens containing high dose melphalan busulphan cyclophosphamide combination total body irradiation tbi associated severe om 911 while om risk among patients receiving conditioning regimens including tbi exceeds 90% risk drops 30%50% individuals treated protocols without tbi conditioning regimens important parameters determining om risk patient related factors also involved although association less clear particular local tissue environment mucosal responses damaging stimuli may part genetically determined govern risk course severity mucosal injury 12 13 genetic determinants om risk include genes regulate availability active chemotherapy drug metabolites for example evaluation genetic variation folate metabolizing enzymes may help identify patients greater risk methotrexate toxicity enzyme deficiencies may relatively rare in contrast differences expression genes associated biological pathways drive mucositis common for instance genetic polymorphisms associated expression inflammatory mediators tumor necrosis factor- tnf- implicated om risk patients undergoing allogeneic hsct recently sonis et al identified single nucleotide polymorphisms- snp- based bayesian network developed saliva sourced dna may predict individual risk develop severe om following conditioning autologous hsct om following ric regimens usually less severe shorter duration 15 16 however ric regimens may vary considerably intensity accompanying toxicity prospective studies necessary considerable progress made past years understanding pathobiology mucositis 1719 summarize recent insights historically om viewed solely epithelium mediated event result nonspecific toxic effects radiation and/or chemotherapy rapidly proliferating basal epithelial cells resulting clonogenic cell death this continues component much complex contemporary model mucositis developed sonis this five phase biological model describes cascade interrelated overlapping genetic histopathological events these phases include initiation upregulation activation signal amplification ulceration healing involving epithelial connective tissues mucosa figure 1 the initiation phase pathobiology mucositis characterized radio- and/or chemotherapy induced dna non dna damage results injury basal epithelial cells submucosal cells endothelial cells particular submucosal cell death contributes injury response damage reactive oxygen species ros ) are generated amplify dna damage clonogenic cell death activate subsequent phase number transcription factors including nuclear factor- nf- b 7 21 nf-b considered gatekeeper various inflammatory pathways involved mucositis activation nf-b occurs virtually epithelial submucosal cells induces expression adhesion molecules activation mitogen activated protein kinase mapk cyclooxygenase- cox- 2 pathways 19 21 22 furthermore finding nf-b activation proapoptotic antiapoptotic effects apoptosis regulator bcl-2 genes makes significant factor determining fate normal tissues following cytotoxic therapy upregulation nf-b generates formation interleukin- il- 1 il-6 tnf- these proinflammatory mediators stimulate additional injury positive feedback loops signal amplification phase whereby tnf- acts pathways reinforce nf-b activation additional support role cytokines provided therapies interfere development mucositis influencing cytokine profile 2431 together alternative nf-b independent pathways ceramide pathway results apoptosis submucosal basal epithelial cells leading mucosal ulceration furthermore metalloproteinases mmps involved pathobiology mucositis 32 33 damage submucosa besides direct effect radiation chemotherapy mediated activation activating protein-1 ap-1 stimulates secretion mmps fibroblasts 19 34 tnf- important regulator transcriptional activity ap-1 initiating mapk signaling pathway activating c jun amino terminal kinase moreover il-1 cox-2 may induce mmp activation increased levels mmp-2 -3 -9 -12 no significant correlation found levels mmp-1 mmp-8 neutrophil collagenase mmp-13 involved degradation extracellular matrix ecm bone oral rinsing samples om scores allogeneic hsct recipients the ulcerative phase comprises loss mucosal integrity microbiological colonization subsequent proinflammatory cytokine production it associated epithelial proliferation often concurrent hematopoietic recovery reestablishment local microbial flora absence factors interfere wound healing infection mechanical irritation the ecm plays significant role signaling tissues complex structural network fibrous proteins proteoglycans glycoproteins ecm stimulates epithelial cell migration proliferation differentiation leading renewal mucosa epidermal growth factor egf transforming growth factor- tgf- il-1 interferon- ifn- appear promote process upregulating tgf- stimulate expression fibronectin collagen type iv healing the oral mucosa appears normal appearances may deceptive ongoing angiogenesis connective tissue maturation result increased risk om additional cytotoxic therapy administered several anti inflammatory cytokines growth factors identified protective effect de koning et al suggested protective role il-10 observing severe intestinal damage following methotrexate treatment il-10 deficient mice compared wild type controls several animal studies indicated il-11 inhibitor downregulator inflammatory mediators including nitric oxide reduces om moreover suggested subcutaneous administration il-11 reduced severity om maintaining keratin production epithelial cells well reducing mucosal proinflammatory cytokine expression unfortunately il-11 administration caused severe fluid retention early mortality clinical trial leading early closure study topical tgf-3 prior chemotherapy administration negatively regulated epithelial cell proliferation reduced om hamster model it mitogenic promotes cell survival upregulating bcl-2 genes suppress apoptosis kgf-1 also activates nuclear factor erythroid 2-related factor 2 nrf2 coordinates expression cytoprotective genes upregulates il-13 anti inflammatory cytokine attenuates effects tnf- human recombinant kgf-1 found beneficial prevention om patients treated high dose ct tbi followed autologous hsct 31 43 it demonstrated mice perturbations local immune responses microbiota lead spontaneous inflammation vice versa loss microbial diversity associated proinflammatory state 44 45 shifts commensal oral bacterial flora associated leukemia neutropenia direct effects anticancer therapy antibiotic use hyposalivation mucosal surface changes well documented 46 47 for example results study breast cancer patients suggested shift complex oral bacterial profile following chemotherapy recent study using 16s rrna 454 pyrosequencing suggested chemotherapy induced changes bacterial composition predictive om risk substitution coagulase negative staphylococci cons streptococci associated om the presence porphyromonas gingivalis strictly anaerobic gram negative microorganism associated periodontitis shown positive predictive value mucosal ulcerations hsct patients it suggested p. gingivalis plays role initiation om upregulating toll like receptors tlrs facilitate nf-b activation their effects synergistic many cases reinforced immune and/or inflammatory reactions oral mucosa some defense proteins like salivary immunoglobulins heat shock proteins involved innate acquired immunity cationic peptides defense proteins e.g. lysozyme bactericidal permeability increasing protein bpi salivary amylase cystatins proline rich proteins mucins peroxidases statherin primarily involved innate immunity however role saliva development om presently unclear 53 54 once ulcerations manifest represent risk systemic infection bacteremia fungemia fever sepsis particularly concomitant neutropenia 7 5557 the damaged mucosa may provide portal entry microorganisms inflammatory products bloodstream 5860 om likely origin bacteremia oral viridans streptococci frequently resulting fever may lead acute respiratory distress syndrome septic shock 61 62 bacteremia may also caused coagulase negative staphylococci cons originating oral mucosa 50 63 it noted however 30% patients mucositis fever bacterial cause could identified mucosal barrier injury likely triggers systemic inflammatory response response may cause neutropenic fever infectious inflammatory complications associated ulcerative om may explain observation reported number studies om associated increased risk early nontumor related mortality hsct recipients 6 64 65 described tissue damage associated mucositis is also thought involved pathogenesis gvhd 66 67 however vokurka et al found evidence notion study om prevented oral cryotherapy allogeneic hsct recipients treated high dose melphalan conditioning regimens in allogeneic hsct recipients gvhd frequently encountered remains major cause morbidity mortality organs risk affected complex immunologic disorder include skin gastrointestinal tract including oropharynx liver eyes ( graft must contain immunologically competent cells cells ii recipient must incapable rejecting graft cells iii recipient must express tissue antigens present donor 66 70 important genetically defined proteins host cells donor cells respond human leukocyte antigens hla the degree hla match donor patient important risk factor gvhd additional risk factors include minor histocompatibility antigens mha older age patient primary disease graft source donor parity sex mismatch toxicity conditioning regimens effectiveness gvhd prophylaxis 71 72 established gvhd difficult treat gvhd and gvl responses usually come together rigorous gvhd prophylaxis treatment may carry cost increased risk disease relapse gvhd classified either acute gvhd agvhd chronic gvhd cgvhd defined clinical pathologic features 74 75 hyperacute oral agvhd may develop early one two weeks hsct differential diagnosis agvhd om infection challenging oral agvhd considered infection excluded ulcerations fail heal hematologic recovery 21 28 days allogeneic hsct the condition potentially underrecognized estimated 35% 60% patients agvhd oral manifestations a pilot study reported patients undergoing ric hsct developed less oral agvhd recipients myeloablative allogeneic hsct recent observational study allogeneic hsct following ric conditioning reported incidence oral agvhd 7% the common sites involved initial diagnosis cgvhd skin 75% mouth 51%63% liver 29%51% eye 22%33% however oral cavity may principal sometimes site involvement serve useful component cgvhd diagnosis staging oral cgvhd may affect mucosa and/or salivary glands may develop mucosal sclerosis although oral cgvhd mild majority patients always considered clinically significant due often prolonged duration subset patients it continuous source pain impairing oral function affecting alimentation nutritional status impeding maintenance oral health reducing quality life 82 83 cohort ric hsct recipients cgvhd related oral symptoms developed median onset seven months transplant persisted median duration six months reoccurred one third affected patients chronic mucosal gvhd oropharynx estimated occur 4583% patients 76 84 characterized lichenoid inflammation particularly affecting tongue buccal mucosa lips figure 2 clinical signs resemble seen lichen planus include white hyperkeratotic reticulations plaques erythema ulcerations may covered pseudomembrane typical histopathological features include apoptotic bodies satellite necrosis lichenoid interface inflammation lymphocytic infiltration junction epithelium subepithelial connective tissue 74 79 it important aware complications mimic oral cgvhd including oral mucosal reactions medications including mammalian target rapamycin mtor inhibitors local allergic reactions infections second primary tumors salivary gland dysfunction common hsct patients related conditioning regimen dehydration medication cgvhd the primary symptom salivary gland cgvhd xerostomia subjective complaint oral dryness patients may also describe oral sensitivity burning cgvhd salivary glands probably underdiagnosed patients experience xerostomia induced hsct conditioning particularly tbi containing regimens anticholinergic medications may persist period salivary gland cgvhd develops making onset diagnosis less evident salivary gland cgvhd mimics sjgren syndrome commonly associated xerophthalmia may also relate pulmonary gvhd involvement saliva plays critical role mastication swallowing taste speech tooth remineralization maintenance oral ph balance prevention oral infections patients salivary gland cgvhd risk developing complications diminished salivary defense mechanisms including antifungal anticariogenic activities 88 89 castellarin coworkers reported cgvhd associated rapidly progressive dental caries cervical interproximal involvement measurement resting stimulated whole saliva flow rates individual analysis risk oral diseases preventive measures part supportive care patients mucoceles subepithelial extravasations sialomucin occur epithelial connective tissue interface around obstructed duct minor salivary glands clinically presents soft fluid filled elevation epithelium 75 91 oral sclerotic involvement resulting limited jaw opening result perioral facial skin sclerosis typically extension generalized sclerotic changes mucosal sclerosis rare may develop complication long standing severe ulcerative mucosal cgvhd it may restrict jaw opening tongue movement may extend throat esophagus resulting dysphagia it associated pain secondary ulceration significantly impairing alimentation performing oral hygiene measures development agvhd occurs three overlapping interrelated steps conditioning ii activation expansion alloreactive cells iii effector phase 74 92 first conditioning regimens induce tissue damage e.g. mucositis skin damage inducing release adenosine triphosphate atp damage signals leading secretion tnf- il-1 il-6 chemokines adhesion factors this promote activation proliferation host antigen presenting cells apcs increased expression costimulatory molecules migration apcs secondary lymphoid organs the impact microbiota gvhd recognized significant postulated intestinal microflora endotoxin exert crucial step apc activation translocation bacteria bacterial components damaged epithelial barriers triggers additional production inflammatory cytokines particularly tnf- il-1 il-12 strong correlation increased tnf- serum levels and inflammation secondary gvhd reported associated major shifts composition intestinal microbiota may aggravate severity inflammation whether interactions oral microbiota host defense mechanisms may contribute pathobiology oral gvhd remains assessed second phase activated host apcs encounter resting donor cells present host antigens cells become activated following activation cells exit lymphoid organs enter blood circulation subsequently migrate host target tissues e.g. skin orodigestive tract liver third effector ) phase complex cascade cellular mediators inflammatory agents induce amplify tissue damage 66 70 donor cells cause tissue damage via direct cytotoxicity epithelial cells release interferon- ifn- il-2 this activates nk cells resident macrophages release proinflammatory cytokines including tnf- il-1 il-6 leading amplification proinflammatory cytokine cascade cytokine storm hallmark acute gvhd 101103 a recent study presented association il1b polymorphisms agvhd well il-1 levels saliva blood agvhd development in addition association found cc genotype high levels il-1 suggesting assessing kinetics il-1 fluid types may useful monitoring progression disease depending conditions activation subsequent cytokine profile cd4 cells subdivided th1 th2 th17 subtypes although oversimplified th1 th2 th17 characterized secretion ifn- il-4 il-17 respectively activation cd8 cytotoxic cells accompanied increased production effector molecules perpetuate damage both fas fasl dependent perforin granzyme dependent apoptosis important gvhd induced tissue damage traditionally agvhd considered driven th1 cytokines mediated cd8 effectors however pathobiology appears far complex b cells may also play role development agvhd our understanding cgvhd limited partly difficulty generating animal models true representatives clinical disease the first theory end stage alloreactivity donor cells augment th2 immune response the second theory postulates cgvhd due poor immunologic recovery development autoreactive lymphocytes due lack thymic control peripheral mechanisms deletion likely pathogenesis cgvhd begins uncontrolled expansion donor cells response allo- autoantigens the activated cells subsequently cause target organ damage inflammatory cytokines cytolytic attack fibrosis and/or promoting b cell activation production autoantibodies evidence exists b cell deregulation expansion host b cells contribute cgvhd miklos et al demonstrated presence antibodies directed h proteins transplantation antigen lead rejection male grafts female recipients correlates cgvhd also elevated levels b cell activating factor baff contribute b cell activation patients active cgvhd furthermore young et al described donor b cells activated donor cd4 cells upregulate mhc ii costimulatory molecules acting efficient apcs activated donor b cells enhance donor cd4 clonal expansion thereby augmenting capacity cells induce autoimmune like cgvhd indeed comparable autoimmune diseases both t- b cell responses appear play role pathogenesis cgvhd suggesting reflects general loss tolerance including abnormalities function regulatory treg cells impairment tregs associated loss peripheral tolerance development cgvhd acute gvhd long conceived dependent upon type cytokine driven cd8 effectors whereas cgvhd associated type ii cd4 cells th2 cytokines il-4 il-10 considered predominant cytokines pathobiology cgvhd however mechanisms far complex agvhd cgvhd initially characterized increased th2 cytokines production studies also shown decreased th2-type cytokine levels among patients developed cgvhd compared 139 140 taken together evidence th2 involvement cgvhd limited depending upon animal model used 3 major subtypes cd4 cells th1 th2 th17 implicated cgvhd imanguli coworkers systematically examined oral mucosal biopsies assessed clinical severity oral cgvhd correlated presence apoptotic epithelial cells these cells often found adjacent infiltrating effector memory cells expressing markers cytotoxicity type cytokine polarization bet+ cells accumulation bet+ cell effectors associated increased proliferation expression type chemokine receptor cxcr3 infiltrating cells keratinocytes increased expression cxcr3 ligand mig cxcl9 il-15 ifn inducible factors type differentiation expansion alloreactive effectors observed salivary gland cgvhd characterized typical histopathological changes figure 3 including periductal mononuclear infiltration particularly cd45 cd45ro cd4 cd8 positive cells atrophy salivary gland lobules periglandular fibrosis 86 143 144 infections including oral sources frequent complication hsct 70 76 92 risk factors obtaining infections include underlying malignant disease medical condition comorbidities presence chronic latent infections type transplant source stem cells use antimicrobials mucosal barrier loss immunosuppression myelosuppression induced hsct conditioning gvhd and/or gvhd management one depends nonspecific defenses integrity surface barriers presence systemic salivary antimicrobial agents defensins the major defense infections immune system virtually components deficient hsct suppressed immunosuppressive therapy prevent gvhd uncomplicated recovery starts healing mucosal tissues recovery granulocytes nk cells two weeks myeloablative conditioning however cell b cell immune responses viral bacterial fungal organisms may suppressed prolonged period time particularly setting gvhd oral infections may associated wide variety microorganisms including bacteria fungi viruses virtually may give rise systemic infectious complications transplant population the time occurrence appearance lesions may contribute differential diagnosis however coexistent oral conditions om gvhd often complicate adequate prompt diagnosis opportunistic infections as described previously oral bacterial flora changes following chemotherapy cohort 37 allogeneic hsct recipients significant increase oral colonization potentially pathogenic microorganisms predominantly enterococcus faecalis candida spp ) it important aware modified clinical symptomatology bacterial infections neutropenic phase hsct erythema pain edema fever may clinical signs otherwise purulent infection om acknowledged principal risk factor bacteremia due oral viridans streptococci ovs bacteremia cons may also originate oral cavity in addition infections related oral mucosa chronic infections associated dentition may give rise complications periodontal infections particular may represent easily overlooked source bacteremia systemic infection neutropenic patients 150 151 periodontal infection inflammation may contribute risk developing ovs cons bacteremia neutropenia following hsct moreover reported positive association p. gingivalis om suggests least mucosal reaction bacterial challenge anecdotal evidence dental infection inflammation also contribute oral gvhd candidiasis typically caused opportunistic overgrowth c. albicans commensal oral yeast it may associated dry mouth taste disturbances mucosal discomfort 153 154 several variables contribute clinical expression including immunosuppression mucosal injury salivary dysfunction in addition antibiotics may alter oral flora thereby creating favorable environment fungal overgrowth the common forms intraoral candidiasis reported oncology patients pseudomembranous erythematous candidiasis current prophylactic strategies reduced systemic candidiasis although oropharyngeal esophageal infections remain common complication potentially serious consequences it recognized different candida species provoke different immunologic reactions making strains virulent others oral infection candida villar et al demonstrated highly invasive strains c. albicans triggered higher levels proinflammatory cytokines including il-1 il-6 il-8 tnf- epithelial cells il-6 il-8 monocyte chemotactic protein- mcp- 1 mcp-2 granulocyte colony stimulating factor gcsf endothelial cells c. glabrata associated oral ulcerations hsct recipients described laheij et al also identified c. kefyr positive predictive value mucosal ulcerations prevalence unknown larger populations did report positive correlation candida colonization presence severity om hsct patients these results indicate role candida species pathogenesis om remains elucidated detail interestingly van der velden et al suggested mycobiome role pathogenesis agvhd colonization mucosa may trigger intestinal agvhd potentially induction th17/il-23 responses activation pattern recognition receptors fungal motifs whether also may occur oral cavity noncandidal fungal organisms may also associated oral infection immunocompromised cancer patients including infection species aspergillus mucormycosis rhizopus lesions associated fungi may resemble om lesions detailed microbiologic documentation needed moreover viruses may give rise systemic infectious complications may trigger gvhd 167 168 often herpes simplex virus hsv varicella zoster virus vzv epstein barr virus ebv infections result reactivation latent virus cytomegalovirus cmv infections result either virus reactivation via newly acquired virus this reduces viral shedding herpetic lesions although reactivation still possible patients receiving prophylaxis when reactivation hsv-1 occurs ulcers may develop aggravate om may confused condition rping et al studied association il-1 tnf- oral saliva viral pathogens severity ulcerations autologous hsct similarly van der beek et al reported oral shedding hsv-1 predicts ulcerations however studies patients receive antiviral prophylaxis whereas hsct recipients getting acyclovir prophylaxis hsv seems major etiologic agent ulcerative om like hsv-1 -2 vzv latent neurons viral particles transported via axons mucosa virus continues replicating epithelial cells increased risk vzv reactivation extends three twelve months transplant allogeneic transplant recipients highest risk salivary glands seem important reservoir cmv virus shed saliva infected saliva main mechanism transmitting cmv correia silva et al found positive correlation cmv dna loads saliva blood allogeneic hsct recipients although recent study find correlation cmv oral rinsing samples oral ulcerations oral ulceration due cmv cases coinfection hsv cmv oral ulcers reported cmv infection causes monocyte cell activation activation tnf system concomitant increase plasma levels il-10 moreover cmv may modulate immunological status host cells inducing local production proinflammatory cytokines tnf il-1 il-6 il-8 il-10 180 181 liu et al investigated mechanism cmv specific cell immune responses hsct cmv specific cd8 cells they could define critical threshold absolute number cmv specific cd8 cells protect cmv reactivation hsct recipients may risk developing ebv related lymphomas ebv associated carcinomas head neck region posttransplantation lymphoproliferative disorder ptld common malignancy first year following allogeneic hsct oral involvement ptld rare may manifest crater like gingival defect ulcerated dark red mass in addition oral hairy leukoplakia attributed ebv infection hsct recipients oral lesions caused nonherpes viruses including adenovirus human papilloma virus hpv described a case rapidly enlarging biopsy documented oral verruca vulgaris patient undergoing myeloablative hsct reported taste dysfunction dysgeusia negatively influences qol may lead impaired nutrition weight loss conditioning regimen related dysgeusia typically associated onset om resolves one two months following hsct taste disorders may persist develop de novo allogeneic hsct recipients patients may report rapid decrease sense taste temporally associated onset exacerbation cgvhd suggesting epithelial derived taste receptor cell immune based target antibiotics may negative impact taste whereas drugs used prevent treat gvhd e.g. cyclosporine mtor inhibitors also induce neurological changes result altered taste with increased numbers survivors late effects hsct concomitant therapies become increasing importance hyposalivation may persist associated salivary gland cgvhd putting patients risk rapidly progressing dental demineralization caries in addition disturbances tooth formation jaw growth development may present pediatric hsct survivors among late effects second malignancies recognized including ptld hematologic malignancies solid tumors solid tumors may develop many years hsct vast majority cases oral tumors squamous cell carcinomas scc several authors described cases scc oral skin sites previously affected cgvhd related inflammatory processes suggesting cgvhd risk factor in addition prolonged immunosuppressive therapy may contribute scc risk large retrospective study hsct recipients 20- 30-fold risk oral cancer 10 years allogeneic hsct changes oral mucosa due gvhd make early detection diagnosis scc clinically challenging long term follow hsct patients recommended detect cancers early stage patients informed cancer risk educated avoid life styles potentiate risk developing oral scc better understanding pathobiology complications risk factors necessary order develop efficient preventative therapeutic strategies hsct conditioning regimens important parameters determining om risk patients differ considerably susceptibility develop severe om exciting progress made predicting individual genetic risk severe om following conditioning autologous hsct sonis et al recently identified snp based bayesian network developed saliva sourced dna studies larger number hsct recipients may ultimately result clinically useful saliva based tool predicting severe om addition studies evaluating role oral microbiome maintaining oral homeostasis versus aggravating om promising recently suggested cancer regimen related adverse events occur isolation rather develop clusters toxicities may related regard time development may also causal relationships one toxicity predisposes subsequent complication moreover toxicities cancer treatment may common pathobiological background share genetically determined risk factors discussed inflammation particularly upregulation proinflammatory cytokine pathways is major common driver complications hsct recipients interventions blocking pathways may affect multiple complications oral complications seem interrelated include om hyposalivation taste alterations oral infections oral gvhd although past studies focused isolated toxicities research necessary assess nature relationships oral complications also link complications involving nonoral tissues well manifesting systemically example neutropenic hsct recipients om associated bacteremia fever sepsis such associations may least part explain observation om associated increased risk early nontumor related mortality hsct recipients 6 64 65 in addition genetic predisposition multiple inflammatory complications hsct presence inflammation may lead dysregulated exaggerated inflammatory response following subsequent inflammatory stimulus interestingly recent study reported time diagnosis acute leukemia high prechemotherapy plasma levels pro- anti inflammatory cytokines low levels antimicrobial protein pro ll-37 associated highest om risk suggesting proinflammatory state preceding high dose chemotherapy may predispose complications similarly proposed periodontitis present initiation cancer treatment may coinduce exaggerated inflammatory response following chemo)radiation patients head neck cancer leading severe om it well established periodontal disease induces low grade systemic inflammation characterized increased levels proinflammatory cytokines acute phase proteins peripheral blood reviewed van dyke winkelhoff 2013 this result bacteria bacterial inflammatory products translocating inflamed ulcerated pocket epithelium circulation periodontitis om may associated primed inflammatory response proposed two hit model the model previously used explain pathogenesis acute respiratory distress syndrome ards following cardiopulmonary bypass association periodontitis inflammation driven systemic diseases including rheumatoid arthritis 200 201 likewise hypothesized oral infections including periodontitis may predispose om hsct recipients taking concept step may speculated inflammatory conditions oral elsewhere either present cytotoxic therapy developing result therapy may predispose inflammation driven acute late complications hsct recipients for example anecdotal evidence periodontal inflammation triggers oral gvhd whereas gvhd ameliorates periodontal foci infection eliminated likewise periodontitis and/or om may involved sepsis risk even absence bacteremia although relationship gastrointestinal mucositis fever increased levels inflammatory markers absence bacteremia proposed 57 202 relative contribution om systemic inflammation remains investigated explore hypotheses longitudinal observational studies involving large numbers patients looking associations oral nonoral complications potentially common underlying mechanisms furthermore investigations using novel techniques provide opportunity evaluate role oral gastrointestinal microbiome mucositis gvhd together studies aimed assessing relationship microbiome host factors including epithelial defense mechanisms may lead successful strategies prevent ameliorate complications moreover longitudinal studies using salivary samples may identify genetic risk factors om well regimen related complications addition studies may identify salivary biomarkers may predict facilitate diagnosis om gvhd response therapy conclusion a holistic approach includes clinical translational studies oral well nonoral complications hsct may lead better understanding potential commonalities complications may open new avenues prevention treatment	hematopoietic stem cell transplantation ( hsct ) is widely used as a potentially curative treatment for patients with various hematological malignancies , bone marrow failure syndromes , and congenital immune deficiencies . the prevalence of oral complications in both autologous and allogeneic hsct recipients remains high , despite advances in transplant medicine and in supportive care . frequently encountered oral complications include mucositis , infections , oral dryness , taste changes , and graft versus host disease in allogeneic hsct . oral complications are associated with substantial morbidity and in some cases with increased mortality and may significantly affect quality of life , even many years after hsct . inflammatory processes are key in the pathobiology of most oral complications in hsct recipients . this review article will discuss frequently encountered oral complications associated with hsct focusing on the inflammatory pathways and inflammatory mediators involved in their pathogenesis .
pulmonary perfusion altered physiological pathological conditions pulmonary embolism pulmonary hypertension chronic obstructive disease therefore assessment pulmonary perfusion physiological clinical importance lung large diffuse inhomogeneous organ it one techniques magnetic resonance imaging mri 20 years mri two principal techniques established arterial spin labeling contrast enhanced perfusion especially tremendous technical developments recents years regarding hardware new sequences make mr based perfusion imaging broadly available therefore review article elucidate current state art sequences clinical applications future developments technique mr offers possibility mark specific part spins magnetically selective radiofrequency rf excitation leading specific magnetisation selected fraction blood this technique called arterial spin labeling asl requires intravenous application contrast material therefore considered completely non invasive it advantage measurements made repeatedly short time periods seconds the absence contrast also means measurements repeated indefinitely cleared blood reimaging possible also absolute number measurements limited total amount contrast material applied 1 day there limitations techniques 1 difficult implement compared dynamic contrast enhanced imaging 2 requires regular cardiac cycle 3 single slice technique 58 slices acquired cover whole lung 4 limited voxel resolution i.e. 5 5 30 mm essence two ecg gated images selected slice taken 58 apart single apnea the two images differ way tagging radiofrequency rf pulses change signal blood flowing imaged section keeping signal stationary structures unchanged images subtraction two images leaves image signal volume element voxel proportional amount pulmonary arterial blood delivered previous heart cycle 3 511 principle true fast imaging steady precession true fisp sequences particular found ideally suited assessment pulmonary perfusion specific types asl techniques allow quantification regional pulmonary perfusion single breath hold called flow sensitive alternating inversion recovery fair flow sensitive alternating inversion recovery extra radio frequency rf pulse fairer perfusion weighted images obtained subtraction control tag images interleaved acquired within one breathholding period 2027 slice cardiac motion pulsatile flow descending aorta generate smearing flow artefacts respectively spatial variation control images can lead ghosting blood vessels spatial movement control tag images causes appearance adjacent dark bright pairs blood vessels a closely related technique called t1 method also used measure pulmonary perfusion fig 1 14 15 it differs primarily experiment conceptualised delivery bolus tagged spins apparent alteration longitudinal relaxation time perfusion weighted images acquired single shot completely saturating static background tissue image acquisition the decrease lung t1 values slice position global selective experiment statistically significant results wash effect noninverted blood water h spins outside imaging slice because perfusion weighted image acquired single shot artefacts arising patient motion different respiratory levels avoided furthermore short acquisition times 5 per slice required perfusion weighted image facilitating rapid comfortable examinations this especially important lung imaging patients able hold breath seconds.fig 1arterial spin labeling asl image healthy volunteer sagittal orientation right lung the spatial resolution 3.9 3.9 10 mm allows visualisation major minor fissure hand the signal noise ratio low making detailed evaluation difficult arterial spin labeling asl image healthy volunteer sagittal orientation right lung the spatial resolution 3.9 3.9 10 mm allows visualisation major minor fissure hand the signal noise ratio low making detailed evaluation difficult asl based techniques allow calculation relative pulmonary blood flow rpbf ml/100 g min 12 16 17 conversion rpbf pbf the lung density required usually assumed constant 0.33 g ml functional residual capacity however normal values reported range 5.5 ml g min using rapid ir snapshot flash technique a spin labeling method within imaging slice used combination simple two compartment lung tissue model the measured pulmonary perfusion rates healthy lung parenchyma order 400 600 ml/100 g min depending subject investigated actual slice position lung in healthy volunteers n 6 quantitative comparison non contrast enhanced contrast enhanced techniques performed two coronal slices middle dorsal part lung ) were assessed maps relative pulmonary blood flow rpbf calculated absolute perfusion measures calculated placing ten regions interest lung right left perfusion ratio analysis performed dorsal slice the middle position however showed 1643% underestimation fair derived rpbf right lung this explained tracer saturation right lung right pulmonary artery plane pulses needed tagging readout internal control this difference present slices acquired sagittal orientation based strength limitations noted above strength techniques lies ability study physiological aspects lung perfusion regional level 2124 important perfusion studies notice snr asl images low particularly anterior portions lung therefore positioning patient area interest gravity may increase snr improve visibility perfusion defects also signal intensity subsequently perfusion increases examination end expiratory breath hold compared end inspiratory breath hold 25 26 normal aging associated decline pulmonary function efficiency gas exchange the effect aging spatial heterogeneity pulmonary perfusion studied 56 healthy non smoking volunteers age range 2176 years relative dispersion increased significantly increasing age 0.1/decade age 5059 years significant positive relationship relative dispersion age found therefore possible investigate age related parenchymal changes cause phenomenon in early study keilholz et al demonstrated ability asl depict gravity dependent perfusion effects healthy volunteers placed inside scanner right left lateral side coronal images acquired within 10-s breath hold using fairer haste sequence positions an increase intensity dependent lung found 229% left lateral 40% right lateral a pulmonary emboli model introduced using balloon catheter placed left pulmonary artery after occlusion left pulmonary artery set fairer images followed contrast enhanced angiography performed huge perfusion defect whole left lung ) it noted 8 required single slice asl 3d acquisition contrast enhanced perfusion needed 30 s. similar experiment done 5 rabbits asl perfusion ventilation images using hyperpolarised 3helium assessed after occlusion pulmonary artery balloon catheter ventilation unchanged asl perfusion images demonstrated large perfusion defect patients susceptible high altitude pulmonary oedema hape possible demonstrate uneven hypoxic pulmonary vasoconstriction compared non susceptible patients assessing relative dispersion blood flow up reports exist clinical application non contrast enhanced perfusion techniques due lengthy acquisition times relatively low signal increase it may imaging technique choice pregnant women rule pulmonary emboli however stetting native imaging techniques like steady state free precession sequences also showed good clinical potential therefore main application exploration physiological processes possibility unrestricted measurements outweighs prolonged acquisition time mr offers possibility mark specific part spins magnetically selective radiofrequency rf excitation leading specific magnetisation selected fraction blood this technique called arterial spin labeling asl requires intravenous application contrast material therefore considered completely non invasive it advantage measurements made repeatedly short time periods seconds the absence contrast also means measurements repeated indefinitely cleared blood reimaging possible also absolute number measurements limited total amount contrast material applied 1 day there limitations techniques 1 difficult implement compared dynamic contrast enhanced imaging 2 requires regular cardiac cycle 3 single slice technique 58 slices acquired cover whole lung 4 limited voxel resolution i.e. 5 5 30 mm essence two ecg gated images selected slice taken 58 apart single apnea the two images differ way tagging radiofrequency rf pulses change signal blood flowing imaged section keeping signal stationary structures unchanged images subtraction two images leaves image signal volume element voxel proportional amount pulmonary arterial blood delivered previous heart cycle 3 511 principle true fast imaging steady precession true fisp sequences particular found ideally suited assessment pulmonary perfusion specific types asl techniques allow quantification regional pulmonary perfusion single breath hold called flow sensitive alternating inversion recovery fair flow sensitive alternating inversion recovery extra radio frequency rf pulse fairer perfusion weighted images obtained subtraction control tag images interleaved acquired within one breathholding period 2027 slice cardiac motion pulsatile flow descending aorta generate smearing flow artefacts respectively spatial variation control images can lead ghosting blood vessels spatial movement control tag images causes appearance adjacent dark bright pairs blood vessels a closely related technique called t1 method also used measure pulmonary perfusion fig 1 14 15 it differs primarily experiment conceptualised delivery bolus tagged spins apparent alteration longitudinal relaxation time perfusion weighted images acquired single shot completely saturating static background tissue image acquisition the decrease lung t1 values slice position global selective experiment statistically significant results wash effect noninverted blood water h spins outside imaging slice because perfusion weighted image acquired single shot artefacts arising patient motion different respiratory levels avoided furthermore short acquisition times 5 per slice required perfusion weighted image facilitating rapid comfortable examinations this especially important lung imaging patients able hold breath seconds.fig 1arterial spin labeling asl image healthy volunteer sagittal orientation right lung the spatial resolution 3.9 3.9 10 mm allows visualisation major minor fissure hand the signal noise ratio low making detailed evaluation difficult arterial spin labeling asl image healthy volunteer sagittal orientation right lung the spatial resolution 3.9 3.9 10 mm allows visualisation major minor fissure hand asl based techniques allow calculation relative pulmonary blood flow rpbf ml/100 g min 12 16 17 conversion rpbf pbf the lung density required usually assumed constant 0.33 g ml functional residual capacity however normal values reported range 5.5 ml g min using rapid ir snapshot flash technique a spin labeling method within imaging slice used combination simple two compartment lung tissue model the measured pulmonary perfusion rates healthy lung parenchyma order 400 600 ml/100 g min depending subject investigated actual slice position lung in healthy volunteers n 6 quantitative comparison non contrast enhanced contrast enhanced techniques performed two coronal slices middle dorsal part lung assessed maps relative pulmonary blood flow rpbf calculated absolute perfusion measures calculated placing ten regions interest lung right left perfusion ratio analysis performed dorsal slice the middle position however showed 1643% underestimation fair derived rpbf right lung this explained tracer saturation right lung right pulmonary artery plane pulses needed tagging readout internal control based strength limitations noted clinical application far limited however strength techniques lies ability study physiological aspects lung perfusion regional level 2124 important perfusion studies notice snr asl images low particularly anterior portions lung therefore positioning patient area interest gravity may increase snr improve visibility perfusion defects also signal intensity subsequently perfusion increases examination end expiratory breath hold compared end inspiratory breath hold 25 26 normal aging associated decline pulmonary function efficiency gas exchange the effect aging spatial heterogeneity pulmonary perfusion studied 56 healthy non smoking volunteers age range 2176 years relative dispersion increased significantly increasing age 0.1/decade age 5059 years significant positive relationship relative dispersion age found therefore possible investigate age related parenchymal changes cause phenomenon early study keilholz et al healthy volunteers placed inside scanner right left lateral side coronal images acquired within 10-s breath hold using fairer haste sequence positions an increase intensity dependent lung found 229% left lateral 40% right lateral a pulmonary emboli model introduced using balloon catheter placed left pulmonary artery after occlusion left pulmonary artery set fairer images followed contrast enhanced angiography performed huge perfusion defect whole left lung ) it noted 8 required single slice asl 3d acquisition contrast enhanced perfusion needed 30 s. similar experiment done 5 rabbits asl perfusion ventilation images using hyperpolarised 3helium assessed after occlusion pulmonary artery balloon catheter ventilation unchanged asl perfusion images demonstrated large perfusion defect patients susceptible high altitude pulmonary oedema hape possible demonstrate uneven hypoxic pulmonary vasoconstriction compared non susceptible patients assessing relative dispersion blood flow up reports exist clinical application non contrast enhanced perfusion techniques due lengthy acquisition times relatively low signal increase it may imaging technique choice pregnant women rule pulmonary emboli however stetting native imaging techniques like steady state free precession sequences also showed good clinical potential therefore main application exploration physiological processes possibility unrestricted measurements outweighs prolonged acquisition time mri contrast enhanced lung perfusion realised rapid imaging first pass contrast material lungs intravenous bolus injection two dimensional approaches acquired fast fashion 0.3 slice hand lack sufficient spatial resolution anatomic coverage characterise perfusion defects inhomogeneities purpose 3d techniques mandatory visualise peak enhancement lungs temporal resolution contrast enhanced mri lung perfusion transit time contrast bolus lungs range 3 4 additionally clinical usage reasonable spatial resolution anatomic coverage required allow visualisation perfusion changes segmental level the frequently used technique 3d gradient echo pulse sequence flash short te tr resulting temporal resolution 1.0 1.5 3d data set dependent used slice thickness 10 mm 5 mm 34 35 improvements k space sampling techniques use parallel imaging techniques allow increased spatial resolution without reduction temporal resolution a second strategy use echo sharing like treat low frequency k space data updated often high frequency k space data interpolated consecutive time frames thus leading effective shortening total acquisition time image quality techniques assessed nine patients using temporal resolution voxel size was decreased 24% treat data sets compared standard perfusion technique techniques used parallel imaging acceleration factor 2 central peripheral vascular perception intermodality comparison showed good agreement kappa 0.74 14 patients various diseases copd lung cancer etc three k space acquisition techniques compared image quality snr 1 generalised autocalibrating partial parallel acquisition grappa internal acquisition reference lines 2 grappa single external acquisition reference lines measurement 3 combination grappa internal acquisition reference lines view sharing all examinations performed ten healthy volunteers 5 ml gadubutrol injection speed 2.5 ml constant voxel size 3.9 3.9 5 mm 1.5 t furthermore temporal resolution shortest 1.07 s. far studies used 0.1 mmol gd dtpa kg bodyweight visualisation pulmonary perfusion different amounts contrast media 0.05 mmol kg bodyweight 0.1 mmol kg bodyweight contrast media concentrations 0.5 mmol l 1 mmol l injection protocols 2.5 ml 5 ml compared 10 healthy volunteers analysing signal noise ratio difference found different contrast media concentrations giving injection speed contrast agents a dose 0.1 mmol kg bodyweight superior half dose protocol combination rapid injection 5 ml highest snr vascular segments achieved regarding contrast media injection speed small bolus profile fast attenuation lung parenchyma optimal it found increased speed mean transit time mtt pulmonary arteries decreased significantly however decrease linear four fold increase injection rate led two fold decrease mtt in study found cardiac function parameters significant influence bolus profile overall injection speed 3 ml recommended pulmonary perfusion basic post processing improvement visualisation perfusion done subtraction data set highest signal intensity baseline data set fig 2 in cases allows rapid analysis clinical situation patient however detailed analysis therapy monitoring presurgical estimation regional pulmonary function quantitative analysis important a summary frequently used contrast media injection regimens provided table 1.fig subtraction data sets c results image suppressed background therefore enhanced perfusion the 3d nature data sets allow reformation plane like axial sagittal e)table 1summary used contrast media injection protocols spatial resolution perfusion weighted mrinjection speed ml s]dosespatial resolution mm]reference2.55 ml gadubutrol3.9 3.9 555 ml magnevist1.9 1.8 1030.05 mmol kg bw magnevist3.9 3.9 6.340.125 mmol kg bw magnevist2.9 1.6 1055 ml omniscan1.9 1.8 1250.1 mmol kg bw magnevist3.5 1.9 450.1 mmol kg bw magnevist1.9 3.8 3.650.1 mmol kg bw multihance1.9 3.8 43 53 5 ml magnevist1.9 1.8 1050.1 mmol kg bw omniscan1.9 3.6 4 concept subtraction perfusion images healthy voluneer subtraction data sets c results image suppressed background therefore enhanced perfusion the 3d nature data sets allow reformation plane like axial sagittal e summary used contrast media injection protocols spatial resolution perfusion weighted mr quantification pulmonary perfusion based indicator dilution theory maximum signal intensity temporal course signal change used quantification arterial input function aif defined placing region interest roi main pulmonary artery the tissue response function lung parenchyma either determined multiple single small rois better whole lung assuming linear relation signal concentration contrast agent signal time curves converted concentration time curves hypothesising negligible amount extravasating contrast agent first pass bolus lungs principles indicator dilution theory applicable the central volume theorem states relationship perfusion parameters regional pulmonary blood flow pbf ml/100 ml lung tissue min regional pulmonary blood volume pbv ml/100 ml lung tissue mean transit time mtt s):\documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ mtt \frac{{pbv}}{{pbf \end{document regional pbv calculated normalising area tissue concentration time curve integral arterial input function aif:\documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ pbv \frac{{\int c(t)dt \int aif(t)dt \end{document consideration finite length bolus dispersion way tissue volume relationship aif tissue concentration time curve described convolution aif residue function r(t):\documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ c(t pbf\int aif(\tau \bullet r(t \tau d\tau \end{document}where r(t amount contrast agent remaining tissue time t. pbf therefore initial height r(t 0 respectively maximum r(t case delay aif(t c(t assessed deconvolving aif(t c(t the deconvolution last equation performed using singular value decomposition svd model independent nonparametric deconvolution analysis potentiality reducing noise contribution applying suitable threshold singular value matrix this method shown reliable results first pass bolus tracking clinical studies however spatial distribution underlying lung disease unknown lung perfusion quantification required entire lung e.g. assess side differences lung perfusion measurement limited lung sample small roi reflect poor estimate lung perfusion one study used cross correlation analysis cca perfusion data sets suppression central pulmonary vessels cca previously used improve snr arteriovenous separation time resolved mr angiography 48 49 it shown feasible identify vessels similar signal intensity time curve reference vessel using cca for purpose reference rois drawn pulmonary artery pulmonary vein the quantification pbv pbf resulted average reduction 25% pbv 15% pbf compared segmentations without vessel exclusion a comparison manual exclusion vessel structures cca revealed average reduction 13% pbv 8% pbf the reduction applying cca significant p 0.001 compared results manual without blood vessel exclusion calculated parameters basically quantitative perfusion evaluation signal time curves converted concentration time curves this especially important arterial input function contrast media passes compact bolus linear relationship however seen small range concentrations 3 4 5 mmol l seen vitro experiments 5153 the linearity signal concentration dependent sequence parameters used like te thus use saturation recovery prepared flash sequence proposed often used myocardial perfusion imaging improve linearity measurements thus contrast noise ratio cnr higher doses applied volunteers usage 0.057 mmol kg bodyweight feasible animal experiment found already 0.05 mmol gd dtpa kg bodyweight resulted vivo concentrations outside linearity range however comparing quantitative measures 0.05 mmol kg bodyweight values high compared results pet pbf found 121 ml min/100 ml pbv 1720 ml/100 ml prospective trial different injection protocols contrast media concentrations investigated compared quantitative analysis perfusion spect the amount mr contrast bolus fixed 5 ml injection speed 5 ml followed 20 ml saline flush it found patients weighing less 70 kg concentration 0.3 mmol ml showed highest accordance spect 0.5 mmol ml patients weighing 70 kg however study used 10-mm thick slice partitions therefore small amount 5 ml contrast media resulted appropriate contrast noise ratio another solution complex problem usage dual bolus approach experiment the arterial input function determined low volume application contrast media i.e. 0.01 mmol kg bodyweight achieve linear relationship contrast agent concentration signal intensity large pulmonary vessels this followed boluses higher doses obtain sufficient cnr lung tissue this may allow absolute quantification well visual analysis perfusion lung tissue often possible single low dose used absolute perfusion quantification the drawback approach small therefore short bolus i.e. 1.5 ml arterial input function requires extremely high temporal resolution perfusion sequence asses peak signal the combination small prebolus 0.01 mmol kg bodyweight main bolus 0.04 mmol kg bodyweight resulted perfusion parameters best comparable literature data a combination prebolus main bolus 0.08 mmol kg bodyweight resulted underestimation pbv for perfusion imaging lung optimal combination temporal resolution contrast noise ratio essential it found temporal resolution approximately 2 achieved correct application deconvolution algorithm the influence noise data especially relevant estimates pbf high noise levels i.e. low cnr values lead substantial underestimation significant loss accuracy pbf estimates it concluded assessment pbf might benefit less aggressive acceleration example lower acceleration factor 2 the cnr notably increased larger voxel sizes employed voxel size thus chosen large clinically acceptable repeatability quantitative perfusion measurements tested two patient groups one large volunteer study one study ten patients bronchioalveolar carcinoma scanned twice within 3 days inspiratory breath hold evaluation performed manually placing three regions interest data set excellent agreement measurements ten patients pulmonary hypertension scanned 3 weeks initial scan three dimensional perfusion data sets acquired inspiratory breath hold evaluation comprised whole lung fourteen volunteers examined twice 24 h inspiratory expiratory breath hold no significant difference found pair measurements performed expiration evaluated observer therefore broad usage technique automatic segmentation approach assisting evaluation developed especially data sets with pathologically changed perfusion i.e. peripheral perfusion defects automatic segmentation algorithms difficult implemented these contours applied perfusion data sets image registration haste perfusion images this reduced time needed evaluation perfusion data sets approximately 10 min however technique applied data sets healthy volunteers reproducibility experiments performed so far mr perfusion lung parenchyma performed 1.5 t. given benefits higher field strengths like 3 higher snr expected beneficial regarding quantification allows increase spatial resolution clinical routine contrast enhanced perfusion easily applied visual assessment disease characteristics qualitative approach the discussion temporal resolution contrast media dose obsolete performed mr scanner perfusion defects due vascular obstruction show typical wedge shape including lung periphery fig 3 in 41 patients acute pe agreement mr perfusion single photon emission computed tomography spect perfusion perfusion defects subsegmental level assessed mr perfusion showed high agreement spect kappa value per examination 0.98 0.98 0.83 0.69 lobar segmental subsegmental perfusion defects respectively quantitative segmental perfusion analysis patients acute pulmonary embolism possible determine obstruction index this perfusion based index showed higher correlation clinical severity also significant predictor outcome this initial report brings mr perfusion pole position discussed new modality choice pe assessment furthermore radiation free technique optimally suited follow studies treatment monitoring visual evaluation also sufficient differentiate different causes pulmonary hypertension ph like pah chronic thromboembolic ph cteph perfusion diffusely reduced pah focal defects occurred cteph fig 4 fig 5 in 45 patients moderate severe copd perfusion matched parenchymal alterations demonstrated mdct high agreement lobar level was found parenchymal destruction reduction perfusion patients severe emphysema kappa 0.8 patients cystic fibrosis the functional score based visual evaluation perfusion defects showed acceptable intra- interreader agreement concordance correlation coefficient 0.89 0.8 respectively .fig 3coronal 10-mm maximum intensity projection mip image patient follow examination acute pulmonary emboli there residual occlusion middle lobe leading wedge shaped perfusion defect right there also residual subtotal obstructions noted left upper lower lobe characterised reduced perfusionfig absolute quantification perfusion parameters pulmonary blood flow b pulmonary blood volume especially pulmonary blood flow nicely pronounces area perfusion defect well areas reduced perfusion original perfusion weighted data set presented maximum intensity projection see fig 5patient pulmonary arterial hypertension pulmonary blood flow b pulmonary blood volume however subpleural perfusion still present wedge shaped perfusion defects seen c original perfusion weighted data set presented 10 mm maximum intensity projection coronal 10-mm maximum intensity projection mip image patient follow examination acute pulmonary emboli there residual occlusion middle lobe leading wedge shaped perfusion defect right there also residual subtotal obstructions noted left upper lower lobe characterised reduced perfusion patient fig absolute quantification perfusion parameters pulmonary blood flow b pulmonary blood volume especially pulmonary blood flow nicely pronounces area perfusion defect well areas reduced perfusion original perfusion weighted data set presented maximum intensity projection see fig 3 patient pulmonary arterial hypertension pulmonary blood flow b pulmonary blood volume however subpleural perfusion still present wedge shaped perfusion defects seen c original perfusion weighted data set presented 10 mm maximum intensity projection semi quantitative analysis 3d perfusion data sets eight healthy volunteers allowed calculation left right perfusion ratio ratio 0.9 confirmed phase contrast flow measurements furthermore shorter transit time higher peak signal found dorsal lung regions quantitative evaluation perfusion compared perfusion scintigraphy assessment left right perfusion ratios 23 patients various lung diseases the mr estimations left right perfusion ratios correlated significantly perfusion scintigraphy scans p 0.01 the mr ratios computed pbf showed highest accuracy followed peak concentration pbv one important clinical field perfusion assessment estimation post surgical lung function example lung cancer resection so far perfusion scintigraphy routinely used purpose 60 patients lung cancer mr outperformed scintigraphy assessment postoperative fev 1 r 0.93 r 0.89 respectively therefore concluded perfusion mr feasible alternative pulmonary perfusion scintigraphy predicting postoperative lung function patients lung cancer however ventro dorsal perfusion gradient observed explained inclusion central pulmonary vessels evaluation application vasodilatative agent inhalation 100% oxygen ) a significant increase redistribution pulmonary perfusion found ten healthy volunteers therefore mr perfusion seems suited estimation therapy response patients ph administration vasodilatative drugs group 13 copd patients the pulmonary perfusion found heterogeneously altered pbf pbv significantly reduced mtt prolonged despite pure quantification another aspect perfusion although harder establish degree homogeneity patients susceptible high altitude pulmonary oedema hape ) the perfusion inhomogeneity compared hape resistant volunteers hape patients 2 h hypoxia equivalent altitude 4,500 parameters indicating perfusion inhomogeneity increased hypoxia populations particularly hape subjects increased significantly almost evaluations therefore kind analysis although yet broadly used may important future applications diseases peripheral vasoconstriction like pulmonary hypertension so far conventional perfusion parameters assessed patients pulmonary hypertension compared healthy aged matched volunteers perfusion parameters different patients pulmonary hypertension reduced pbf pbv increased mtt 74 75 only mtt showed moderate linear relationship mpap r 0.54 r 0.56 respectively it remains determined perfusion mr might role follow treatment however large data sets difficult handle even visual evaluation might challenging therefore future developments needs aim providing easy use post processing utilities visual quantitative evaluation mri contrast enhanced lung perfusion realised rapid imaging first pass contrast material lungs intravenous bolus injection two dimensional approaches acquired fast fashion 0.3 slice hand lack sufficient spatial resolution anatomic coverage characterise perfusion defects inhomogeneities purpose 3d techniques mandatory visualise peak enhancement lungs temporal resolution contrast enhanced mri lung perfusion transit time contrast bolus lungs range 3 4 additionally clinical usage reasonable spatial resolution anatomic coverage required allow visualisation perfusion changes segmental level the frequently used technique 3d gradient echo pulse sequence flash short te tr resulting temporal resolution 1.0 1.5 3d data set dependent used slice thickness 10 mm 5 mm 34 35 improvements k space sampling techniques use parallel imaging techniques allow increased spatial resolution without reduction temporal resolution a second strategy use echo sharing like treat low frequency k space data updated often high frequency k space data interpolated consecutive time frames thus leading effective shortening total acquisition time image quality techniques assessed nine patients using temporal resolution voxel size was decreased 24% treat data sets compared standard perfusion technique techniques used parallel imaging acceleration factor 2 central peripheral vascular perception intermodality comparison showed good agreement kappa 0.74 14 patients various diseases copd lung cancer etc three k space acquisition techniques compared image quality snr 1 generalised autocalibrating partial parallel acquisition grappa internal acquisition reference lines 2 grappa single external acquisition reference lines measurement 3 combination grappa internal acquisition reference lines view sharing all examinations performed ten healthy volunteers 5 ml gadubutrol injection speed 2.5 ml constant voxel size 3.9 3.9 5 mm 1.5 t furthermore temporal resolution shortest 1.07 s. far studies used 0.1 mmol gd dtpa kg bodyweight visualisation pulmonary perfusion different amounts contrast media 0.05 mmol kg bodyweight 0.1 mmol kg bodyweight contrast media concentrations 0.5 mmol l 1 mmol l injection protocols 2.5 ml 5 ml compared 10 healthy volunteers analysing signal noise ratio difference found different contrast media concentrations giving injection speed contrast agents a dose 0.1 mmol kg bodyweight superior half dose protocol combination rapid injection 5 ml highest snr vascular segments achieved regarding contrast media injection speed small bolus profile fast attenuation lung parenchyma optimal it found increased speed mean transit time mtt pulmonary arteries decreased significantly however decrease linear four fold increase injection rate led two fold decrease mtt in study found cardiac function parameters significant influence bolus profile overall injection speed 3 ml recommended pulmonary perfusion basic post processing improvement visualisation perfusion done subtraction data set highest signal intensity baseline data set fig 2 in cases allows rapid analysis clinical situation patient however detailed analysis therapy monitoring presurgical estimation regional pulmonary function quantitative analysis important a summary frequently used contrast media injection regimens provided table 1.fig subtraction data sets c results image suppressed background therefore enhanced perfusion the 3d nature data sets allow reformation plane like axial sagittal e)table 1summary used contrast media injection protocols spatial resolution perfusion weighted mrinjection speed ml s]dosespatial resolution mm]reference2.55 ml gadubutrol3.9 3.9 555 ml magnevist1.9 1.8 1030.05 mmol kg bw magnevist3.9 3.9 6.340.125 mmol kg bw magnevist2.9 1.6 1055 ml omniscan1.9 1.8 1250.1 mmol kg bw magnevist3.5 1.9 450.1 mmol kg bw magnevist1.9 3.8 3.650.1 mmol kg bw multihance1.9 3.8 43 53 5 ml magnevist1.9 1.8 1050.1 mmol kg bw omniscan1.9 3.6 4 concept subtraction perfusion images healthy voluneer subtraction data sets c results image suppressed background therefore enhanced perfusion the 3d nature data sets allow reformation plane like axial sagittal e summary used contrast media injection protocols spatial resolution perfusion weighted mr quantification pulmonary perfusion based indicator dilution theory maximum signal intensity temporal course signal change used quantification arterial input function aif defined placing region interest roi main pulmonary artery the tissue response function lung parenchyma either determined multiple single small rois better whole lung assuming linear relation signal concentration contrast agent signal time curves converted concentration time curves hypothesising negligible amount extravasating contrast agent first pass bolus lungs principles indicator dilution theory applicable the central volume theorem states relationship perfusion parameters regional pulmonary blood flow pbf ml/100 ml lung tissue min regional pulmonary blood volume pbv ml/100 ml lung tissue mean transit time mtt s):\documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ mtt \frac{{pbv}}{{pbf \end{document regional pbv calculated normalising area tissue concentration time curve integral arterial input function aif:\documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ pbv \frac{{\int c(t)dt \int aif(t)dt \end{document consideration finite length bolus dispersion way tissue volume relationship aif tissue concentration time curve described convolution aif residue function r(t):\documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ c(t pbf\int aif(\tau \bullet r(t \tau d\tau \end{document}where r(t amount contrast agent remaining tissue time t. pbf therefore initial height r(t 0 respectively maximum r(t case delay aif(t c(t assessed deconvolving aif(t c(t the deconvolution last equation performed using singular value decomposition svd model independent nonparametric deconvolution analysis potentiality reducing noise contribution applying suitable threshold singular value matrix this method shown reliable results first pass bolus tracking clinical studies however spatial distribution underlying lung disease unknown lung perfusion quantification required entire lung e.g. assess side differences lung perfusion measurement limited lung sample small roi reflect poor estimate lung perfusion one study used cross correlation analysis cca perfusion data sets suppression central pulmonary vessels cca previously used improve snr arteriovenous separation time resolved mr angiography 48 49 it shown feasible identify vessels similar signal intensity time curve reference vessel using cca for purpose reference rois drawn pulmonary artery pulmonary vein the quantification pbv pbf resulted average reduction 25% pbv 15% pbf compared segmentations without vessel exclusion a comparison manual exclusion vessel structures cca revealed average reduction 13% pbv 8% pbf the reduction applying cca significant p 0.001 compared results manual without blood vessel exclusion calculated parameters basically quantitative perfusion evaluation signal time curves converted concentration time curves this especially important arterial input function contrast media passes compact bolus linear relationship however seen small range concentrations 3 4 5 mmol l seen vitro experiments 5153 the linearity signal concentration dependent sequence parameters used like te thus use saturation recovery prepared flash sequence proposed often used myocardial perfusion imaging improve linearity measurements thus contrast noise ratio cnr higher doses applied volunteers usage 0.057 mmol kg bodyweight feasible animal experiment found already 0.05 mmol gd dtpa kg bodyweight resulted vivo concentrations outside linearity range however comparing quantitative measures 0.05 mmol kg bodyweight values high compared results pet pbf found 121 ml min/100 ml pbv 1720 ml/100 ml prospective trial different injection protocols contrast media concentrations investigated compared quantitative analysis perfusion spect the amount mr contrast bolus fixed 5 ml injection speed 5 ml followed 20 ml saline flush it found patients weighing less 70 kg concentration 0.3 mmol ml showed highest accordance spect 0.5 mmol ml patients weighing 70 kg however study used 10-mm thick slice partitions therefore small amount 5 ml contrast media resulted appropriate contrast noise ratio another solution complex problem usage dual bolus approach experiment the arterial input function determined low volume application contrast media i.e. 0.01 mmol kg bodyweight achieve linear relationship contrast agent concentration signal intensity large pulmonary vessels this followed boluses higher doses obtain sufficient cnr lung tissue this may allow absolute quantification well visual analysis perfusion lung tissue often possible single low dose used absolute perfusion quantification the drawback approach small therefore short bolus i.e. 1.5 ml arterial input function requires extremely high temporal resolution perfusion sequence asses peak signal the combination small prebolus 0.01 mmol kg bodyweight main bolus 0.04 mmol kg bodyweight resulted perfusion parameters best comparable literature data a combination prebolus main bolus 0.08 mmol kg bodyweight resulted underestimation pbv for perfusion imaging lung optimal combination temporal resolution contrast noise ratio essential it found temporal resolution approximately 2 achieved correct application deconvolution algorithm the influence noise data especially relevant estimates pbf high noise levels i.e. low cnr values lead substantial underestimation significant loss accuracy pbf estimates it concluded assessment pbf might benefit less aggressive acceleration example lower acceleration factor 2 the cnr notably increased larger voxel sizes employed voxel size thus chosen large clinically acceptable repeatability quantitative perfusion measurements tested two patient groups one large volunteer study one study ten patients bronchioalveolar carcinoma scanned twice within 3 days inspiratory breath hold evaluation performed manually placing three regions interest data set excellent agreement measurements ten patients pulmonary hypertension scanned 3 weeks initial scan three dimensional perfusion data sets acquired inspiratory breath hold evaluation comprised whole lung fourteen volunteers examined twice 24 h inspiratory expiratory breath hold no significant difference found pair measurements performed expiration evaluated observer therefore broad usage technique automatic segmentation approach assisting evaluation developed especially data sets pathologically changed perfusion i.e. peripheral perfusion defects automatic segmentation algorithms difficult implemented these contours applied perfusion data sets image registration haste perfusion images this reduced time needed evaluation perfusion data sets approximately 10 min however technique applied data sets healthy volunteers reproducibility experiments performed so far mr perfusion lung parenchyma performed 1.5 t. given benefits higher field strengths like 3 higher snr expected beneficial regarding quantification allows increase spatial resolution in clinical routine contrast enhanced perfusion easily applied visual assessment disease characteristics qualitative approach the discussion temporal resolution contrast media dose obsolete performed mr scanner perfusion defects due vascular obstruction show typical wedge shape including lung periphery fig 3 in 41 patients acute pe agreement mr perfusion single photon emission computed tomography spect perfusion perfusion defects subsegmental level assessed mr perfusion showed high agreement spect kappa value per examination 0.98 0.98 0.83 0.69 lobar segmental subsegmental perfusion defects respectively quantitative segmental perfusion analysis patients acute pulmonary embolism possible determine obstruction index this perfusion based index showed higher correlation clinical severity also significant predictor outcome this initial report brings mr perfusion pole position discussed new modality choice pe assessment furthermore radiation free technique optimally suited follow studies treatment monitoring visual evaluation also sufficient differentiate different causes pulmonary hypertension ph like pah chronic thromboembolic ph cteph perfusion diffusely reduced pah focal defects occurred cteph fig 4 fig 5 in 45 patients moderate severe copd perfusion matched parenchymal alterations demonstrated mdct high agreement lobar level was found parenchymal destruction reduction perfusion patients severe emphysema kappa 0.8 patients cystic fibrosis the functional score based visual evaluation perfusion defects showed acceptable intra- interreader agreement concordance correlation coefficient 0.89 0.8 respectively .fig 3coronal 10-mm maximum intensity projection mip image patient follow examination acute pulmonary emboli there residual occlusion middle lobe leading wedge shaped perfusion defect right there also residual subtotal obstructions noted left upper lower lobe characterised reduced perfusionfig absolute quantification perfusion parameters pulmonary blood flow b pulmonary blood volume especially pulmonary blood flow nicely pronounces area perfusion defect well areas reduced perfusion original perfusion weighted data set presented maximum intensity projection see fig 3fig 5patient pulmonary arterial hypertension pulmonary blood flow b pulmonary blood volume however subpleural perfusion still present wedge shaped perfusion defects seen c original perfusion weighted data set presented 10 mm maximum intensity projection coronal 10-mm maximum intensity projection mip image patient follow examination acute pulmonary emboli there residual occlusion middle lobe leading wedge shaped perfusion defect right there also residual subtotal obstructions noted left upper lower lobe characterised reduced perfusion patient fig absolute quantification perfusion parameters pulmonary blood flow b pulmonary blood volume especially pulmonary blood flow nicely pronounces area perfusion defect well areas reduced perfusion original perfusion weighted data set presented maximum intensity projection see fig 3 patient pulmonary arterial hypertension pulmonary blood flow b pulmonary blood volume however subpleural perfusion still present wedge shaped perfusion defects seen c original perfusion weighted data set presented 10 mm maximum intensity projection semi quantitative analysis 3d perfusion data sets eight healthy volunteers allowed calculation left right perfusion ratio ratio 0.9 confirmed phase contrast flow measurements furthermore shorter transit time higher peak signal found dorsal lung regions quantitative evaluation perfusion compared perfusion scintigraphy assessment left right perfusion ratios 23 patients various lung diseases the mr estimations left right perfusion ratios correlated significantly perfusion scintigraphy scans p 0.01 the mr ratios computed pbf showed highest accuracy followed peak concentration pbv one important clinical field perfusion assessment estimation post surgical lung function example lung cancer resection so far perfusion scintigraphy routinely used purpose 60 patients lung cancer mr outperformed scintigraphy assessment postoperative fev 1 r 0.93 r 0.89 respectively therefore concluded perfusion mr feasible alternative pulmonary perfusion scintigraphy predicting postoperative lung function patients lung cancer however ventro dorsal perfusion gradient observed explained inclusion central pulmonary vessels evaluation application vasodilatative agent inhalation 100% oxygen ) a significant increase redistribution pulmonary perfusion found ten healthy volunteers therefore mr perfusion seems suited estimation therapy response patients ph administration vasodilatative drugs group 13 copd patients the pulmonary perfusion found heterogeneously altered pbf pbv significantly reduced mtt prolonged despite pure quantification another aspect perfusion although harder establish degree homogeneity patients susceptible high altitude pulmonary oedema hape ) the perfusion inhomogeneity compared hape resistant volunteers hape patients 2 h hypoxia equivalent altitude 4,500 parameters indicating perfusion inhomogeneity increased hypoxia populations particularly hape subjects increased significantly almost evaluations therefore kind analysis although yet broadly used may important future applications diseases peripheral vasoconstriction like pulmonary hypertension so far conventional perfusion parameters assessed patients pulmonary hypertension compared healthy aged matched volunteers perfusion parameters different patients pulmonary hypertension reduced pbf pbv increased mtt 74 75 only mtt showed moderate linear relationship mpap r 0.54 r 0.56 respectively it remains determined perfusion mr might role follow treatment however large data sets difficult handle even visual evaluation might challenging therefore future developments needs aim providing easy use post processing utilities visual quantitative evaluation non contrast enhanced techniques assessment pulmonary perfusion important tool understanding lung physiology given low spatial resolution limited signal noise ratio broad clinical application appears difficult contrast enhanced perfusion techniques broadly available easily quickly performed even critical ill patients	backgroundlung perfusion is one of the key components of oxygenation . it is hampered in pulmonary arterial diseases and secondary due to parenchymal diseases.methodsassessment is frequently required during the workup of a patient for either of these disease categories.resultsthis review provides insight into imaging techniques , qualitative and quantitative evaluation , and focuses on clinical application of mr perfusion.conclusionthe two major techniques , non - contrast - enhanced ( arterial spin labeling ) and contrast - enhanced perfusion techniques , are discussed .
rituximab chimeric monoclonal antibody mab approved fda 1997 single agent treatment relapsed refractory low grade follicular cd20-positive b cell non hodgkin lymphoma nhl later 2006 treatment combination cyclophosphamide doxorubicin vincristine prednisone chop anthracycline based chemotherapy regimens patients diffuse large b cell lymphoma dlbcl cases it increases response rate diminishes disease progression events augments patients survival 13 the molecular weight rituximab 144,544 da constituted 1328 aa igg isotype 1/kappa rituximab contains conserved n glycosylation site asn297 heavy chains occupied biantennary glycan structures murine variable regions human constant regions define chimeric nature rituximab mechanisms action comprise binding fab domain cd20 b lymphocytes induction apoptosis either directly throughout recruitment immune effector functions fc domain thus mediating b cell lysis complement dependent cytotoxicity mechanism cdc binding c1q antibody dependent cellular cytotoxicity mechanism adcc recognized fc receptors fcrs effector cells including natural killers granulocytes macrophages 46 besides current knowledge concerning monoclonal antibodies mab permits us correlate immunomodulatory activity mab critical quality attributes cqas depict chemical composition spatial configuration regard rituximab cqas associated appropriate recognition cd20 b cells achievement effector functions nevertheless rituximab subject posttranslational modifications acquired lifecycle provides inherent physicochemical heterogeneity could impact functionality 7 8 although heterogeneity expected occur batch batch variability breadth controlled manufacturing process thus acceptance range established cqa depending observed safety efficacy given process capabilities this particularly important development follow products demonstration highly similar cqas variability along demonstration comparable pharmacological responses respect reference product grant biosimilar denomination 1012 it reported acidic basic isoforms coming mainly oxidation deamidation isomerization amination cyclization glycation presence c terminal lysines could alter mab affinity target receptor molecules due modification electrostatic hydrophobic interactions cell membranes hand glycosylation contributes maintaining stability mabs three dimensional structure modulates binding interaction fc domain effector cells influencing cdc adcc mechanisms regarding immunogenicity rituximab considered low risk molecule although potentially immunogenic since exhibit cross reactions endogenous antibodies autoimmunity induction however due chimeric nature production human anti chimeric antibodies hacas may lead loss efficacy certain cases consequently discard differential immunogenic response biosimilar rituximab comparability chemical composition i.e. sequence posttranslational modifications demonstrated 15 16 aggregation another attribute also identified cqa participates development immunogenic response work conducted comprehensive characterization followed pharmacodynamics immunogenicity clinical study two products containing rituximab the characterization exercise focused comparison cqas associated pharmacodynamic profile pd potential immunogenicity rituximab protein identity amino acid sequence charge glycosylation heterogeneity aggregates content binding affinity fcriia fcriiia biological characterization included measurement affinity cd20 potency adcc cdc the clinical evaluation intended demonstrate products exhibit behaviour result high physicochemical comparability dibasic sodium phosphate heptahydrate na2hpo47h2o monobasic sodium phosphate monohydrate nah2po4h2o sodium chloride nacl tris hydrochloride nh2c(c2oh)3hcl sodium hydroxide naoh obtained j. t. baker center valley pa sodium azide nan3 ammonium formate ch5no2 rpmi-1640 medium fetal bovine serum fbs formic acid acquired sigma aldrich st louis mo ( hayward ca pngase f purchased new england biolabs woburn human igg fc antibody bethyl laboratories inc tetramethylbenzidine tmb substrate obtained thermo scientific waltham adcc reporter bioassay kit celltiter 96 mtt purchased promega madison wi water obtained millipore milli q biocel system billerica two products containing rituximab employed kikuzubam probiomed s.a de c.v ; manchester uk coupled acquity uplc h class bio system waters corp chromatographic separation carried using acquity uplc h class bio system linear gradient 22 50% acetonitrile using 100 mm ammonium formate aqueous solution ph 4.50 mobile phase a. fluorescence detection set excitation wavelength 250 nm 420 nm emission using 150 2.1 mm 1.7 acquity uplc beh glycan column coupled 1.7 vanguard beh glycan precolumn waters corp rituximab purity assessed 4.6 mm 300 mm acquity ethylene bridged hybrid 200 analytical column particle pore diameters 1.7 200 respectively waters corp milford 20 mm phosphate buffer containing 150 mm nacl 3 mm nan3 ph 6.8 used mobile phase isocratic gradient uv detector set 280 nm acquity uplc h class bio system affinity constants equilibrium ka obtained isothermal titration calorimetry itc using nano itc instrument ta instruments inc ( new castle de 300 l fcriia fcriiia solutions 5.0 pbs ph 7.0 titrated continuous injections 1.9 l rituximab solutions 50 pbs ph 7.0 saturation 25c ; new castle de used integration heat signals nonlinear regression analysis data wil2-s cell line atcc crl-8885 expresses cd20 antigen incubated presence different concentrations rituximab rpmi-1640 medium 10% fbs 2 h 37c a secondary antibody anti human igg fc coupled radish peroxidase added detect rituximab wil2-s complex 1 h incubation 37c using tmb substrate 30 min room temperature the test results expressed relative percentage ec50 concentration response curve kikuzubam respect reference product cd20 positive cells wil2-s atcc crl-8885 incubated rpmi 1640 media 10% fbs different concentrations rituximab complement human serum 4 h 37c 5% co2 then mts substrate added well incubation 2 h conditions the result assay expressed relative potency obtained comparing ec50 dose response curve kikuzubam respect ec50 dose response curve reference product adcc reporter bioassay kit promega madison wi ) positive cells wil2-s atcc crl-8885 incubated different concentrations test antibody specific concentration jurkat transformed cells expressing cd16 the result assay expressed relative potency kikuzubam respect reference product double blind two arms 1 2 crossed three cycles treatment order review expected use conditions kikuzubam possible impact efficacy suggested mexican health authorities the study protocol approved irb iec institutional review board independent committee participating research centres mexican health authorities study protocol codes cas or/01/cmn/0833004101444 0114/2009 cas or/01/cmn/07330021830339 0816/2008 the study conducted accordance regulations ethical principles based declaration helsinki principles international conference harmonization ich guidelines good clinical practice gcp an informed consent obtained patients prior participation study the aim study evaluate biological effects safety kikuzubam compared reference product six treatment cycles chop therapy patients received either kikuzubam reference product cycle according treatment group dose 375 mg every 14 days iv infusion 59 patients diagnosed moderate high degree diffuse cd20 b cell non hodgkin lymphoma randomly assigned three groups group 1 treated kikuzubam first three cycles subsequently reference product remaining three cycles group 2 initially treated reference product three cycles kikuzubam next three cycles blood samples collected patients determination cd20 b cells levels pd endpoint visits 1 3 4 5 6 7 8 9 10 11 12 using cd20 becton dickinson fitc labelling kit epic xl beckman coulter inc additionally levels serum human anti chimeric antibodies hacas determined using human antirituximab hada haca hama haha igg elisa kit human alpha diagnostics san antonio tx the assay precision determined graphs obtained serum samples resulting coefficient variation cv lower 10% accuracy ranging 90 110% analysis covariance performed evaluate effect treatments kikuzubam reference product number cd20 b cells relative basal values covariable the anova test evaluated significance level 0.05 avoid effect crossing treatments the cd20 b cells depletion analyses performed considering results first three cycles treatment either kikuzubam reference product order compare response treatments parallel design the physicochemical properties rituximab discussed according impact pd immunogenicity potential identity heterogeneity purity biological activity cqas studied comparing several batches kikuzubam reference product the identity products verified tryptic peptide chromatographic profiles followed ms ms analyses matched theoretical sequence rituximab figure 1 the theoretical sequence obtained reverse engineering comprising de novo protein sequencing reference product esi ms ms maldi psd using trypsin glu c asn n digestions along edman degradation selected fragments this sequence employed design construction expression system kikuzubam data shown revealed inconsistencies invention patents 21 22 rituximab amino acid positions 14 219 heavy chain our results agree sequence published groups 23 24 united states pharmacopeia products sequence verification expressed ms ms sequence coverage exceeded accepted consensus value 90% 98.7% 98.6% kikuzubam 98.7% 97.2% reference product heavy light chains respectively figures 2 3 order confirm identity kikuzubam exact mass whole deglycosylated molecule coming uniquely amino acid sequence determined table 1 hand as previously reported correspondence glycoform theoretical mass 99.98% observed within among kikuzubam reference product these results confirm primary sequences products identical also reveal charge glycosylation heterogeneities comparable thus risk differential immunomodulatory response diminished the glycosylation heterogeneity kikuzubam reference product also evaluated relevant cqa immunomodulatory activity rituximab table 2 shows content highly mannosylated hybrid sialylated afucosylated galactosylated glycoforms products it reported glycan isoforms could affect affinity receptors involved effector function stability mab due charge steric hindrances for instance hybrid bisected afucosylated glycans tend increase affinity fc gamma riiia resulting enhanced adcc response 27 28 sialylated isoforms could increase immune responses nonetheless glycan heterogeneity biosimilar must correspond reference product analysis products revealed similar glycan heterogeneity consistent presence glycoforms observed ms analyses whole molecule although minor differences found nonfucosylated hybrid glycan content products impact observed potency efficacy adcc assay afterwards figure 5 14 27 28 regarding charge heterogeneity changes higher 1.0 units isoelectric point pi mab could affect therapeutic activity 13 29 common pi variation observed manufacturing 0.1 0.2 pi units common pi variation observed manufacturing table 3 show pi range main isoform overall calculated pi values kikuzubam reference product the observed differences lower 0.1 pi units confirming comparability charge heterogeneity among products another relevant cqa related immunomodulatory activity rituximab aggregation level involves irreversible interaction two denatured protein molecules revealing new epitopes could stimulate immune system a positive correlation protein aggregation immunogenicity reported therapeutic proteins well affectations biological activity either directly indirectly formation neutralizing binding antibodies thus evaluation aggregates important component analytical comparability assessment therapeutic proteins the aggregates content kikuzubam comparable reference product table 4 cases complied pharmacopeial established limit in addition physicochemical analyses extensive biological characterization assess comparability functions mechanisms action described reference product kikuzubam performed vitro assays studies designed taking account interactions fab fc domains associated biological activities described literature affinity cd20 fcriia fcriiia the main mechanism action rituximab binding cd20 4 6 whose interaction affinity related structure complementary domain regions cdrs fab fragment reveals presence appropriate chemical structural properties fragment our results showed kikuzubam reference product comparable affinities cd20 figure 4 rituximab also induce death cd20 b cells activating effector cells natural killer cells nk monocytes macrophages binding fcr receptors fc domain clinical studies shown affinity fcriia fcriiia receptors associated better response rituximab patients follicular lymphoma itc results affinity fcriia fcriiia kikuzubam reference product within order magnitude figure 4 thus modulatory functions lead b cell depletion products assumed follow molecular basis the described fc fab affinities modulate cdc adcc mechanisms rituximab 5 6 evaluated comparatively kikuzubam reference product figure 5 these analyses also confirmed physicochemical characteristics fc domain kikuzubam capable achieving biological functions comparable potency reference product abbreviated study conducted cd20 non hodgkin lymphoma patients was designed confirm physicochemical functional characteristics kikuzubam adequate exhibit pd profile reference product cd20 used main endpoint treatment cd20 b cells were depleted serum levels lower 20 cell ml three arms study figure 6 this explained effect rituximab products since levels blood components recovered within 7 days completion concomitant chop chemotherapy regimen application granulocyte colony stimulating factor filgrastim g csf cd20 component recovery serum despite stimulation completion chemotherapy once six cycles rituximab chop completed recovery serum levels cd20 b cells three groups study observed nonmalignant recovery demonstrated pet images absence neoplasms data shown order determine comparability primary endpoint statistical analyses three arms before shapiro wilk test revealed departures normality data p 0.05 mean comparison among groups performed student test wilcoxon tests revealing significant differences cd20 depletion kikuzubam reference product p 0.05 table 5 combined groups also analysed using data arms 1 3 compare patients treated kikuzubam reference product one outlier excluded the results obtained exercise also revealed meaningful differences among treatments figure 6 the production antichimeric human antibodies hacas result loss tolerance rituximab immune system evaluated three study arms on arm 1 two patients showed positive results screening test hacas right shift kikuzubam reference product visit 5 table 6 thus immunogenic response triggered medication shifting since first humoral immunogenic response production igm antibodies half life plasma approximately four weeks followed isotype switching igg loss tolerance consequent hacas production presented also arm 2 presence hacas two patients detected shift treatment table 6 then immunogenic response produced 4 28 patients first two groups considered consequence drug shifting the immunogenic response analogous kikuzubam reference product therefore differential immunogenicity observed likewise three patients arm 3 presented positive results screening hacas test table 6 these data suggest proportion patients positive hacas comparable study arms the presence antibodies represent risk patient safety justify abandoning study the biological effect comparable hacas negative patients products hematologic recovery r chop cycles even patients positive hacas screening test kikuzubam reference product was accomplished within expected period reported studies chemotherapy thus inferred neither hacas developed kikuzubam reference product negative effect hematologic recovery patients included study the comprehensive physicochemical biological vitro characterization studies including verification amino acid sequence glycosylation charge heterogeneity aggregates content affinity cd20 fciia fciiia receptors provided valuable information demonstrate comparability kikuzubam reference product the information provided analyses supported design rational clinical evaluation demonstrate similar immunomodulatory response pharmacodynamics immunogenicity profiles physicochemical along biological comparability resulted similar immunomodulatory activity evaluated products	rituximab is a chimeric monoclonal antibody employed for the treatment of cd20-positive b - cell non - hodgkin 's lymphoma , chronic lymphocytic leukemia , rheumatoid arthritis , granulomatosis with polyangiitis and microscopic polyangiitis . it binds specifically to the cd20 antigen expressed on pre - b and consequently on mature b - lymphocytes of both normal and malignant cells , inhibiting their proliferation through apoptosis , cdc , and adcc mechanisms . the immunomodulatory activity of rituximab is closely related to critical quality attributes that characterize its chemical composition and spatial configuration , which determine the recognition of cd20 and the binding to receptors or factors involved in its effector functions , while regulating the potential immunogenic response . herein , we present a physicochemical and biological characterization followed by a pharmacodynamics and immunogenicity study to demonstrate comparability between two products containing rituximab . the physicochemical and biological characterization revealed that both products fit within the same response intervals exhibiting the same degree of variability . with regard to clinical response , both products depleted cd20 + b - cells until posttreatment recovery and no meaningful differences were found in their pharmacodynamic profiles . the evaluation of anti - chimeric antibodies did not show differential immunogenicity among products . overall , these data confirm that similarity of critical quality attributes results in a comparable immunomodulatory activity .
migraine chronic neurological disorder affecting 12% population estimated prevalence 18.2% women 6.5% men.1,2 etiology also seems hereditary component.3 70% migraine sufferers family history migraine.4 migraine varies age tends occur commonly second third decades life.5 common occasionally severe disabling disorder usually characterized recurrent headaches frequently unilateral lasting 4 72 hours typically aggravated routine physical activity often accompanied variety gastrointestinal neurologic autonomic symptoms including loss appetite nausea vomiting photophobia phonophobia osmophobia.5,6 approximately one third migrainous patients experience migraine attacks aura typically visual symptoms scintillating shapes hallucinations black spots preceding occurring attack sensory language disturbances may occur.7 transient focal neurological symptoms develop gradually period least 5 minutes last less 1 hour.6 migraine attacks heterogeneous regard symptomatology frequency severity duration disability impact quality life different patients separate attacks individual sufferer.8 clinical economic perspectives great demand rapidly acting effective safe abortive headache agents migraine attacks believed caused activation trigeminal nerve trigeminovascular system leading release several neurotransmitters calcitonin gene related peptide substance p affect vasomotor tone causing neurogenic inflammation intracranial extracranial cerebral vessels.9 aura thought caused cortical spreading depression slowly propagating wave intense neuronal glial depolarization progressing cortex followed period inactivity.10 common external triggers migraine attacks decreasing frequency stress 80% hormonal fluctuations women 65% skipping meals 57% changes weather 53% lack sleep 50% perfumes odors 44% neck pain 38% certain foods 27% physical activity 22%).11 addition environmental triggers several genetic factors contribute migraine pathophysiology.12 family twin studies clearly demonstrated rare common forms migraine significant genetic basis however approaches understand genetic basis varying degrees success.13 recent genetic findings revealed ion channel transporter mutations causative migraine.7 considerable insights pathogenesis migraine come investigation rare autosomal dominant subtype migraine aura familial hemiplegic migraine three susceptibility genes cacna1a atp1a2 scna1 encode either ion channels ion transport proteins involved regulating membrane potential far identified it likely mutations genes reduced threshold cortical spreading depressions however mutations found typical migraine aura suggesting ion channels may involved.7 recently mutation ksnk18 gene encoding two pore domain potassium channel tresk twik related spinal cord potassium channel described large family migraine aura tresk modulates neuronal excitability seems involved pain pathways activated volatile anesthetics shown inhibit cortical spreading depression key mechanism generation migraine aura moreover channel abundantly expressed trigeminal ganglia controls sensitivity pain nerves this possible new approach treatment migraine.4 wide range medications used treatment acute migraine headache dihydroergotamine used several decades produces good relief 70%80% patients within 2 h administration.14 triptans produce similar efficacy.15 despite widespread use availability significant proportion patients migraine refractory agents require opiate analgesics control acute headache.16 moreover presence cardiovascular risk factors prohibits use triptans ergotamines many patients.17 recent studies suggest well risk development chronic daily headaches overuse acute medication including triptans ergots analgesics.18 management migraine divided acute abortive preventive treatment patients frequent severe headaches often require approaches.6 preventive therapy important reducing migraine morbidity it considered patients attacks long severe frequent two month marked impact daily functioning in addition may used adverse events overuse acute care medicines the main goal prophylaxis reduction frequency intensity duration migraine attacks well prevention chronicity however good prophylaxis usually result better response acute treatment improved daily function reduction disability the ultimate target improve quality life patient performance daily activities work productivity reduce healthcare costs when choosing prophylactic treatment one take account efficacy tolerability existence comorbid conditions.6,1921 currently recommended first line agents come different pharmacological classes primary indications usually approved medical conditions they include beta adrenoceptor blocking drugs propranolol metoprolol antidepressant amitriptyline calcium channel blocker flunarizine recently neuromodulator drugs valproate topiramate playing increasingly important role second line drugs either less effective clinical trials tested small number less well designed trials require investigation table 1 lists preferred prophylactic agents according efficacy strength evidence frequency side effects.22,23 proposed epilepsy migraine share pathophysiological mechanisms table 2 including abnormal function voltage gated sodium calcium channels imbalance gaba mediated inhibition excitatory glutamate mediated transmission.24 evidence suggests epilepsy comorbid condition migraine it occurs commonly patients migraine general population prevalence migraine epileptic patients higher controls.25 use antiepileptic drugs migraine prevention well known effectiveness medications demonstrated several clinical trials however anti epileptic drugs shown effective migraine prophylaxis valproate topiramate effective well tolerated migraine prevention suitable first line agents on hand acetazolamide lamotrigine oxcarbazepine vigabatrin effective the efficacy gabapentin migraine prevention variable considered first line treatment requires evaluation.8,23 the antiepileptic drugs also referred neuro modulators appear act migraine targeting multiple molecular sites brain figs 1 2 ) altering neurotransmission effects ion channels neurotransmitter receptors neurotransmitter metabolism.3,26 interaction multiple sites decreases abnormal brain excitability protects vulnerable neurons conditions high energy demand neuronal hyper activity well metabolic impairment.27 valproate available valproic acid divalproex sodium formulations without differences efficacy various forms 3a stops prevents migraine clearly understood.2 valproate shown central peripheral mechanisms action may relevance migraine cascade.28 1 increases gamma aminobutyric acid gaba levels synaptosomes brain via activation glutamic acid decarboxylase gaba synthetic enzyme via inhibition gaba aminotransferase succinate semialdehyde dehydrogenase gaba degradative enzymes).29 2 inhibits voltage sensitive calcium channels type).2 3 interacts central 5-ht system thereby reducing effect inflammation serotoninergic neurons brainstem ( 4 reduces central trigeminal nerve activation increasing gaba levels).25 5 finally valproate shown reduce experimental neurogenic inflammation peripheral trigeminal vascular system effect mediated gabaa receptor agonism.28 valproate effective long term migraine prophylaxis initial benefits maintained periods excess 3 years.30 rapidly absorbed gastrointestinal tract metabolized almost entirely liver the relationship dose plasma concentration linear bioavailability depends formulation dosing regimen.31 topiramate sulfamate substituted monosaccharide derived naturally occurring sugar fructose fig its antimigraine potential based several possible mechanisms action namely 1 modifies excitability nerves blocking voltage sensitive sodium channels l type voltage activated calcium channels.27,28 2 inhibits carbonic anhydrase activity.32 3 inhibits excitatory glutamate pathway enhancing inhibitory effect gaba.30 actual mechanism action antimigraine activity known.5 rapidly almost completely absorbed gastrointestinal tract tmax 1 4 hours high oral bioavailability 81% 95% virtually unaffected food it low level binding plasma proteins 10%20% significantly inhibit induce drug metabolizing enzymes it extensively metabolized approximately 20% metabolized liver readily enters central nervous system cns it shows linear steady state pharmacokinetics long half life ranging 19 25 hours.3133 zonisamide sulphonamide derivative fig this new generation antiepileptic drugs available japan 10 years recently introduced usa europe it mechanisms action similar topiramate including blockade voltage gated sodium channels inhibition carbonic anhydrase inhibition potassium mediated release glutamate enhancement gaba release furthermore specific mechanism action reducing ion flow type calcium channels.19,33,34 also reduces nitric oxide production scavenges nitric oxide free radicals.1 well tolerated presents favorable pharmacokinetic profile clinical use it rapidly completely absorbed gastrointestinal tract peak plasma concentrations occurring 2 4 hours following administration it long plasma elimination half life 63 69 hours healthy volunteers allows reduced frequency administration since metabolized cytochrome p450 3a4 drugs inducing inhibiting enzyme may affect plasma elimination.35,36 gabapentin fig it binds high affinity two four known 2 subunits 21 22 voltage gated calcium channels producing inhibition high voltage activated calcium currents resulting reduction synaptic transmission.37 attractive pharmacokinetic profile it bound plasma proteins significant drug drug interactions induce hepatic enzymes metabolized the effectiveness valproate migraine prophylaxis first reported open label study,38 another open label study demonstrating decreased severity frequency headaches migrainous patients.39 efficacy demonstrated three randomized double blind controlled studies.4244 first trial 107 patients treated valproate n 70 placebo n 37 respectively period 3 months valproate started dose 250 mg day titrated gradually achieve plasma concentration approximately 70 120 mg l the number participants 50% greater reduction headache frequency valproate significantly better 48% placebo 14%).40 efficacy safety valproate evaluated second study 3 month period a total 176 patients randomized four groups placebo n 44 valproate 500 mg day n 45 1000 mg day n 43 1500 mg day n 44 the initial dose valproate treated patients 250 mg day increased 250 mg every 4 days every 8 days 500 mg group assigned randomized dose achieved the monthly migraine frequency decreased significantly 500-mg day group 4.5 2.8 1000-mg day group 4.7 2.7 1500-mg day group 4.7 3.0 versus placebo group 6.1 5.6 however overall median reduction 38% valproate 1000-mg day group significantly greater overall 19% median reduction observed placebo group.41 third study 234 patients treated period 17 weeks valproate n 119 matching placebo n 115 the treatment initiated 500 mg daily 1 week dose increased 1000 mg second week mean migraine frequency decreased significantly valproate treated group 5.8 3.7 versus placebo group 6.3 4.6).42 efficacy topiramate migraine prevention initially shown small preliminary studies,43,44 thereafter established three pivotal multi centre randomized double blind placebo controlled trials.45,47,48 first multicentre 6-month trial performed 49 locations usa a total 487 patients randomized four groups placebo n 117 topiramate 50 mg day n 125 100 mg day n 128 200 mg day n 117 topiramate started 25 mg day increased 25 mg week 8 weeks maximum assigned dose given divided doses morning evening reached the mean monthly migraine frequency decreased significantly 100-mg day group 6.4 2.7 3.7 3.3 p 0.001 200-mg day group 6.6 3.1 3.9 3.4 p < 0.001 versus placebo group 6.4 2.6 5.3 3.6 50-mg day group 5.8 2.5 4.5 3.1 p 0.12 topiramate treated patients 50 mg day 35.9% p 0.04 100 mg day 54% p 0.001 200 mg day 52.3% p 0.001 exhibited 50% reduction monthly migraine frequency responder rate placebo treated patients 22.6%).45 second trial conducted period 26 weeks 52 north american clinical centers a total 483 patients randomized four groups placebo n 114 topiramate 50 mg day n 116 100 mg day ( n 120 200 mg day n 117 mean monthly migraine frequency decreased significantly patients receiving topiramate 100 mg day 5.8 2.6 3.5 3.5 p 0.008 200 mg day 5.1 2.0 3.0 2.2 p 0.001 versus placebo group 5.6 2.2 4.5 2.9 topiramate treated patients 50 mg day 39% p 0.01 100 mg day 49% p 0.001 200 mg day 47% p 0.001 exhibited significant reduction monthly migraine frequency placebo treated patients 23% patients received 200 mg day tended frequent adverse events.46 third study took place 88 neurology clinics throughout 21 countries europe middle east a total 559 patients completed 26-week open label phase study 514 completed phase continued 26-week randomized double blind placebo controlled phase trial patients assigned topiramate n 255 placebo n 259 although number migraine days increased quality life lower sustained benefit observed discontinuation topiramate the mean increase number migraine days topiramate discontinuation greater placebo group 1.19 days 4 weeks p 0.0001 compared topiramate group 0.10 days p 0.5756 the results trial suggest patients treated 6 months option continue 12 months cases.47 pivotal trials supported fourth study performed headache centre rome 35 patients assigned topiramate 37 patients placebo moreover observed significant reduction quantity symptomatic drugs taken compared placebo group 6.17 1.80 2.57 0.80 significant downward trend number days disability.48 combined analysis piramate showed greater reduction migraine frequency placebo several large randomized placebo controlled clinical trials shown topiramate administered 100 mg daily significantly reduced number migraine headache days patients episodic migraine experienced three 12 migraine episodes per month48,49 patients chronic migraine experienced 15 headache days per month.52,53 furthermore number participants 50% greater reduction headache frequency topiramate significantly better placebo.49 clinical trials topiramate treatment safe generally well tolerated double blind randomized clinical trial compared zonisamide efficacy topiramate migraine prophylaxis a total 80 patients recruited randomly allocated zonisamide 200 mg day topiramate 100 mg day zonisamide gradually titrated 50 mg day 200 mg day topiramate 25 mg day 100 mg day both drugs associated significant decrease frequency severity migraine along decrease need acute medication migraine attacks migraine disability assessment score no significant differences observed 2 groups greater reduction headache severity zonisamide these results suggest zonisamide effective topiramate migraine prophylaxis therefore considered alternative treatment patients poor tolerance topiramate larger studies still needed zonisamide expect fda approval.1 two double blind randomized placebo controlled trials shown gabapentin reduces frequency intensity migraine attacks.50,51 first study conducted period 3 months seven participating centers ninety eight patients assigned gabapentin 45 matching placebo 4-week titration phase patients started 300-mg day gabapentin increasing 900 mg day first week thereafter weekly increases 2400 mg day mean migraine frequency decreased significantly gabapentin treated group 4.2 2.7 versus placebo treated patients 4.1 3.5 the number patients achieving least 50% reduction monthly headache frequency gabapentin significantly better placebo 46% versus 16% p 0.01).51 second study gabapentin used dosage 1200 mg day compared placebo it associated significant reduction frequency intensity migraine compared placebo.50 the primary measure efficacy change frequency migraine attacks per month 28 days baseline frequency results considered clinically relevant reduction 50% migraine frequency demonstrated.46 preventive drugs must used periods months although general agreement ideal duration prophylaxis recently published data suggest greater efficacy longer treatment periods.52 valproate demonstrated efficacious well tolerated agent preventive treatment migraine chronic daily headache cluster headache received approval fda.28 recommended oral starting dose 250 mg taken bedtime gradually increased usually 125250 mg per week desired dose 750 mg per day 23 divided doses.53 topiramate fda approval migraine prophylaxis.54 dose 100 mg per day reported effective well tolerated drugs used migraine prevention.55 dose 200 mg per day effective 100 mg per day well tolerated responders positive effects usually seen within first month improvement continued 6-month observation period.43,49 efficacy topiramate increased longer periods prophylaxis a group migraine patients treated 8 months open label extension phase two large double blind placebo controlled trials 26 weeks duration the mean number attacks decreased 3.4 2.6 per month end double blind treatment periods 2.2 2.4 per month completion open label extension phase active drug.56 zonisamide acts slower topiramate requiring 3 months reach 2/3 reduction frequency migraine attacks it shown effective well tolerated migraine prevention patients refractory topiramate.34,57 better control headache severity obtained zonisamide comparison topiramate these advantages explained specific mechanisms action.1 gabapentin less effective topiramate valproate therefore considered drug second choice.58 efficacy shown daily dose 1200 1600 mg.51 adverse effects leading withdrawal therapy likely occur initial titration periods demonstrated drop rate lower long term treatment extension phases initial treatment periods.55 order avoid minimize side effects therefore reduce risks withdrawal treatment daily dose increased slowly period least 4 weeks targeted clinical benefits achieved adverse effects interfere if side effects emerge desired clinical response yet achieved dose increased providing ceiling dose drug the majority migraine prophylactic drugs cause tiredness dizziness therefore better give evening.19,58 important always bear mind contraindications risk benefit ratio drug patient the common side effects valproate tiredness drowsiness dizziness weight gain tremor hair loss skin rash nausea its use pregnancy contraindicated due teratogenicity neural tube defects).52 long term treatment neuromodulators may alter metabolism sex hormones use valproate women appears associated frequent occurrence reproductive endocrine disorders characterized polycystic changes ovaries high serum testosterone concentrations hyperandrogenism menstrual disorders.59,60 younger women seem especially vulnerable effects valproate serum androgen levels likely develop polycystic ovary syndrome the age patients therefore considered prescribing medication.60 males causes sexual dysfunction decreasing follicle stimulating hormone luteinizing hormone.61 endocrine effects new generation neuromodulators yet widely studied.59 topiramate generally considered safe well tolerated migraine prophylaxis clinical trials paresthesia frequent reported half patients.62 adverse events usually mild moderate severity transient decrease substantially time cognitive adverse events including tiredness psychomotor slowing drowsiness language difficulties difficulties memory concentration arise 22% patients treated 100 mg per day topiramate compared 10% given placebo these usually decrease second month treatment typically require discontinuation drug unlike migraine prevention drugs topiramate likely associated weight loss two three patients weight gain serious adverse events leading treatment discontinuation infrequent clinical trials 2% risk renal calculi increased especially patients underlying predisposition the risk secondary angle closure glaucoma rare.43 despite efficacious patients tolerate adverse effects hence need alternative.1 zonisamide well tolerated antiepileptic drug generous safety profile.63 similar mechanism action topiramate similar lower incidence side effects.57 gabapentin commonly causes dizziness tremor somnolence nausea ataxia the choice drug take account comorbidities patient preferences addition overt risk benefit ratio medication.65 sometimes infrequent migraine attacks might enough impair quality life patient feels commencing prophylaxis warranted hence decision start regular prevention tailored individual one must take patient preference account physicians understand patient treatment preferences help select drug suited needs.66 axiomatic patient understand reasons starting preventive treatment feel comfortable drug chosen this increases likelihood adherence long term preventive treatment plan.3 factors influencing patient preference likely involve following parameters effectiveness duration relief attack recurrence ease use required doses side events time go back normal functioning.67 patient aware timing extent clinical benefit many preventive medications take minimum 3 4 weeks therapeutic response particular dose maximum clinical effect might take another 2 3 months time compliance important the inefficacy one drug necessarily mean migraine prophylactic drugs ineffective different drugs may tried one identified really helpful prophylaxis it also useful explain potential side effects drugs order engage patient decision making process ensure compliance the patients assured medications induce tolerance addiction.19,58,68 unlike patient preference acute migraine treatment patient preference prophylaxis well studied one study evaluating patient preference migraine prophylaxis patients asked rate following aspects headache prevention efficacy speed onset pocket expenses adverse events formulation therapy type treatment frequency dosing each patient also evaluated 12 different clinical scenarios containing simulation 2 hypothetical headache preventive treatments wherein patients could choose product product b neither patients informed product efficacy data 50% 75% 100% headache elimination adverse events profile weight gain concentration difficulty and/or fatigue dosing frequency patients likely choose treatments higher efficacy rates fewer adverse events less frequent dosing schedule they also preferred treatment options higher efficacy rates even increased adverse events occurred frequent dosing necessary.66 the selection migraine prevention agent made basis efficacy cost potential adverse events impact quality life headache profile patient preference previous efficacious unsuccessful treatments coexisting disorders.54 european federation neurological society efns guidelines aim give evidence based recommendations drug treatment migraine attacks prophylaxis level a recommendation corresponds drugs first choice efficacy safety well established clinical trials b drugs second line evidence efficacy either less effective side effects level a. level c drugs third line probable efficacy based guidelines valproate dose least 600 mg topiramate dose 25 100 mg two recommended first line agents prophylactic treatment migraine level evidence gabapentin dose 1200 1600 mg grade c drug third choice migraine major socioeconomic impact causing considerable burden patients families society it deeply affects wellbeing general functioning acute attack also terms work performance family social relationships school achievement.70 major goals migraine prophylaxis improving patients quality life reducing migraine frequency severity duration disability the results different randomized controlled clinical trials proven migraine prophylaxis anticonvulsants valproate topiramate generally safe effective way reducing attack frequency thus burden migraine despite good efficacy some patients discontinued prophylaxis agents clinically significant adverse events low rate side events better tolerance valproate topiramate furthermore long half life permits daily dosing may enable better patient compliance.57 antimigraine prophylaxis still relatively underused only 15%20% patients fulfill criteria migraine prophylaxis treatment receive appropriate treatment.71 side effects compliance cost prolonged treatment important limiting factors physicians therefore aware treatment strategies migraine prophylaxis require patient understanding acceptance all drugs currently used migraine prophylaxis discovered serendipitously without consideration migraine pathophysiology the next generation prophylactic drugs developed basis recent understanding migraine pathophysiology the identification new anti migraine drug targets hopefully lead effective specific treatments fewer side events cortical spreading depression inhibition calcitonin gene related peptide antagonists talcagepant seem promising need investigation drugs melatonin vitamin e botulinum toxins seem marginal effect.72 migraine polygenic multifactorial disorder likely influenced multiple genes environmental triggers.13 emerging genetic findings implications better understanding migraine pathogenesis they hopefully lead development new effective drugs better design fewer side effects change future migraine therapy the tresk channel represents interesting target development migraine specific treatment needs therefore explored upregulation channel activity could great benefit migraine sufferers either acute treatment long term prophylactic.4	migraine is among the 10 most disabling disorders worldwide . it is characterized by episodes of moderate or severe headaches with various degree of disability , resulting in a considerable health burden upon the sufferers and their family . the objective of this article is to review the use of prophylaxis with antiepileptic drugs . particular focus is given to their mechanism of action , metabolism , pharmacokinetics , safety profile , efficacy and to provide a summary of the most relevant clinical studies and patient preference .
since first isolated opium poppy early nineteenth century morphine related opioids remain powerful analgesics treat many forms acute chronic pain however repeated prolonged use opioids leads tolerance analgesic tolerance problematic lead therapeutic failure i.e. inadequate pain control mcquay 1999 cases even highest tolerable dose opioid achieve desirable analgesic effect patients wang wang 2006 harden 2008 development opioid tolerance limits analgesic efficacy increased doses opioids order counter tolerance exacerbate another problem namely opioid addiction significant medical public health problem extensive efforts made elucidate mechanisms underlying opioid tolerance drug addiction kieffer evans 2002 increasing evidence implicates contribution transcriptional epigenetic regulation opioid tolerance drug addiction activation inhibition transcription factors carlezon et al 2005 zachariou et al 2006 modification chromatin dna structure renthal et al 2008 guo et al 2011 induction non coding rnas including micrornas pietrzykowski 2011 robison nestler 2011 micrornas mirs small non coding rna molecules repress target gene expression base pairing partially complementary sequences 3-untranslated region 3-utr target mrnas owing recent cloning sequencing computational efforts numbers known mirs rapidly increasing date total 21,643 mature mirs found across 103 species 1921 mirs found humans mirbase release 18.0 november 2011 emerging identification mirs humans viruses a crucial pervasive layer post transcriptional gene regulation mirs elucidated ambros 2004 taft et al 2010 it generally accepted mirs serve important class epigenetic regulators participate variety cellular activities respect diverse functions mirs play integral role fundamental neurobiological processes including neuronal development plasticity metabolism apoptosis kosik 2006 one form long lasting synaptic plasticity opioid tolerance particularly interesting research area study mir mediated cellular adaptation review we summarize recent findings mirs opioid tolerance focus role let-7 mirs regulating opioid tolerance the opioid receptor mor member g protein coupled receptor superfamily primary receptor responsible opioids analgesia antinociceptive tolerance matthes et al 1996 sora et al 1997 opioid tolerance may result opioid receptor desensitization trafficking include opioid receptor regulation internalization uncoupling g proteins due chronic exposure opioid agonists bailey connor 2005 martini whistler 2007 koch hollt 2008 lopez gimenez milligan 2010 receptor regulation one mechanisms contributing opioid tolerance previously proposed davis et al 1979 tao et al 1987 bhargava gulati 1990 bernstein welch 1998 diaz et al 2000 chronic morphine treatment produced marked decrease brain mor density davis et al down regulation high affinity mor site rats also reported following continuous infusion morphine i.t wong et al 1996 etorphine s.c morphine induced mor regulation also observed sh sy5y cells without differentiation zadina et al in addition receptor regulation chronic treatment morphine shown significantly reduce mor signaling sensory neurons brainstem nuclei sim et al 1996 johnson et al 2006 agreement findings reduced receptor number resultant reduced mor signaling on hand reports mor expression altered dum et al 1979 or even regulated lewis et al 1984 brain various opioids some discrepancies may caused uncontrolled variables e.g. different opioids doses methods opioid treatments anatomical regions times samples taken integrality tissue samples assays opioid receptor subtypes studied well detection methods it suggested mor regulation agonist selective depends agonist intrinsic efficacy nishino et al 1990 ; the purity selectivity radiolabeled ligands problem early studies also recent reports employing questionable materials used studies potential culprits conflicting findings the long 3-utr mor mrna ide et al 2005 han et al 2006 ) suggests region may contain physiologically relevant elements regulating receptor expression mechanisms mir targeting indeed early research 3-utr human mor mrna suggested mor expression increased 712-bp segment immediately downstream stop codon removed zollner et al 2000 comparative bioinformatics predicted potential mirs may interact human mouse mor table 1 let-7 family mirs identified top candidate according number putative target sites alignment pattern our group experimentally validated silico prediction members let-7 mir family interact 3-utr mor mrna predicted positions et al 2010 furthermore downregulating let-7 specific lna modified antisense oligodeoxynucleotides lna let-7-as found increase mor expression sh sy5y cells human neuroblastoma cell line suggesting 1 mor target let-7 2 expression mor constitutive suppression let-7 microrna targets predicted miranda http://www.microrna.org/microrna/getgeneform.do ranked according alignment scores order elucidate physiological role let-7 regulating mor opioid tolerance examined vivo relevance let-7 mirs cellular animal models opioid tolerance former sh sy5y cells treated morphine 110 2448 h induce cellular tolerance the expression let-7 mirs significantly regulated chronic treatment morphine expression level mor reduced determined western blotting method et al 2010 receptor radioligand binding using h damgo wang unpublished data therefore chronic morphine treatment caused increase let-7 decrease mor expression development opioid tolerance sh sy5y furthermore regulation let-7 expression morphine occurred mouse model opioid tolerance mice implanted s.c 75-mg morphine pellet 75 mg morphine pellet mouse s.c brain expression let-7 increased gradually time morphine treatment temporally correlating development antinociceptive tolerance morphine interestingly regulation let-7 occurred mor expressing cells mor negative cells mice brain cortex region determined situ hybridization et al 2010 this agreement aforementioned finding mor direct target let-7 order examine causative role let-7 leading opioid tolerance directly targeted let-7 mouse model opioid tolerance treatment let-7 inhibitor i.c.v decreased brain let-7 levels partially attenuated opioid antinociceptive tolerance et al 2010 previous reports number different cell lines animal models e.g. brodsky et al 1995 johnson et al 2006 indicated mor mrna changed upon treatment morphine for example mor mrna remained sh sy5y cells following chronic morphine treatment we confirmed let-7 affect mor mrna stability however polysome bound mor transcript significantly decreased so intriguing data led us propose following regulatory mechanism upon let-7 regulate opioid tolerance let-7 recruits sequesters mor mrna p bodies deprived translational machinery effectively reducing polysome bound mor mrna leading translation repression similar pathway observed hek293 hela cells pillai et al 2005 thus translation repression may serve general mechanism let-7 regulate target gene expression figure 1 keep mind let-7 activity turned opioid tolerance regulation transcripts nature works wonder ensure activity let-7 ultimately dampening activity opioids upon persistent activation schematic diagram proposing mechanism regulation target gene let-7 pri- pre let-7 produced exported cytosol mature let-7 incorporated rna induced silencing complex risc the latter recruits sequesters target mrna p bodies deprived translational machinery effectively reducing polysome bound mrna leading translation repression modified et al 2010 its family members highly conserved across species sequence function pasquinelli et al 2000 major roles let-7 include regulation stem cell differentiation neuromuscular development cell proliferation differentiation reinhart et al 2000 ; let-7 initially identified heterochronic gene pasquinelli et al 2000 mammals let-7 levels increase embryogenesis brain development schulman et al 2005 ; let-7 undetectable human mouse embryonic stem cells level let-7 increases upon differentiation thomson et al 2004 2006 ; this high expression let-7 maintained various adult tissues sempere et al furthermore let-7 widely viewed tumor suppressor mir boyerinas et al 2010 there clear link loss let-7 expression development poorly differentiated aggressive cancers takamizawa et al 2004 ; 2009 using computational algorithm targetscan 6.0 screen human 3-utr sequences containing let-7 family mirs complementary sites 886 conserved targets total 989 conserved sites 111 poorly conserved sites predicted high mobility group hook 2 hmga2 top scoring candidate gene list table 2 confirmed direct let-7 target vitro vivo lee dutta 2007 mayr et al hmga2 chromatin associated non histone protein capable modulating chromatin architecture thus affecting transcription in addition abundant studies hmga2 embryogenesis zhou et al 1995 sun et al 2009 tumorigenesis peng et al 2008 qian et al 2009 would interesting investigate possible involvement opioid tolerance functional target gene let-7 top 100 predicted targets let-7 mirnas ranked total context score targetscan 6.0 http://www.targetscan.org/. seed pairing rules widely used predict functional mir target sites mir mrna recognition requires perfect complementarity 6-nucleotide mrna seed sites 5 end mirs positions 27 bartel 2009 however predictions based short complementary sequences compared experimental results proteomic studies false positive false negative rates appear 50% easow et al 2007 baek et al 2008 mourelatos 2008 selbach et al several previous findings strongly indicated sizeable fraction mir targets obey canonical seed rule ha et al 1996 didiano hobert 2006 tay et al 2008 stefani slack 2012 let-7 biological studies clearly demonstrated genetically verified let-7 targets caenorhabditis elegans contain imperfect binding sites bulges gu wobble pairs seed region vella et al a recent study identified new class mir target site nucleation bulges alternative mode mir target recognition pivot pairing rule chi et al 2012 they proposed transitional nucleation model transitional nucleation state determines binding mirs nucleation bulge mrnas therefore identification non canonical let-7-mrna interactions may lead important breakthroughs discovering new let-7 targets decipher functional role let-7 opioid tolerance with respect let-7 target gene identification another important issue need addressed redundancy let-7 family members there 14 13 different let-7 family members mouse human respectively roush slack 2008 human different members let-7a-1 7a-2 7a-3 7b 7c 7d 7e f7 1 7f-2 7 g 7i mir-98 mir-202 located nine different chromosomes ruby et al 2006 let-7 initially viewed one single activity emerging data suggest let-7 family contains mirs different activities i.e. targets example reported let-7b highly expressed let-7e drastically reduced malignant mesothelioma guled et al 2009 so question remains whether individual let-7 family member expression pattern exerts specialized function opioid tolerance development opioid tolerance even analgesic actions drugs likely caused single mechanism rather intricate neuronal circuitry involving multiple mechanisms may ultimately lead expression tolerance seen humans regulation opioid tolerance mor mechanisms represents one mechanisms a typical study mir research field tends survey transcript levels mirs disease state zheng et al 2010 for example morphine induced regulation mir-15b human monocyte derived macrophages dave khalili 2010 mir-133b decreased morphine zebrafish embryos sanchez simon et al 2010 furthermore moving cell line vivo relevance another big hurdle overcome case let-7 mirs identified critical regulator human mouse mor moreover demonstrated relevant cellular opioid tolerance well animal models opioid tolerance et al 2010 let-7 represents one several mirs contributing opioid tolerance example found mir-23b could interact mor 3-utr via k box motif 5-ugugau-3 sh sy5y mouse p19 cells wu et al 2008 2009 while mor involved development morphine tolerance target action mirs opioid tolerance matthes et al 1996 sora et al 1997 ) further research needed identify target genes mirs including let-7 number receptors ion channels protein kinases implicated opioid tolerance nmda receptors pkc camkii kieffer evans 2002 wang wang 2006 ; ueda ueda 2009 may become potential targets let-7 summary mir mediated mechanisms provide novel direction toward unraveling complex mechanisms involved development opioid tolerance studies enrich knowledge basic principles neuronal behavioral adaptation opioid tolerance eventually lead novel design development pharmacological treatments opioid tolerance the authors declare research conducted absence commercial financial relationships could construed potential conflict interest	this chapter will focus on the role of micrornas ( mirs ) in regulating the actions of opioid drugs through the opioid receptors . opioids , such as morphine , are analgesics that are used for treating many forms of acute and chronic pain . however , their chronic use is limited by undesirable effects such as opioid tolerance . the opioid receptor ( mor ) is the primary receptor responsible for opioids analgesia and antinociceptive tolerance . the long 3-untranslated region ( 3-utr ) of mor mrna is of great interest since this region may contain elements for the post - transcriptional regulation of receptor expression , such as altering the stability of mrna , influencing translational efficiency , and controlling mrna transport . micrornas are small non - coding rna molecules that exert their functions through base - pairing with partially complementary sequences in the 3-utr of target mrnas , resulting in decreased polypeptide formation from those mrnas . since the discovery of the first mir , lin-4 in caenorhabditis elegans , hundreds of mirs have been identified from humans to viruses , which have provided a crucial and pervasive layer of post - transcriptional gene regulation . the nervous system is a rich source of mir expression , with a diversity of mir functions in fundamental neurobiological processes including neuronal development , plasticity , metabolism , and apoptosis . recently , the let-7 family of mirs is found to be a critical regulator of mor function in opioid tolerance . let-7 is the first identified human mir . its family members are highly conserved across species in sequence and function . in the review , we will present a brief review of the opioid receptors , their regulation , and opioid tolerance as well as an overview of mirs and a perspective how mirs may interact with mor and serve as a regulator of opioid tolerance .
thanks good preventive dental programs developed knowledge importance oral hygiene vitality teeth within oral cavity extended recent times led increase non carious cervical lesions dental erosions abrasions etc dentine hypersensitivity dh characterized acute sharp pain area exposed dentine response thermal chemical osmotic tactile stimuli 3 although sensitivity occur part tooth commonly felt vestibular area dental cervical region canines first premolars root surface the frequency occurs ranges 3 57% much frequent 72 98% patients suffering periodontal disease it often occurs 20 50 years age common among women 4 5 difficulties treating cervical dh gave rise large number techniques therapeutic procedures currently used pain alleviation dh 6 therapy uses various impregnating agents form solutions gels recent times laser based hydrodynamic theory several methods application fluoride dentine adhesives corticosteroids silver nitrate solution work blocking open dentine tubules number treatments compared average vas value baseline beginning treatment baseline assessment tooth sensitivity number treatments recent decades classic treatments desensitizing agents supplemented use laser using lasers treat dh dates back 80s advent erbium lasers even though initial results quite disappointing improvement technology scientific knowledge time led development new lasers wavelengths suitable therapeutic treatment 7 most studies conducted different types lasers different wavelengths duration application reveal effectiveness treatment immediately upon completion therapy circa 6 months first treatment result pain reduced many cases eradicated 8 9 10 among published works confirm exceptional efficacy use diode lasers treatment dh thus aim study investigate effects diode laser therapy hypersensitive dental cervix dentine hypersensitivity stimulated touching dental cervix tip probe mesial distal directionality all patients asked assess level dentine hypersensitivity using vas scale 0 10 0 represents pain 10 represents greatest pain initial sensitivity assessed recorded laser therapy initiated laser treatment protocol low power diode laser smilepro980 biolitec used study the laser operated continual regime 2 w power applied tooth surface 60 seconds exposure tooth tissue around 2 mm away laser exposure time 60s repeated sensitivity control using vas scale seven fourteen days initial exposure teeth still sensitive working laser therapist patient wore protective goggles work space the study included 18 patients average age 27 years 82 sensitive teeth there significant difference tooth sensitivity values measured baseline teeth different number laser treatments say 95% confidence teeth lower dentine sensitivity beginning require fewer laser treatments order determine teeth difference is observed given number treatments post hoc analysis carried using turkey honest significant difference hsd test differences occur mean sensitivity values baseline teeth one treatment teeth three laser treatments p=0.037 difference vas value baseline teeth one laser treatment treated twice p=0.073 teeth two three laser treatments p=0.934 there significant difference vas values measured baseline first laser treatment t=9.275 p=0.000 there significant difference vas values measured baseline second laser treatment t= 1.268 p=0.000 there significant difference vas values measured baseline third laser treatment t=8.749 p=0.000 vas values teeth treatment following first second third laser application vas values teeth first second third application laser baseline measurement prior application laser significant difference vas values measured baseline first laser treatment t=9.275 p=0.000 well 7 days second laser treatment 14 days t=7.085 p=0.000 14 days third laser treatment t=.517 p=0.000 supports effectiveness therapeutic procedure dentine hypersensitivity dh common individual needs treatment depend aetiology well subjective experience painful sensations degree tolerance type pain study some patients reported pain severe become physical emotional problem affects quality life many able consume hot cold foods liquids acidic foods liquids even difficulty brushing teeth as data previous studies suggest several methods applied treatment order obtain satisfactory results since aetiology dh may multifactorial 11 12 13 ) conventional methods treating dh include topical application desensitizing agents either professionally home protein precipitates agents occlusion dentinal tubules 14 recently lasers 15 16 17 it believed occlusion dentinal tubules leads decrease permeability dentine proportionally also reduces dh 18 according hydrodynamic theory efficacy dentine desensitization agents directly related ability efficiently close dentinal tubules 19 20 study yilmaz et al compared effectiveness application sodium fluoride diode laser treatment dh they concluded within scope study gaalas laser therapy effective treatment dh comfortable faster treatment traditional treatments dh 21 several studies 22 23 describe synergistic effect lasers conjunction desensitization agents reason our study included laser irradiation cervical portion tooth obtained exceptionally good results terms lowered dentine hypersensitivity f 3.77 p 0.027 therefore state 95% confidence teeth lower dentine sensitivity beginning require fewer laser treatments previous published data indicate nd yag laser additional analgesic effect compared lasers these findings result effect radiation temporarily alter endings sensory axons block c ab fibres thereby reducing pain 24 parameter power used study 2 w accordance study liu et al their study 25 demonstrated 2 w 166 j cm suitable parameter 980 nm diode laser sealed dentinal tubules without excessive melting dentine thus achieving good level analgesia comparable results good results arise closure dentinal tubules prevents internal communication dental pulp oral cavity fluids 15 26 based results study in diode laser used believe modern low power lasers also provide good results treatment dh finding also supported results research umberto et al 27 our research well research authors 28 29 demonstrates low energy lasers including gaalas diode laser wavelengths 780 980 nm effect nerve endings thus eliminating sensitivity study conducted 27 patients 55 hypersensitive teeth lopes et al assessed efficacy various protocols treating dentine hypersensitivity they concluded desensitising protocols effective reducing dentine hypersensitivity different effects therefore believe combination protocols interesting alternative treatment cervical dentine hypersensitivity 30 this conclusion follows need achieve satisfactory results treatments possible the results study indicate applied multiple treatments modern therapeutic procedure independently achieves good results even teeth greater level hypersensitivity we believe research needed assess long term effects therapeutic procedures larger sample order provide recommendations use routine clinical practice within scope conducted study laser therapy provided extremely safe effective results treatment cervical dentine hypersensitivity	introduction : dentine hypersensitivity is characterized by acute , sharp pain arising from the exposed dentine , most commonly in response to thermal , tactile , or chemical stimuli , and which can not be linked to any other pathological changes in the tooth or the environment . therapy uses various impregnating agents in the form of solutions or gels and , in more recent times , laser.aim:the aim of this research was to examine the effects of treatment of hypersensitive dental cervix with diode laser.materials and methods : the study included 18 patients with 82 sensitive teeth . the degree of dentine hypersensitivity was evaluated by visual analogue scale ( vas ) , and the treatment was carried out by application of low - power diode laser over the span of three visits , which depended on the initial sensitivity.results:there is a significant difference in vas values measured at the onset of treatment ( baseline ) and immediately after the first laser treatment ( t=9.275 ; p=0.000 ) , after 7 days , after the second laser treatment ( 14 days ) ( t=7.085 , p=0.000 ) , as well as after 14 days and the third laser treatment ( t=5.517 , p=0.000 ) , which confirms the effectiveness of this therapeutic procedure . the results showed a reduction of hypersensitivity in response to tactile stimulus with a probe after the third treatment , even with teeth whose value on the vas was very high at the beginning of treatment ( baseline).conclusion : within the scope of the conducted study , laser therapy has provided extremely safe and effective results in the treatment of cervical dentine hypersensitivity .
postmenopausal osteoporosis pmo become major epidemic last millennium expected problem health care providers present millennium well osteoporosis disease net loss bone exceeds bone formation occurs women estrogen loss postmenopause 13 postmenopausal osteoporosis pmo major public health epidemic worldwide most women pmo present fracture first indication disease it estimated usa 25 million women suffer osteoporosis cost treat osteoporosis related fractures orfs exceeds 10 billion year 5 6 the prevalence pmo saudi arabia recognition problems associated pmo realized last decade studies pmo saudi arabian women reported 710 the serious complication osteoporosis hip fracture increases patients morbidity mortality rates the incidence costs fractures sequelae continue rise population ages year 2025 costs related osteoporotic fractures projected reach 25.3 billion united states alone assessment of the annual cost orf saudi arabia bubshait sadat ali 2007 found sr 4.27 billion spent yearly treat osteoporosis related femoral fractures osteoporotic hip fracture usually requires hospitalization surgery may result lengthy permanent disability even death within first year injury a patient hip fracture 1015% greater chance dying others age men though suffering fewer hip fractures women 25% likely women die within one year injury 1315 family histories twin studies molecular genetics it quite evident patient predisposition osteoporosis inherited genetic control osteoporosis polygenic enumeration specific genes involved initial phases 2 1618 there study yet genetic influence osteoporosis related fractures saudi arabian women this study conducted find influence known genes osteoporosis among saudi arabian women without fractures after approval ethical review board university dammam written consent patients two hundred ethnic saudi arabian women diagnosis postmenopausal osteoporosis dexa machine basis z scores described subjects study done january 2009 june 2010 baseline blood hematology biochemistry bone panel also done genetic analysis 5 ml whole blood collected several candidate osteoporosis genes reported caucasian race influence bmd fragility fractures genotyping 3 polymorphisms three genes pilot study ethnic saudi arabian postmenopausal women the three genetic polymorphisms convincingly shown affect bmd fragility fractures white race three taqman mgb probes two predesigned one design assays used analyze snp variants requested genes alox15 rs7220870 lrp5 c_25752205_10 tnfrsf11b c_11869235_10 dna 100 l blood samples extracted using dneasy tissue extraction kit qiagen positive dna control known genotype wild type heterozygote mutant added pcr well negative control dna genotyping visualized taqman 7000 applied biosystems data patients including age history fractures hip spine bmd entered analyzed using spss inc 's statistical package social sciences spsss version 14.0 chicago il usa p values less than.05 ci 95% used indicate statistical significance the average age patients 62.5 5.9 years variant alox15 17p13 rs7220870 c snp c ancestral allele freq 0.10.3 majority 69% women cc homozygous c allele even though bmd hip region significantly lower p 0.001 ci 0.017 0.06 history fractures lower two alleles p 0.0002 ci 3.4 15.7 table 1(a the number women homozygous allele 4% higher bmd a history fractures found 50% patients p 0.001 table 1(b regarding analysis lrp5 rs3736228 the alleles c snp c ancestral allele freq 0.70.9 allele variant allele freq 0.10.3 over 96% patients exhibited cc ct alleles women homozygous allele the bmd significantly higher hip spine fragility fractures the statistical analysis lrp5 gene snp given table 2(b in tnfrsf11b c_11869235_10 gene majority patients belonged aa ag alleles homozygous heterozygous allele 3% belonged gg allele bmd hip spine significantly higher gg allele history fractures common gg group p 0.001 ci 59.85 60.146 tables 3(a 3(b allele group risk low bmd higher risk osteoporosis without fractures whereas patients g allele higher bmd hip spine higher prevalence fractures our study provides evidence earlier reported snps alox 15 lrp5 tnfrs11b influences bmd osteoporosis fragility fractures caucasians also influences condition ethnic saudi arabian females found genotype alox15 33% higher rate osteoporosis fractures study found although 4% women carried genotype fracture rate carried 50% mullin et al reported polymorphisms alox15 associated influencing bmd white men women low density lipoprotein receptor related protein 5 lrp5 reported influence bmd risk fractures variations lrp5 linked bmd susceptibility osteoporosis koller et al suggested lrp5 major influence attainment peak bmd hip spine white women reported findings indicate lrp5 influence bmd fracture risk throughout life general population mizuguchi et al found japanese women c c genotype higher adjusted bmd adjbmd value compared c p 0.022 saudi women c c genotype lowest bmd hip spine women tt allele fragility fractures compared cc ct variants meanwhile found significant difference bmd three alleles white men the distribution cc ct tt alleles study 73.5% 23% 3.5% similar frequency the cc ct tt genotypes found 75.6% 21.8% 2.6% participants respectively reported strong evidence association snp rs4355801 chromosome 8 near tnfrsf11b along bmd increased risk osteoporosis they found g allele rs4355801 associated higher bmd allele low bmd patients bmd significantly higher g alleles compared aa ag alleles p 0.001 ci 0.1966 lower aa ag alleles even though risk osteoporosis higher patients allele fracture prevalence increased our results concur findings richards et al regard risk fractures allele the number osteoporotic patients small compared many studies genetic analysis since pilot comparative study one draw reasonable conclusions genetic influence osteoporosis among ethnic saudi arabian population as many researchers resort gwas get minimal new data opted study influence reported target osteoporotic genes upon white race conclusion strong similarity snps genes influence bmd osteoporosis fragility fractures among reported snps genes caucasian race ethnic saudi population may snps influence osteoporosis risk gives direction study reported targeted genes among saudi population	background and objectives . the purpose of the present study is to find the genes and snp that influence bmd and postmenopausal saudi women . material and methods . two - hundred ethnic saudi arabian women with a diagnosis of postmenopausal osteoporosis were the subjects of this study . baseline blood hematology , biochemistry , and bone panel were done . blood was collected , and three taqman - mgb probes were used to analyze snp variants in alox15 ( rs7220870 ) , lrp5 ( c 25752205 10 ) , and tnfrsf11b ( c 11869235 10 ) . results . the variant of alox15 17p13 showed that the bmd of the spine was lower in the aa allele ( p value < 0.002 ) and fractures were highest at 50% compared to cc allele . in the tnfrsf11b gene , bmd of the hip and spine was significantly higher in the gg allele and the history of fractures was significantly higher in gg group . with regard to the lrp5 ( c 25752205 10 ) gene , there was no significant difference between allele groups . conclusion(s ) . this study shows that the genetic influence of osteoporosis in the caucasian and saudi arabians population is similar . we believe that the same genetic markers that influence osteoporosis in the caucasian race could be used for further studies in the saudi arabian population .
retinal vein occlusion rvo second common retinal vascular disorder diabetic retinopathy significant cause visual morbidity patients the development followed rvo hypothesized caused fluid flux vessels tissue according starling law,1,2 based breakdown blood retinal barrier result damage tight junctions capillary endothelial cells,3 vitreoretinal adhesion,4 secretion vasopermeability factors produced retina vitreous.5,6 observations noma et al suggest patients rvo vascular occlusion induces expression vascular endothelial growth factor vegf interleukin-6 il-6 resulting breakdown blood retinal barrier increased vascular permeability.6 thus vegf il-6 may contribute development progression vasogenic rvo me closely associated retinal hypoxia degree hypoxia center macula corresponds decrease visual acuity va if marked hypoxia persists irreversible structural changes macula occur disturbed va permanent spontaneous improvement occurs treatment mandatory decrease duration edema prevent photoreceptor damage gutman et al found chronic poor prognosis terms final va longstanding often results permanent cystic macular changes.7 treatment modalities rvo laser treatment intravitreal periocular application steroids intravitreal injection vegf inhibitors radial optic neurotomy vitrectomy techniques the present study looked new surgical treatment based previous hypotheses role vitreoretinal interface pathogenesis popularity vitrectomy techniques recent years management mandelcorn et al reported promising results macular decompression using vitrectomy internal limiting membrane ilm peeling cases severe visual loss due rvo.8 postulated removal ilm association vitrectomy cases may allow edematous retina decompress dispersion retained intraretinal extracellular fluid blood vitreous cavity inner retinal surface ilm removed this report describes results macular decompression vitrectomy ilm peeling performed authors first nine consecutive cases severe visual loss due rvo this study prospective nonrandomized clinical series including total nine eyes nine patients patients known cases crvo brvo confirmed optical coherence tomography oct inclusion criteria onset disease 3 9 months surgery best corrected visual acuity bcva 20/40 exclusion criteria history macular photocoagulation history anti vegf corticosteroid injections vitreous concurrent pathology eye decreased vision all surgeries performed surgeon spontaneous posterior vitreous detachment preretinal vitreous cortex removed retinal surface posterior vitreous detachment formation after air fluid exchange injection 0.1 ml 2.5 mg ml indocyanine green dye icg solution akom inc buffalo grove il made vitreous cavity macula allowed act 30 seconds stain ilm the icg stained ilm grasped vitreous forceps peeled away inner retinal surface macular area point outside foveal avascular zone an air fluid exchange carried postoperative prone positioning patient 48 hours egress extracellular fluid blood inner retina could facilitated using squeegee mechanism similar pneumatic displacement submacular hemorrhage.913 patient first postoperative evaluation done 1 week surgery check possible complications last examination evaluate final outcome surgery performed 2 months postoperatively last visit retinal thickness there complications surgery follow period according fundus fluorescein angiography ffa findings the time initial onset rvo surgical intervention ranged 3 9 months mean 5.3 months preoperative bcva ranged 20/100 20/800 preoperative foveal thickness ranged 411 701 mean 563.9 90.0 two months surgery bcva crvo cases improved half brvo cases gained better va there statistically significant decrease macular thickness postoperative mean macular thickness 361 61.1 p 0.001 test visual acuity improved crvo cases three six brvo cases improvement bcva statistically significant mean preoperative bcva logmar 1.23 0.29 versus mean postoperative bcva logmar 1.06 0.49 p 0.09 test when ischemic cases excluded improvement bcva still statistically significant p 0.06 test the mechanism visual loss due rvo thought combination interference photoreceptor stimulation thickened hemorrhagic edematous retina association cases ischemic retinal damage due concomitant retinal ischemia.1419 hypothesized vitrectomy removal ilm would allow congested hemorrhagic retina decompress facilitating release extracellular fluid blood vitreous would turn restore normal retinal thickness intraretinal tissue pressure reduce opacities within retina could interfere light transmission photoreceptors reduce intraretinal pressure around adjacent retinal venules capillaries would allow blood vessels reopen possible furthermore performing vitrectomy sequestered cytokines il-6 vegf removed eye adverse effects eliminated the vitrectomy performed intervention probably improved preretinal oxygen tension2,20,21 secondarily may decreased levels vegf removal ilm might resulted decompression improvement preretinal oxygen tension.8,22 vasoconstriction stimulated increased oxygen tension might reduced hydrostatic vessel pressure thus decreasing edema the results showed 2 months surgery retinal thickness decreased cases va improved improvement statistically significant the decrease macular thickness observed study agrees nearly previous studies,8,2224 statistically insignificant improvement bcva contrast one recent study,24 one older literature.25 mandelcorn found intraretinal hemorrhage retinal thickness diminished within average 39 days following vitrectomy ilm peeling.22 study therefore last visit evaluating outcome procedure scheduled 2 months surgery eyes decreased retinal thickness improvement might solely result improved physiologic features partly result inner retinal atrophy secondary retinal ischemia retinal atrophy might responsible apparent anatomic improvement oct may account lack statistically significant corresponding improvement bcva even resolves va recovery may limited photoreceptor layer damage ota associates retrospectively examined eyes poor va despite resolved brvo demonstrated damage photoreceptor layer retina defined lack visualization related high reflectance band high resolution oct correlated poorer final va.26 relatively small number nonrandomized consecutive cases examined study without control group improved anatomic outcome compared natural history disease except comparisons published data mandelcorn22 liang et al23 studies present study difference outcome ischemic nonischemic cases ischemia evaluated ffa according hayreh,27 method defining ischemia criticized provides reliable evaluation retinal capillary perfusion approximately 50%60% cases combined information assessment relative afferent pupillary defects electroretinography proposed superior method evaluation able differentiate ischemic nonischemic crvo 97% cases eyes present study classified nonischemic ffa criteria actually may severe disease cases ischemic rvo might detected examined using alternative methods one pitfalls present study comparison mandelcorn nrusimhadevara,8 authors surgeries ilm peeling complete they peeled ilm beyond arcades two cases study authors peeled ilm macula seems insufficient drainage fluid retina cases 1 6 another issue concern retinal toxicity icg.28 although using chromovitrectomy technique ilm peeling inevitable clear cut safety profiles different dyes used chromovitrectomy yet established.29 finally study duration symptoms cases 3 months whether early intervention advantageous final outcome able evaluated study according previous studies pars plana vitrectomy ilm peeling one method decreasing due rvo multiple possible causes decreased va rvo photoreceptor ischemia atrophy suggested larger randomized controlled trial precise case selection using appropriate imaging electrophysiologic techniques undertaken surgery also performed soon possible diagnosis irreversible photoreceptor damage occurs	purpose : to evaluate the effects of vitrectomy and internal limiting membrane peeling for treatment of macular edema secondary to retinal vein occlusion ( rvo).methods : nine cases of visual loss due to macular edema caused by central retinal vein occlusion or branch retinal vein occlusion underwent pars plana vitrectomy with removal of the preretinal hyaloid , peeling of the internal limiting membrane stained with indocyanine green dye , air fluid exchange , and postoperative prone positioning . best - corrected visual acuity ( bcva ) and central foveal thickness by optical coherence tomography were measured pre- and postoperatively then compared to assess the outcome of surgery.results:in all cases intraretinal blood and retinal thickening diminished within 2 months of surgery . visual acuity improved in all of the central retinal vein occlusion cases and 3/6 branch retinal vein occlusion cases . the decrease in macular thickness was statistically significant ( mean postoperative macular thickness 361 61.1 versus mean preoperative macular thickness 563.9 90.0 , p = 0.001 , t - test ) . the improvement in bcva was not statistically significant ( mean preoperative bcva in logmar 1.23 0.29 versus mean postoperative bcva in logmar 1.06 0.49 , p = 0.09 , t - test).conclusion : in eyes with macular edema secondary to rvo , pars plana vitrectomy with internal limiting membrane peeling can resolve macular edema , but the improvement in bcva was not statistically significant in this study .
77-year old female referred clinic prolonged period delayed healing following uneventful extraction lower right second molar tooth may 2007 point the patient taking alendronic acid 70 mg orally per week seven years clinical examination revealed mild erythema overlying socket evidence osteonecrotic process either clinically radiographically the patient attended following year november 2008 right sided facial pain following recent curettage affected socket dentist the patient discharged following extended course penicillin v metronidazole accompanied chlorhexidine mouthwashes three years later june 2012 patient attended repeat occurrence symptoms clinically evidence infection discharge radiographically remained clearly demarcated radiolucency right posterior mandible fig the histopathology findings confirmed bone necrosis consistent mronj ruled dysplasia malignancy the patient recent attendance october 2013 attended increasing trismus swelling right posterior mandible radiographic examination revealed much extensive area necrosis right body ramus mandible spreading involve coronoid process appearance pathological fracture fig 2 ct image taken assess extent necrosis exploration right side mandible removal fractured coronoid process debridement necrotic bone carried royal surrey county hospital december 2013 an incision made explore body ascending ramus coronoid process mandible the coronoid process gripped firmly prevent temporalis pulling fragment superiorly gently removed fig once coronoid process removed gentle curettage necrotic bone carried using slow hand piece saline irrigation necrotic bone removed leaving margin bleeding bone normal appearance thus indicating sufficient metabolic potential healing take place fig 8) 36 the patient admitted two nights following procedure received intravenous metronidazole discharged oral antibiotics chlorhexidine mouthwashes four times per day two weeks this case demonstrates unpredictable nature mronj disease progress cause significant morbidity case extensive surgery required remove necrotic fragments bone guarantee necrosis stop spreading present incidence mronj patients taking alendronic acid osteoporosis 1:10001:1,700 however incidence increases duration treatment 79 our case illustrates extent damage caused straightforward dental procedures carried low risk patients taking oral bisphosphonates it important realise osteonecrosis may remain asymptomatic long periods absence infection it seems matter great importance national evidence based guidelines published dental treatment patients taking bisphosphonates information regarding possible consequences bisphosphonate use given general medical practitioners there conflicts interest written informed consent publication print electronic form publication radiographic photographic images written informed consent publication print electronic form publication radiographic photographic images granted patient authorsconception design study review case seriesacquisition data laboratory clinical/ literature searchanalysis interpretation data collecteddrafting article and/or critical revisionfinal approval guarantor manuscriptadam jowett clinical/ literature searchanwer abdullakutty clinical/ literature searchmalcolm bailey clinical/ literature search	highlightsthis case reports the first case to our knowledge of pathological fracture of the coronoid process of the mandible secondary to long term use of alendronic acid.demonstrates the unpredictable nature of symptoms associated with medication related osteonecrosis and its management within the hospital environment.demonstrates the rapidly progressing and unpredictable nature of the spread of the necrotic process in medication related osteonecrosis.clear clinical photographs of the surgical procedure involved in the removal of necrotic bone and curettage of the surgical site in medication related osteonecrosis .
collected ticks nakai district khammouan province dry seasons december april 20122014 previously described 4 technical appendix figures 1 2 a total 6,692 ticks pooled n 768 pools 110 ticks pool according genus sex developmental stage collection period site we extracted dna using nucleospin 8 virus extraction kit macherey nagel dren germany pools screened using single quantitative real time pcrs specific rickettsia spp five microliters diluted 1:10 template containing 1 platinum supermix udg invitrogen carlsbad ca usa bovine serum albumin 40 mg ml used assay results considered positive cycle quantitation cq value 40 likely positive cq value 4045 9 sequencing attempted pools cq values 40 online technical appendix table 2 performed macrogen seoul south korea consensus sequences analyzed using clc main workbench 7 http://www.clcbio.com/products/clc-main-workbench/ blast http://blast.ncbi.nlm.nih.gov/blast.cgi submitted genbank phylogenetic trees constructed using kimura-2 parameter model neighbor joining method 36.3% 279/768 a. testudinarium 3.8% 29/768 dermacentor auratus pools 3% 23/768 contained adults 36.5% 280/768 contained larvae 60.5% 465/768 contained nymphs table 1 * were identified 5.7% 44/768 pools additional 2.3% 18/768 pools likely positive rickettsia spp sequences consistent 5 described rickettsia species genotypes identified r. tamurae r. japonica rickettsia sp the tree constructed using partial nucleotide sequences 350 bp 17-kda gene kimura 2-parameter model neighbor joining method candidatus rickettsia laoensis pool 447 identified 1 haemaphysalis sp pool phylogenetic analysis 28452920-bp concatenated sequences glta sca4 ompb genes suggested bacteria belonged r. massiliae group rickettsiae technical appendix figure 3 candidatus rickettsia mahosotii pools 81 372 identified haemaphysalis spp a. testudinarium pools phylogenetic analysis glta sca4 ompb genes suggested bacteria belonged r. rickettsii group technical appendix figure 3 phylogenetic analysis glta 17-kda ompb genes suggested relationship r. helvetica group technical appendix figure 4 in addition 15 a. testudinarium pools showed dual peaks 17-kda gene sequences suggested presence r. tamurae rickettsia sp sequencing sca4 ompa ompb genes 1 pools pool 239 identified unique sequences table 2 technical appendix figure 4 b897888 belong relapsing fever group borrelia figure 2 the tree constructed using partial nucleotide sequences 299323 bp flab gene kimura 2-parameter model neighbor joining method ( table 1 additional 6 pools 0.8% likely positive nymph pool pool 357 obtained sequence showed 100% identity 116/116 bases genus ehrlichia no pools positive anaplasma spp 2 likely positive table 1 ( n 511 1 pool 0.2% positive 4 pools likely positive c. burnetti the 1 tick contained blood meal a. testudinarium nymph showed negative results screening pcrs infections r. tamurae 2 r. japonica well described southeast asia 10 however pathogenicity rickettsia sp twkm01 11 rickettsia sp kagoshima6 genotypes 13 potential novel candidatus rickettsia laoensis candidatus rickettsia mahosotii candidatus rickettsia khammouanensis unknown candidatus rickettsia khammouanensis phylogenetically related r. helvetica serologic evidence role human pathogen laos 2 unique ompa ompb sca4 sequences identified study table 2 might indicate presence rickettsia sp att 12 previously believed identical r. tamurae 14 suggests might distinct species further studies including whole genome sequencing required identify confirm novel genotypes understand role human disease pools shown high concordance shiretoko haemaphysalis borrelia isolated haemaphysalis spp ticks deer japan 15 the species belongs relapsing fever group borrelia related b. lonestari sequence data ehrlichia spp indicated presence bacteria sufficient identify species level the cq values high 4045 anaplasma spp sequence data obtained were screened using primers is1111 specific c. burnetii confirmatory sequence data obtained limited reagents screening 768 pools coxiella spp completed second sequences obtained a. testudinarium pools dual peaks suggestive multiple infections could therefore interpreted third ticks collected 1 area laos khammouan province thus extrapolating findings entire country must done cautiously these findings emphasize need research tick associated bacteria role human disease additional information large scale survey tickborne bacteria khammouan province laos	we screened 768 tick pools containing 6,962 ticks from khammouan province , laos , by using quantitative real - time pcr and identified rickettsia spp . , ehrlichia spp . , and borrelia spp . sequencing of rickettsia spp.positive and borrelia spp.positive pools provided evidence for distinct genotypes . our results identified bacteria with human disease potential in ticks in laos .
cell adhesion molecules cams cell surface glycoproteins located cell surface plasma membrane neurons cells cams large extracellular domain either transmembrane proteins attached plasma membrane via glycosylphosphatidylinositol gpi anchor the extracellular domains cams mediate cell adhesion either forming homophilic adhesion bonds via binding molecules cell surface membranes adjacent cells interacting heterophilically proteins cell surface membranes adjacent cells extracellular matrix cams accumulating synapses neurons often called synaptic cams represent members major families cell adhesion molecules including immunoglobulin superfamily igsf cams cadherins integrins neuroligins neurexins also cell surface proteins mediate cell adhesion cellular prion protein prp amyloid precursor protein app figure 1 synaptic cams perform numerous functions synapses figure 1 developing neurons cams promote mechanical stabilization contacts axons dendrites neurons formation synapses synaptic cams also play key roles establishment neurotransmission recruiting synaptic components synaptic scaffolding proteins interact intracellular domains synaptic cams associated neurotransmitter receptors figure 1 inducing maturation neurotransmitter release machinery mature neurons cams play role stabilization synapse ultrastructure 57 regulation neurotransmitter release 8 9 synaptic remodeling plasticity 1013 the multiple roles synaptic cams regulation synapse formation function described number recent reviews 14 15 discussed mostly context alzheimer disease alzheimer disease ad neurodegenerative brain disorder predominantly affects aging population synapse loss ad linked least partly toxicity induced peptide accumulates brains ad patients 1719 synaptic cell adhesion directly involved ad pathogenesis since app precursor protein peptide also synaptic cell adhesion molecule playing role regulation synaptic morphology synaptic plasticity hippocampus dependent behavior functions app synapses molecular mechanisms formation subject number recent reviews 2123 discussed review we summarize current data changes levels function synaptic cams ad brains complex interactions suggesting abnormal function different synaptic cams important factor contributing synapse dysfunction ad the involvement cams ad suggested genome wide association studies gwas significantly altered expression cam pathway genes ad found samples cerebellum temporal cortex ad affected individuals ad nonaffected controls besides app among synaptic cams found associated risk ad prnp gene coding prp identified ad susceptibility gene systematic meta analysis ad genetic association studies the methionine valine v polymorphism codon 129 within prnp gene represents known risk factor creutzfeldt jakob disease cjd also reported risk factor early onset ad 2628 single nucleotide polymorphisms snps neural cell adhesion molecule 2 ncam2 synaptic igsf cam highly expressed hippocampal synapses reported risk factor related progression ad japanese population snps ncam2 gene also show association levels cerebrospinal fluid humans suggesting ncam2 involved pathogenic pathway senile plaques concentrate ad brains another large gwas involving 16,000 individuals snps contactin-5 another member synaptic igsf cams localizing presynaptic membranes shown significantly associated ad the junctional adhesion molecule 2 jam2 another member igsf potentially linked ad jam2 localized tight junctions epithelial endothelial cells also expressed retinal ganglion cells the link jam2 ad also suggested study reporting chromosomal 21 region duplication spanning 0.59 mb comprising jam2 app genes patient ad whether jam2 functions regulation synapses neurons however known the association ad also observed snps gene coding leucine rich repeat transmembrane neuronal 3 lrrtm3 synaptic cam highly expressed hippocampus meta analysis five gwas also identified gene coding neurexin-3 gene playing role susceptibility ad males changes levels synaptic cams ad brains reported number studies performed last 25 years reduced levels largest ncam isoform longest intracellular domain ncam180 total ncam levels have reported one early studies comparing samples control ad frontal cortex quantitative crossed immunoelectrophoresis suggesting changes expression ncam ad later studies analysis control ad brain sections immunohistochemistry antibodies ncam found significantly fewer ncam positive neurons frontal cortex ad affected individuals compared normal aging individuals agreement the levels ncam shown reduced frontal temporal cortex ad patients elisa interestingly little difference levels ncam occipital cortex hippocampus control ad patients 39 41 however immunohistochemical analysis ad hippocampus using antibodies polysialic acid psa unique carbohydrate attached predominantly ncam revealed increase immunoreactivity numbers psa ncam positive neurons ad hippocampus especially dentate gyrus indicating changes posttranslational processing ncam psa ncam highly expressed developing nervous system expression mature nervous system restricted brain areas undergoing plastic changes suggesting increase psa ncam ad related extensive neuronal remodeling ad brains levels contactin-2 gpi anchored igsf cam also called transient axonal glycoprotein 1 tag-1 shown western blot reduced temporal lobe ad patients contactin-2 cleaved -site amyloid precursor protein cleaving enzyme 1 bace1 levels ad brains inversely correlate bace1 levels amyloid plaque density suggesting increase bace1 activity observed late onset ad 4549 results increased contactin-2 cleavage bace-1 also cleaves synaptic cams igsf cam l1 close homologue l1 chl1 50 51 the intracellular domain l1 also cleaved -secretase human carcinoma cells -secretase induced proteolytic cleavage l1 increased mouse model ad carries human app pathogenic swedish mutation l166p mutated human presenilin-1 changes activity bace-1 -secretase may therefore affect expression number synaptic cams ad brains in addition igsf cams levels prp analyzed western blot also found decreased hippocampus patients sporadic ad familial ad levels prp also lower temporal cortex samples ad patients 54 55 levels n cadherin also reduced temporal cortex ad patients in contrast western blot analyses revealed significant changes levels contactin-5 temporal cortex ad patients levels full length n cadherin superior frontal gyrus ad patients levels platelet endothelial cell adhesion molecule 1 pecam1 igsf cam also similar frontal temporal cortex control subjects moderate severe ad patients therefore expression subset synaptic cams appears affected ad brain regions interestingly recent study levels ncam2 shown western blot increased hippocampus ad patients strongly reduced synaptosomes isolated brain region figure 2 levels ncam2 significantly affected temporal cortex cerebellum ad patients these observations indicate changes total protein levels lack changes necessarily correlate changes subcellular localization function synaptic cams changes levels synaptic cams synapses ad brains whether alterations overall levels synaptic cams reflect changes synaptic localization remain investigated future studies in addition changes levels full length synaptic cams changes levels proteolytic products synaptic cams also found ad brains interestingly changes proteolytic products synaptic cams necessarily correlate changes total protein levels total levels n cadherin appear unaffected superior frontal gyrus ad patients levels ectodomain shed c terminal fragment n cadherin the levels extracellular domains ncam2 proteolytically released neuronal cell surface increased ad hippocampus figure 2 this increase levels proteolytic products ncam2 inversely correlates levels full length ncam2 synapses total levels ncam2 also increased ad hippocampus figure 2 it therefore possible changes proteolytic products synaptic cams ad brains reflect changes proteolysis specific subcellular locations synapses rather changes overall turnover proteins a number studies indicate proteolytic products cams also present varying levels cerebrospinal fluid csf serum humans western blot analyses antibodies specific different portions molecules show proteolytic products detectable antibodies epitopes within extracellular domains intracellular domains detectable these observations indicate proteolytic products cams csf serum represent fragments extracellular domains cams possibly released csf shedding cell surface neurons brain proteolytic products several cams reported increased csf serum ad patients for example csf levels l1 analyzed elisa reported significantly increased ad this study also reported increase csf levels ncam however statistically significant compared normal controls increased levels several proteolytic products ncam also found sera ad patients in contrast elisa analysis revealed significant differences levels neuronal cell adhesion molecule nrcam l1 family member csf samples healthy controls ad patients analysis levels proteolytic products cams therefore proposed useful diagnostics ad it noted however levels proteolytic products cams ncam l1 csf serum samples healthy individuals ad patients overlap considerably 60 61 also changes csf levels products often specific ad for example levels proteolytic products l1 also increased vascular dementia dementia mixed type levels proteolytic products ncam increased csf people suffering schizophrenia bipolar mood disorder type recurrent unipolar major depression bipolar mood disorder type ii patients however levels ncam changed serum patients autism although levels ncam180 protein mrna reduced brains patients also contrast ad csf levels l1 decreased schizophrenia therefore analysis specific isoforms cleavage products derived via different proteolysis pathways might required establish proteolytic products cams markers specific neurologic conditions including ad a number observations indicate synaptic cams act receptors oligomers synaptic sites the extracellular domain l1 extracellular domain chl1 interacts label free binding assay figure 3 the fibronectin type iii homologous repeats 13 extracellular domain l1 mediate effect interestingly recombinant extracellular domain l1 recombinant extracellular domain chl1 inhibits aggregation vitro furthermore overexpression l1 injection adenoassociated virus encoding l1 decreases plaque load levels a42 a42/40 ratio astrogliosis mouse model ad carries human app pathogenic swedish mutation l166p mutated human presenilin-1 the extracellular domain ncam2 also binds oligomers vitro vivo cultured mouse hippocampal neurons hippocampus generating transgenic mice overexpressing human app containing pathogenic swedish mutation a oligomers also directly associate n terminus prp vitro human ad brain binding sites located within residues 2327 95110 prp 6771 interaction prp function load brain depend prp levels prp interacts synaptic proteins including n methyl aspartic acid- nmda- type glutamate receptors ncam binding oligomers prp interrupt physiological interactions prp synapses resulting disturbed neuronal communication prp deficient mice resistant neurotoxic effect oligomers antibodies prp prp peptides prevent oligomer induced neurotoxicity indicating prp involved molecular pathways activated oligomers induce neuronal cell death the cleavage fragment prp containing binding sites strongly suppresses toxicity cultured mouse hippocampal neurons vivo mice intracerebroventricular injections 69 76 however memory impairment induced injection oligomers reduced prp knockout mice ablation overexpression prp effect impairment hippocampal synaptic plasticity transgenic model ad synaptic depression reduction spine density blockade ltp induced organotypic hippocampal slice neurons wild type prp knockout mice neuroligin-1 enriched excitatory synapses extracellular domain binds vitro cultured rat hippocampal neurons rat cerebral cortex 80 81 neuroligin-1 acts nucleating factor aggregation process stimulating formation oligomers the soluble extracellular /-hydrolase fold che like domain neuroligin-1 reduces a-induced reduction synaptic density cultured rat hippocampal neurons field excitatory postsynaptic potentials fepsp rat hippocampal slices possibly competing synaptic neuroligin-1 binding indirect observations also suggest interacts integrins since toxicity inhibited human neurons pretreated adhesion blocking antibodies different subunits integrins particular 1 2 v inhibition 11 integrin also shown reduce toxicity rat hippocampal cultures a toxicity also inhibited disintegrin echistatin peptide isolated snake venom shown inhibit rgd dependent integrins v1 integrin ligands vitronectin fibronectin superfibronectin suggesting integrin ligands compete binding integrins application also reduces overall expression n cadherin cultured mouse cortical neurons suggesting bind n cadherins although reduction n cadherin proteolysis application reported another study the association n cadherin app mouse brains shown coimmunoprecipitation experiments unbiased search binding partners app using time controlled transcardiac perfusion cross linking followed high stringency immunoaffinity purification tandem mass spectrometry several cell adhesion molecules identified including prp igsf cams thy-1 contactin ncam1 neurofascin spite homology ncam2 ncam1 binds region app different a-containing region indicating interactions may play role physiological functions molecules agreement binding contactin-2 app increases release intracellular domain app -secretase dependent cleavage contactin-2 competitively inhibits binding app transforming growth factor 2 tgf2 binding tgf2 app induces neuronal cell death effect inhibited tag-1 suggesting tag-1 regulates interactions app extracellular ligands bace1 potential therapeutic target ad since bace1 cleavage app rate limiting step production synaptic cell adhesion molecules shown play role regulation bace1 activity high throughput sirna screen assessing 15,200 genes role secretion lrrtm3 identified neuronal gene promotes app processing bace1 knockdown lrrtm3 expression using sirna results reduced secretion cultured cells primary neurons overexpression lrrtm3 increases secretion suggesting lrrtm3 promotes bace1 activity in contrast overexpression prp results inhibited bace1-mediated cleavage app reduced production production increased brains prp knockout mice cultured n2a cells sirna mediated knockdown prp expression suggesting prp inhibits bace1 activity agreement follow study prp shown interact prodomain bace1 trans golgi network regulate targeting bace1 cell surface endosomes preferentially cleaves app prp reduces bace1-mediated cleavage wild type app human app swedish indiana familial mutations suggesting prp may play role sporadic ad familial ad interestingly region extreme n terminus prp critical interaction prp bace-1 prp dependent inhibition app cleaving activity also contains binding site oligomers these observations suggest prp play protective role inhibition bace1 pathogenic role binding toxic oligomers ad also suggest protective function prp affected oligomers an increase secretion also observed cells cotransfected n cadherin 85 95 cadherin promotes cell surface expression -secretase increases accessibility -secretase app altogether observations thus indicate synaptic cams involved regulation key enzymes involved production inhibition n cadherin function blocking inp peptides mimic short sequence ec1 domain n cadherin thus impair homophilic transsynaptic interaction n cadherin molecules accelerates a-induced synapse impairment characterized reduction frequency ampa receptor mediated miniature excitatory postsynaptic currents ampa mepscs reduced density synaptic boutons along dendrites cultured cortical neurons similar effects observed n cadherin function inhibited expression dominant negative truncated n cadherin lacking extracellular cadherin domains overexpression ectodomain shed c terminal fragment human n cadherin accumulates ad brains it noteworthy ectodomain shed c terminal fragment human n cadherin cleaved -secretase inhibition -secretase activity also accelerates a-induced synapse impairment inhibition n cadherin function alone effect numbers synapses frequency ampa mepscs interestingly disruption ncam2-mediated synaptic adhesion using recombinant extracellular domains ncam2 ncam2-ed results reduction synapse density along dendrites hippocampal neurons dispersion ampa receptors synapses ncam2-ed accumulates ad hippocampus effect synapse integrity similar additive effect it therefore possible a-dependent proteolysis ncam2 one initial synapse destabilizing effects followed disruption n cadherin containing adhesion complexes resulting complete synapse disassembly the complex formed neuroligin-1 also contains glun2b glun2a subunits nmda receptors suggesting directly affect function neuroligin-1 anchoring nmda receptors synapses whether binding synaptic cams directly contributes synapse loss investigated future studies while number observations indicate synaptic cell adhesion molecules affected ad understanding molecular cellular mechanisms underlying changes role disease progression still incomplete further studies assessing levels synaptic cams specifically synapses needed understand whether changes overall levels cams reflect changes synaptic adhesion whether increase levels specific proteolytic products cams csf sera ad patients reflect a-dependent proteolysis cams synapses interesting possibility analyzed future studies since synaptic cams play key roles maintenance synapse integrity function interacting synaptic scaffolding proteins neurotransmitter receptors analysis effects a-dependent disruption synaptic adhesion synaptic level may help understand molecular mechanisms initial stages ad furthermore number reports showing toxicity reduced targeting synaptic cams indicate synaptic cams deserve consideration molecular targets designing new treatments ad	alzheimer 's disease ( ad ) is a neurodegenerative brain disorder associated with the loss of synapses between neurons in the brain . synaptic cell adhesion molecules are cell surface glycoproteins which are expressed at the synaptic plasma membranes of neurons . these proteins play key roles in formation and maintenance of synapses and regulation of synaptic plasticity . genetic studies and biochemical analysis of the human brain tissue , cerebrospinal fluid , and sera from ad patients indicate that levels and function of synaptic cell adhesion molecules are affected in ad . synaptic cell adhesion molecules interact with a , a peptide accumulating in ad brains , which affects their expression and synaptic localization . synaptic cell adhesion molecules also regulate the production of a via interaction with the key enzymes involved in a formation . a-dependent changes in synaptic adhesion affect the function and integrity of synapses suggesting that alterations in synaptic adhesion play key roles in the disruption of neuronal networks in ad .
well established widely accepted virtually cervical cancer immediate precancerous lesions arise persisting cervical infection highly oncogenic hpv genotypes 1 2 the important hpv genotypes hpv16 hpv18 account ~70% invasive cervical cancers minor variations percentage continents fifteen hpv genotypes date classified high risk hr types 16 18 31 33 35 39 45 51 52 56 58 59 68 73 82 3 probably hr 26 53 66 12 low risk lr 6 11 40 42 43 44 54 61 70 72 81 cp6108 1 4 the majority hpv infections transient persistence hr hpv significant risk factor development cervical cancer it could genetic predisposition inadequate immune response and/or possible uncontrolled reaction tumor suppressor genes 5 6 type specific detection hpv increasingly important monitoring impact hpv vaccine implementation tool cervical cancer screening consequence the commercial hpv detection kits hybrid capture ii digene corporation gaithersburg md usa cervista hpv hr third wave technologies inc madison usa cervista 16/18 tests approved fda use routine screening hpv however assays unable discriminate specific genotypes identify infections involving multiple genotypes cervista assay detects two hpv types types 16 18 various molecular assays hpv detection typing used epidemiological studies based two different technologies 1 hybridization based assays e.g. hc ii 2 pcr based tests e.g. gp5+/gp6 pgmy09/11 inno lipa hpv genotyping innogenetics belgium linear arrays hpv test roche molecular systems inc branchburg nj usa clart hpv2 genomica madrid spain advantages disadvantages two basically different methodologies extensively discussed 719 qualitative linear array hpv la hpv hpv genotyping test developed roche molecular systems offers reliable sensitive standardized approach hpv typing cervical specimens it distributed research use submitted fda review this test utilizes amplification target dna pcr nucleic acid hybridization detection 37 types cervical cells collected lbc media dna extraction pcr amplification hybridization amplified products specific probes colourimetric detection hybrids strip 13 17 2022 current specimen processing protocols recommend use manual extraction dna using amplilute liquid media extraction kit based qiaamp method qiagen inc an alternative method dna extraction automated magna pure lc extraction system developed company the objective study evaluate compare automated magna pure dna extraction method amplilute dna extraction method detecting hpv dna form thinprep pap tests using linear array la hpv genotyping detection assays also correlate results cytological histological diagnosis in present study cervical brush specimens obtained women aged 17 70 years attended gynecologic outpatient clinic attikon university hospital athens greece opportunistic examination july 2009 may 2010 women considered eligible study fulfilled following criteria agreed undergo colposcopy necessary cervical biopsy b enough residual biological material cytological examination two molecular assays completed this patient population represent general population women attending public screening programs samples thinprep pap tests collected means brun's like brush the preservcyt vials corporate headquarters hologic inc ltd uk containing cell samples addressed department cytopathology aforementioned hospital preparation thin layer slides using thinprep 2000 automated slide processor corporate headquarters hologic inc cytological findings interpreted according bethesda classification system classified follows within normal limits wnl b atypical squamous cells undetermined significance asc us c low grade squamous intraepithelial lesion lsil high grade squamous intraepithelial lesion hsil the cytopathologists biologist conducting hpv testing blinded clinical profile ensure unbiased reporting the histological evaluation revealed following categories negative hpv cin 1 cin 2 cin 3 case histology showed cin 2 cin 3 patient referred appropriate treatment after slide preparation cytological examination remaining preservcyt samples vortexed vigorously 15 sec maximize homogeneity two aliquots 250 l 1 ml generated clinical specimen dna isolated using two different procedures 250 l aliquot extracted amplilute liquid media kit roche molecular systems conjunction qiavac 24 plus vacuum system according manufacturer instructions product insert ii 1 ml aliquot extracted magna pure lc extraction system using dna kit blood cells high performance protocol roche molecular systems briefly manual extraction samples hpv positive negative controls processed parallel clinical samples mixed vortexing form homologous state 250 l removed lysed proteinase k solution buffer atl 56c 30 min the samples underwent second incubation 70c 15 min presence buffer al containing carrier rna the lysate transferred vacuum columns isolation purification dna completed via washing different solutions bind dna remove cellular materials specimens controls immediately stored 2c8c 7 days frozen 20c 8 weeks automated extraction samples prepared using modified procedure involving centrifugation 1 ml aliquots preservcyt samples 13000 g 20 min prior discarding supernatant the resulted cell pellets resuspended 200 l sterile phosphate buffered saline procedure automated extraction followed according manufacturer instruction using dna kit the method based magnetic bead technology special buffer containing chaotropic salts proteinase k. nucleic acids bound surface magnetic glass particles cellular debris removed several washing steps purified nucleic acids eluted 100 l volume extracted genomic dna product obtained magnetic beads separated solution specimens controls immediately stored 2c8c 7 days frozen 20c 8 weeks after nucleic acid purification samples analyzed la hpv assay hpv genotyping the la genotyping test use pool biotinylated primers designed amplify approximately 450 bp sequence within polymorphic l1 region genome 37 hpv genotypes additional 268 bp primer pair targets human -globin gene is included assay provide control cell adequacy extraction amplification pcr carried samples controls using linear array hpv genotyping mastermix contains tris buffer potassium chloride amplitaq gold dna polymerase microbial amperase uracil n glycosylate enzyme microbial datp dctp dutp dgtp dttp upstream downstream primers biotinylated -globin primers sodium azide magnesium chloride amaranth dye the reaction mixture contained 50 l hpv mastermix 50 l eluted dna the amplification performed applied biosystems gold plated 96-well geneamp pcr system 9700 applied biosystems foster city calif usa using following thermal profile 2 min 50c 9 min 95c 30 sec 95c 1 min 55c 1 min 72c 40 cycles ramp rate set 50% followed 5 min 72c final hold 72c indefinitely pcr amplicons immediately denatured addition 100 l dn denaturation reagent stored 4c analysis within 7 days the detection hpv genotypes carried using la hpv detection kit once amplification completed 75 l denatured amplicon added linear array strips contain multiple copies hpv genotype specific probes defined area 37 genotypes -globin reference lines the hpv types detected hpv6 11 16 18 26 31 33 35 39 40 42 45 5156 58 59 61 62 64 6673 8184 is39 cp6108 the biotin labeled amplicon bound strips using hybridization buffer shaking waterbath 53c once bound strips washed high stringency remove nonbound material streptavidin horseradish peroxidase conjugate added bound biotin labeled amplicon hybridized oligonucleotide probes the strips washed substrate solution containing hydrogen peroxide 3,3,5,5-tetramethylbenzidine tmb presence hydrogen peroxide bound streptavidin horseradish peroxidase catalyzed oxidation tmb form blue colored complex precipitated probe positions hybridization occurred colourimetric determination color precipitation allowed manual reading strips genotype detection comparison with la test directly detect hpv52 combines set probes detects hpv33 35 58 hpv mix specimens test negative hpv33 35 58 individually positive hpv mix considered hpv52 positive the specimens test positive hpv mix hpv33 35 and/or 58 uncertain hpv52 status analysis specimens considered hpv52 negative since coinfection hpv52 ruled test the procedure performed two physically separated areas pre pcr post pcr order avoid contamination samples previously amplified products the reading strips produced two methods made one well experienced biomedical scientist discrepant interpretations resolved second biomedical scientist consensus review performed without knowledge prior results the la hpv test cross react variety viruses bacteria protozoa yeast could present cervical specimens pairwise comparison amplilute method magna pure method performed using kappa statistics a value 0 indicates agreement better chance value 1 indicates perfect agreement values 0 0.20 0.21 0.40 0.41 0.60 0.61 0.80 0.81 1.00 indicate poor fair moderate good good strengths agreement respectively receiver operating characteristics roc curve analysis applied calculate compare amplilute method magna pure method cytological findings in addition roc analysis applied calculate compare amplilute method magna pure method histological findings all statistical analyses obtained statistical package social sciences spss computer software a total 253 women analyzed present study means screening presence hpv dna using two different dna extraction methods 253 cervical smears 253 nucleic acid extracts produced using amplilute liquid media extraction method 253 dna extracts generated using magna pure automated extraction system all women referred colposcopy visible lesions found sampled the dna extracts evaluated la hpv genotyping test compared reported cytological histological diagnoses the levels sample adequacy cytological examination nucleic acid extraction amplification efficiency among specimens based -globin positivity differ dramatically tests table 1 sample adequacy higher amplilute extracts 100% magna pure method 99.6% cytology examination 97.6% only one nucleic acid extract generated magna pure lc invalid la genotyping test due absence high low -globin result the comparison hpv la test results using amplilute extracts equivalent magna pure extracts showed overall concordance 93.3% 0.864 p < hpv genotype profiles identical 228/253 90.1% specimens including 103 hpv negative samples 125 positive samples identical hpv status detected methods out 125 cases hpv profile identified 73 single infections 52 multiple infections discrepant results observed 25 samples including 11 cases amplilute(+)/magna( 5 cases amplilute()/magna(+ 5 cases identified single infections magna multiple type infections amplilute 3 cases multiple infections detected different hpv profile two methods one case magna generated invalid result opposed amplilute table 3 overall 94/253 37% women diagnosed normal cytology 50/253 19.8% exhibited ascus 91/253 36% diagnosed lsil 5/253 2% lsil positions hsil 7/253 3% hsil 6 cases 2.4% ) the cytological diagnosis difficult due inadequacy clinical samples tables 4 5 hpv positivity detected amplilute slightly higher compared magna pure 57.3% 54.9% respectively analytically cytological category wnl hpv positivity observed amplilute method 29/94 31% ascus 46% lsil 77% lsil hsil 100% hsil 100% hpv positivity detected magna pure lc method aforementioned categories 33% 44% 78% 80% 100% respectively tables 4 5 within studied population in total single hpv infections detected amplilute 28.5% magna pure 30.4% whereas multiple type infection observed 26.5% 23% respectively study the hpv distribution single infections divided two categories according hpv genotype oncogenicity lr hr well multiple infections divided three categories lr low risk hpv types present hr lr low- high risk hpv types present hr high risk hpv types present cytological categories studied given figure 1 amplilute method figure 2 magna pure more multiple infections detected amplilute method cytological categories compared magna pure p statistical significant analytically cytological category wnl composition multiple infections observed amplilute method 6.4% hr 4.2% hr lr 1% lr ascus 4% hr 12% hr lr 2% lr lsil 9% hr 24% hr lr 9% lr lsil hsil 40% hr 20% hr lr hsil 40% hr 20% hr lr multiple infections detected magna pure lc method aforementioned categories wnl 4.2% hr 4.2% hr lr 2% lr ascus 4% hr 8% hr lr 2% lr lsil 4% hr 23% hr lr 9% lr lsil hsil 20% hr 20% hr lr hsil 14% hr 43% hr lr the hpv type prevalence according two extraction methods given hpv16 frequent type detected types infections two methods followed hpv31 hpv53 hpv6 hpv33 hpv45 hpv42 hpv51 detected amplilute method hpv31 hpv53 hpv18 hpv51 hpv18 hpv6 hpv33 detected magna method data showed the two extraction methods compared cytological findings inadequate cytological samples excluded terms processing evaluation amplilute method obtained better results magna pure method amplilute sensitivity se 73.2% specificity sp 69.15% positive predictive value ppv 79.43% negative predictive value npv 61.32% magna pure se 67.32% sp 67.02% ppv 76.87% npv 55.75% both methods performed well compared cytological diagnosis nevertheless amplilute method demonstrated slightest higher area curve auc 0.712 std positive histological result found 129 cases patients normal cytology 13 94 13.8% biopsy hpv lesion cin 1 diagnosis patients ascus 14 50 28% hpv biopsy 8/50 16% cin 1 whereas 1 2% patient cin 2 lsil 29/91 31.8% biopsy diagnosis hpv 39/91 42.8% cin 1 7/91 7.7% cin 2 2/91 2.2% cin 3 all cases classified hsil thinprep cytology biopsy diagnosis either cin2 4/7 57.2% cin3 3/7 42.8% in lsil hsil category 1 patient 20% cin1 3/5 60% cin2 1/5 20% cin3 four patients cytological diagnosis due inadequate sampling biopsy revealed lesions hpv results biopsy reading hpv genotyping two extraction methods demonstrated tables 7 8 once amplilute method showed greater performance magna pure amplilute se 100% sp 87.5% ppv 98.47% npv 100% fpr 12.5% fnr 0.00% oa 98.62% magna pure se 91.47% sp 81.25% ppv 97.52% npv 54.17% fpr 18.75% fnr 8.53% oa 90.34% error 0.018 95% ci 0.9000.971 p .001 higher compared auc magna pure method 0.877 std the la hpv genotyping test provides standardized consistent rapid means hpv detection genotyping this test provides capacity identify 37 individual hpv genotypes within given specimen ascertain whether recurrent hpv positivity fact due persistence specific hr hpv genotype meaning substantially increased risk disease progression 2325 current specimen processing protocols recommend use manual extraction dna using amplilute liquid media extraction kit based qiaamp method qiagen inc this method dna preparation time consuming labor intensive prone potential specimen cross contamination particularly large numbers specimens processed an alternative method dna extraction automated magna pure lc extraction system developed company could facilitate assay minimizing potential sample contamination hands time well increase labor efficiency sample accuracy present study assessed dna extracts form preservcyt cervical samples generated automated magna pure extraction system manual amplilute method recommended roche hpv testing using la hpv genotyping detection assays in addition correlated results cytological histological findings enrolled participants among 253 thinprep pap tests analyzed study only one extract magna pure modified dna extraction protocol found invalid due absence low high -globin in contrast nucleic acids generated amplilute protocol valid hpv dna genotyping this marginal difference sample adequacy could either due high amplilute protocol efficiency variations aliquoting specific sample resulting inadequacy cellular material automated procedure comparison hpv genotyping results obtained amplilute dna magna demonstrated substantial level agreement 93.3% value 0.864 both extraction methods terms qualitative results performed equally well compared cytological diagnosis amplilute method demonstrating small predominance auc amplilute 0.712 versus auc magna 0.672 nevertheless amplilute method exhibited higher sensitivity specificity positive negative predictive values opposed magna method outcome amplilute method efficient magna noticed compared two methods histological diagnosis auc amplilute 0.935 contrast auc magna 0.877 hpv types identified individual samples method largely agreement 90.1% 228/253 studied cases for former hpv overall positivity calculated 57.3% comprising 30.4% hpv detected single infection 27% multiple latter respective positivity 54.5% 32% single 23% multiple type infection the prevalence hpv infected samples increased methods severity cytological diagnoses 30.8% amplilute versus 33% magna wnl 46% versus 44% ascus 84.6% versus 77% lsil 100% versus 80% lsil hsil 100% hsil since limited greek epidemiological data available studies yielded similar findings healthy women results report papachristou et al found corresponding prevalence 31.5% agorastos et al 36.3% other studies country demonstrated hpv dna presence wnl varied 24% 28 29 18% 30 31 lowest prevalence reported 2.5% this variability also observed widely literature mainly due different criteria used selecting study population also due different molecular test applied the biological meaning latent hpv infections apparent underlying disease would otherwise diagnosed cytological evaluation detectable highly sensitive pcr based methods amplilute correctly identified 87.5% negative histological cases hpv negative samples compared 81.2% magna in addition cases histological evaluation hpv cin2 magna missed 10 cases counting 8% 10/123 population specific histological abnormalities whereas cases accurately detected hpv positive samples amplilute 144 cases cytological findings wnl ascus hpv detected approximately 52 cases 50% hr hpv types 33 participants exhibited histological lesions hpv cin2 the remaining cases need followed closely due elevated risk developing high grade cervical lesion future the small number cases investigated present study limits ability conclude correct representative epidemiological data hpv prevalence greek women nevertheless data report hpv distribution add rich body literature demonstrating hpv 16 frequent type detected types infections followed hr hpv 31 53 33 45 18 51 the observation hpv 53 among three prevalent hr hpv types detected consistent findings previous greek studies 28 31 however prevalence clinical role hpv 51 needs clarified studies critical points multiple infections succinctly presented since detailed analysis multiple infections identified clinical specimens beyond scope work discussed analytically report nevertheless highly detected among hpv positive participants 47% 68/145 amplilute 42% 58/138 magna multiple type hpv infections identified approximately 50% hpv infected individuals wnl category 34% ascus 50% lsil lsil hsil finally 60% hsil category the elevated incidence rate multiple infections results line results described sandri et al found multiple infections 43% studied population gargiulo et al in 49.7% regarding discordant results observed two extraction methods showed table 3 44% 11/25 cases magna failed detecting hpv opposed amplilute ten eleven cases histological confirmed hpv correctly identified amplilute 20% 5/25 cases positive magna negative amplilute method there either negative histology normal cytology without visible lesion upon colposcopy thus women cervical biopsy taken this regard amplilute method gave correct negative call cases could considered magna false positive results 32% 8/25 cases positive two methods differing number hpv genotypes detected amplilute demonstrated higher level detecting additional hpv genotypes seven cases apart common shared types opposed magna those extra genotypes detected carry increased clinical significance since hr genotypes could alter clinical outcome patient one case 4% 1/25 hpv genotypes completely different two methods also one case magna detected one extra genotype amplilute even though patient population studied represent general population attending hospital women agreed undergo examination necessary clinical samples tested covered range pathologies samples cytologically normal samples hsil therefore results well discordant result rate hpv detection generated two extraction methods demonstrated present study representative hpv infection screening population it important mention decision utilizing modified dna protocol automated magna pure extraction system made based recent report it compares dna extraction efficiencies using extraction system incorporation three different working dna extraction kits blood cells high performance protol dna kit ii total nucleic acid tna kit iii modified dna kit manual amplilute protocol amplicor la hpv tests 150 specimens although women enrolled study histological confirmed cervical abnormalities comparison made dna extracts hpv genotyping test cytohistological findings we used modified dna kit blood cells high performance protol using 1 ml preservcyt sample reported stevens et al since performed better two protocols recommended author point important emphasise even though manual amplilute method used one fourth biological material 250 l opposed automated magna dna modified protocol 1000 l equal amount dna extract inputs used pcr amplification 50 l subsequently hpv detection hpv positive cases detected manual method someone would assume increased hpv genotype detection would occur bigger amount clinical sample incorporated dna extraction procedure since representative epithelial cells would present sample tested thus increasing possibility hpv genotypes detected assay used the findings report contrast previous reported one declared opposite indicating current manual amplilute protocol dna preparation provides adequate dna quality consequently capable detecting hpv infections high sensitivity having mind methods gave comparative results tested cytology histology data provide additional advantage amplilute since reliable results obtained even small volumes biological material available molecular use literature also report utilizing magna pure automated extraction system compares amplicor hpv test inno lipa hpv genotyping test using tna extraction kit dna isolation amplicor test making thus difficult direct comparison work several studies undertaken assessment utility various automated dna extraction platforms conjunction la hpv test without comparing manual extraction methods 34 36 37 moreover literature limited studies address variability hpv genotyping introduced small changes front end dna extraction procedures prior use la hpv genotyping test 38 39 reports interesting found minor changes equally valid dna extraction methods appeared vary assay performance for example varying volume preservcyt dna extraction varying centrifuge speed dna extraction varying amount template dna used amplification impact assay results it well documented widely accepted difficult achieve reproducible accurate hpv genotyping results using pcr based methods particularly individual specimens may contain multiple concurrent infections and/or low viral copy numbers each many steps testing collection cervical sample final recording result introduce important variability large scale data comparing different methods dna isolation needed reach optimal protocol hpv presence detection accurate genotyping order monitor viral clearance importantly hpv persistence considered key factor cervical cancer development moreover accurate sensitive methods detection hpv determined since performance strongly affect results epidemiological studies clinical treatment strategy selected therefore magna extraction method tested automated manual nucleic acids isolation techniques large population studies implemented routinely used laboratories if would proven accurate detecting hpv infection laboratories particularly involved large scale hpv genotyping studies handling large amount clinical specimens afford cost automated procedure two half times pricey manual procedure could profit automated nucleic acid isolation technique accurate laboratory assays diagnosis hpv infection recognized increasingly essential clinical management women cervical precancerous lesions the first important step molecular diagnosis hpv infection nucleic acid isolation an alternative approach manual extraction procedures time consuming labor intense automated processing clinical specimens hpv detection genotyping minimizes potential sample contamination hands time data concluded dna extraction methods demonstrated similar clinical performance significant difference outcomes assessed even outcomes amplilute method exhibited higher sensitivity specificity positive negative predictive values opposed magna methods based results study automated nucleic acid isolation method tested versus automated manual techniques routinely implemented in addition additional studies larger populations required carried using automated extraction system order potential value accurate hpv detection determined	nucleic acids of human papillomavirus ( hpv ) isolated by manual extraction method ( amplilute ) and automated magna pure system were compared and evaluated with cytohistological findings in 253 women . the concordance level between amplilute and magna was very good 93.3% ( = 0.864 , p < .0001 ) . overall hpvpositivity detected by amplilute was 57.3% ( 30.4% as single and 27% as multiple infections ) in contrast to magna 54.5% ( 32% and 23% , resp . ) . discrepant results observed in 25 cases : 11 magna()/amplilute(+ ) , 10 of which had positive histology ; 5 magna(+)/amplilute( ) with negative histology ; 8 magna(+)/amplilute(+ ) : in 7 of which amplilute detected extra hpv genotypes and 1 magna(invalid)/amplilute(+ ) with positive histology . both methods performed well when compared against cytological ( area under curve ( auc ) of amplilute 0.712 versus 0.672 of magna ) and histological diagnoses ( auc of amplilute 0.935 versus 0.877 of magna ) , with amplilute showing a slightly predominance over magna . however , higher sensitivities , specificities , and positive / negative predictive values were obtained by amplilute .
mycobacterium avium subspecies paratuberculosis map cause johne disease jd emerged major pathogen concern human health worldwide also associated crohn disease cd human beings 13 cd chronic incurable inflammatory bowel disease ibd gastrointestinal tract git involving mesenteric regional lymph nodes resulting chronic segmental inflammation commonly involves distal ileum proximal colon though lesions occur location throughout git association map cases cd supported frequent isolation map significantly higher number cd patients patients bowel disease syndromes healthy controls 2 3 studies also shown like animal paratuberculosis map infection humans systematic 3 4 pcr situ hybridization molecular tools successfully detected map dna tissues blood samples cd patients 57 immunological studies using specific highly purified recombinant antigens also supported association map infection cases cd 810 developed countries commercial elisa kits employed detection map antibodies animals successfully adopted screening human serum samples 11 12 indigenous elisa kit developed india significantly superior compared imported commercial elisa kits screening animals 13 14 recently singh et al reported high prevalence map animal health care workers cd patients however view lack indigenous diagnostic kits reagents information prevalence map ibd patients consisting ulcerative colitis crohn disease 1.2 billion human population country limited the study employed indigenous absorbed elisa kit based protoplasmic antigen native map genotype recovered biopsies cd patient 46 estimation sero prevalence map antibodies human population north india the study conducted three phases semipurified protoplasmic antigen pa ) strain a46 map recovered biopsies cd patient fourth passage level map subpassaged 710 slants hey medium mycobactin j 37c 8 months growth harvested washed sonicated 100 w 15 hz 20 min ice slurry giving 20 cycles 30 rest sonicate centrifuged 9727 g 30 min 4c using biocentrifuge supernatant dispensed aliquots 0.5 1 ml stored 20c till use a portion aliquots used protein measurement per lowry et al presently country lacks indigenous kits screening either animal human serum samples present study standardized per milner et al employed optimum concentration antigen serum second antibody conjugate determined checkerboard analysis pa 0.1 g per well serum dilution 1 50 rabbit anti human horseradish peroxidase 1 8000 reduce background colour nonspecific binding protein optimum blocking agent concentration standardized using signal noise ratio since skimmed milk 3% pbs had highest noise ratio therefore employed blocking agent indigenous absorbed elisa kit the 0.1 g semipurified protoplasmic antigen pa 100 l carbonate bicarbonate buffer ph 9.6 used coating duplicate wells flat bottom 96 well elisa plate grenier bio one plates incubated overnight 4c followed washing thrice washing buffer pbst pbs 0.05% tween 20 blocking done 200 l 3% skimmed milk pbs incubated 37c 1 h. incubation plates washed thrice pbst 100 l test serum preabsorbed pbst containing 1% bsa 2 mg ml mycobacterium phlei overnight 4c per method klausen et al added duplicate well incubated 2 h 37c incubation three washings 5 minutes given pbst 100 l optimally pbs diluted 1 8000 conjugate sigma added wells plate incubated 1 h 37c washed three times pbst finally 200 l freshly prepared substrate ortho phenylene diamine dihydrochloride-(opd 5 mg per plate substrate buffer ph 5.0 added well following incubation dark 20 min room temperature absorbance read 450 nm elisa reader without addition stop solution 5 n h2so4 blank positive conjugate controls also run along serum samples plate od values test samples transformed p ratio per collins samples positive ratios corresponding strong positive category collins considered positive map infection sensitivity specificity kit were evaluated per arizmendi grimes using 40 human serum samples 5 cd 22 uc patients 13 healthy human subjects known map culture record samples cd uc patients collected department gastroenterology india institute medical sciences aiims new delhi asopa hospital research center agra india samples healthy human subjects blood donors aastha pathology laboratory agra india performance kit respect stool culture compared calculating kappa scores proportional agreement per altman 0 poor 0.00.20 slight 0.210.40 fair 0.410.60 moderate 0.610.80 substantial 0.81100 almost perfect serum samples collected randomly 452 human beings 329 males 123 females northern region country 2004 2008 screened map antibodies geographically serum samples obtained human beings belonging states uttar pradesh 180 rajasthan 47 jammu kashmir 16 uttra khand 12 himanchal pradesh 2 punjab 50 haryana 65 new delhi 70 north india these serum samples obtained human subject without known disease history map antibodies therefore considered normal serum samples screened using indigenous absorbed elisa kit reproducibility results reduce well well plate plate variations tests performed using four known positive three negative control serum samples obtained earlier studies to estimate sensitivity specificity indigenous absorbed elisa kit culture elisa tests compared stool serum samples 40 human beings the 15.0 6 12.5% 5 samples positive exclusively culture elisa kit respectively there substantial perfect agreement proportion agreement 0.72 kappa value 0.24 two tests of 40 human serum samples cd uc patients normal human beings used optimization indigenous absorbed elisa kit prevalence map higher 18.5% inflammatory bowel disease cd uc patients compared normal human subjects 15.3 however individually 80.0 4.5 15.3% serum samples positive cd uc patients normal human beings respectively table 1 of 452 human serum samples screened north india 23.4% positive anti map antibodies table 2 seroprevalence map antibodies higher females 31.7% compared male population 20.3% north india state wise highest seroprevalence found samples punjab 34.0% followed uttarakhand 33.3% new delhi 32.8% himachal pradesh 25.0% haryana 23.% uttar pradesh 17.7% jammu kashmir 12.5% in present study indigenous absorbed elisa kit based native isolate map human origin was standardized detect map antibodies ibd cd uc patients estimate seroprevalence map infection human beings north india elisa rapid cost effective alternative organism detection detect low concentration antibodies early late stages map infection optimum antigen concentration 0.1 g well compared 1.0 g well used molina et al in present study 1 50 serum dilution used compared 1 25 lower serum dilution used molina et al detection map antibodies animals the use lower concentration native antigen higher dilution serum indigenous absorbed elisa kit may due higher pathogenicity indian map strain indian bison type animals to reduce background noise proteins 3% skimmed milk found optimum blocking agent compared 5 10% skimmed milk 3 5 10% bovine serum albumin johnson et al also reported superiority skimmed milk blocking agent comparison bsa cutoff value calculated sample positive p ratio instead average od negative samples 2 sd 15 18 22 several researchers advocated quantitative evaluation od values p ratios rather relying solely positive negative classifications defined single cutoff value 30 31 studies reported relatively consistent increase likelihood ratios optical density p ratios increased relative concurrent fecal culture result known infection status 32 33 other researchers also used p ratio cutoff value detection map antibodies human 11 12 animals 16 31 samples the presence map antibodies higher cd patients 80.0% compared uc patients 4.5% normal human subjects 15.3% using indigenous absorbed elisa kit other researchers 10 11 also reported higher presence map cd patients compared uc patients control subjects the lower presence antibodies uc patients compared healthy controls may attributed altered immune response due use immunosuppressive drugs treatment unlike present findings 35.0% seropositivity rates groups population based study reported bernstein et al and difference rate positive samples cd uc patients healthy controls nonaffected siblings sensitivity specificity indigenous absorbed elisa kit respect stool culture 40.0 83.3% respectively slightly lower specificity elisa kit may attributed presence cell wall deficient cwd forms map bacilli human beings indigenous absorbed elisa kit comparable sensitivity specificity respect imported commercial elisa kits employed screen serum samples cattle goat sheep origin unpublished data therefore indigenous absorbed elisa kit may employed screening anti map antibodies humans animals the new indigenous elisa kit facilitated screening large number human serum samples seropresence map antibodies human beings north india 23.4% a previous study reported 38.0% prevalence map human subjects agra region using indigenous un absorbed elisa kit marginally lowered prevalence map antibodies present study may due pre adsorption test serum m. phlei female subjects 31.7% higher presence map antibodies compared male subjects 20.3% this may attributed poor sanitation lowered nutritional status additional physical stress pregnancy parturition lactation etc females reported animals therefore high prevalence map human beings may due higher bioburden map environment and/or presence map food chain 19 37 38 bernstein et al also reported higher 33.6% seroprevalence map population manitoba adapting . indicated manitobans simply exposed map population north india different genetic ability mount response infection within states india seropresence map human beings ranged 12.5 34.0% table 1 higher sero presence map antibodies may conclusive map infection human population north india however detection map antibodies higher numbers human samples indicated higher exposure human population map infection therefore control map infection source population animals required reduce exposure human population	in present pilot study aimed to estimate , presence of mycobacterium avium subspecies paratuberculosis ( map ) antibodies in the human serum samples originating from north india using indigenous absorbed elisa kit ( elisa kit ) . the phase i , elisa kit was optimized using protoplasmic antigen from native isolate of map indian bison type recovered from the biopsies of crohn 's disease patients . the phase ii , sensitivity and specificity of the kit were estimated as 40.0 and 83.3% , respectively , when evaluated in 40 human serum samples ( 5 crohn 's disease and 22 ulcerative colitis patients and 13 healthy human subjects ) with defined map status with respect to stool culture . seroprevalence of map antibodies was higher in cd patients ( 80.0% ) as compared to ulcerative colitis patients ( 4.5% ) and normal human subjects ( 15.3% ) . the phase iii , seroprevalence of map antibodies was estimated as 23.4% , on the basis of the screening of 452 human serum samples ( without history ) from different geographical regions of north india . region - wise , 34.0 , 33.3 , 32.8 , 25.0 , 23.0 , 17.7 , and 12.5% samples were positive from the states of punjab , uttarakhand , new delhi , himachal pradesh , haryana , uttar pradesh and jammu and kashmir , respectively . study reported moderately higher presence of map antibodies in human population , which necessitates programs to reduce the bioburden of map in the environment and in animal population .
numerous biological processes including immune recognition animal development misregulation development cancer cell progression involve signaling interactions across cell cell junctions juxtacrine configuration ligands receptors bind apposed cell surfaces supported lipid membranes reconstitute functional juxtacrine signaling interfaces living cells useful tool study manipulate interactions protein ligands would naturally occur one cell surface instead synthetically coupled supported membrane the lateral mobility supported membrane enables ligands diffuse assemble functional clusters engage cognate ligands adjacent live cell surface signaling clusters emerging general phenomenon common many juxtacrine signaling interactions recent studies eph egfr families receptor tyrosine kinases rtks indicate heterooligomerization proteins within signaling clusters may exert additional layers regulatory control the increasing numbers therapeutic bispecific antibodies entering clinical trials suggest may possible modulate signaling cluster content therapeutic benefit goal extending utility supported membranes study complex multicomponent clusters demonstrated success dna based protein assembly we report dna based assembly strategy associate proteins membranes control assembly defined heterodimers higher order oligomers thiol functionalized dna coupled maleimide functionalized supported membranes unlike strategies incorporate long alkyl chains onto dna solid phase synthesis strategy permitted dna conjugation preformed membranes study supported membranes 1:20 molar ratio maleimide functionalized phospholipids 1,2-dioleoyl sn glycero-3-phosphocholine used the supported membrane prepared phosphate buffered saline pbs 10 mm phosphate buffer 150 mm nacl vesicle deposition clean glass described supporting information si attachment dna lateral fluidity membrane confirmed fluorescence recovery photobleaching frap treating supported membrane 20 nt single stranded dna ssdna bearing 5-thiol modifier 3-6-carboxyfluorescein fam moiety figure 1a ( representative frap characterization supported membrane fluorescently labeled ssdna shown ( b surface density coupled dna varied large concentration range excitation light interleaved allow time resolved data collection shown graph thus removal contribution fluorescence signal bleedthrough cross correlation ( b fccs analysis indicated codiffusion dna bound fluorophores suggesting formed heterodimer ( c table compares relative cross correlation amplitudes lower two autocorrelation amplitudes including positive negative control samples shown si figure s5 the surface density conjugated dna quantified using membrane standards known lipid fluorophore surface densities figure s1 si conjugation 20 nt 41 nt ssdna supported membranes hybridization tex615 alexa fluor 488 af488 labeled complementary strands resulting samples allowed quantification dna membrane surface comparing observed fluorescence intensities dna samples membrane standards surface density dna increased proportionally concentration thiol dna applied figure 1b incubation concentrations dna low micromolar range surface densities range 03000 strands/m observed addition thiol dna concentrations 6 resulted increases measured surface density however larger variations identical samples observed relationship surface density incubation concentration became nonlinear ssdna 41 nt coupled supported membrane less efficiently 20 nt ssdna conditions pbs ph 7.4 use ph 8.5 borate buffered saline bbs 10 mm borate 150 mm nacl higher ph buffer yielded surface densities 41 nt ssdna similar 20 nt ssdna coupled lower ph figure 1b assembly complex structures designed dna heterodimers using previously published assembly sequences several strand configurations evaluated shown si figure s3 particularly successful strategy formation four strand the two arms branched structures labeled green red fluorophores shown figure 2b allowing characterization two color fluorescence cross correlation spectroscopy fccs pulsed interleaved excitation pie see figure 2a experimental diagram si figure s2 fccs used characterize binding characteristics biomolecules enzymatic activity clustering cell membranes pie eliminates artifactual cross correlation fluorescence spectral bleed exciting sample interleaved laser pulses the red peak broad since pulsing achieved electro optic modulation continuous wave krar laser the amplitude cross correlation function proportional concentration dual labeled species measurement parameter obscured variety artifacts raise lower measured cross correlation amplitude using control samples establish upper lower bounds cross correlation measurement enables calibration cross correlation signal quantification amount heterodimer formed si figure s5 performing analysis data shown figure 2c provides estimate 5260% yield assembled heterodimer formation protein heterodimers demonstrated assembling heterodimers fab fragment dna conjugates effectively reconstructing membrane bound antibodies fab fragments generated igg antibodies readily obtained many proteins for study f(ab)2 fragments generated polyclonal donkey anti mouse antibodies obtained commercial source labeled fluorophores partially reduced 2-mercaptoethylamine 2-mea produce fab fragments free thiol groups c terminal regions figure 3a the products thoroughly desalted treated maleimide functionalized 20 nt ssdna see si procedures figure s6 maldi tof ms characterization data the conjugates purified size exclusion chromatography figure 3b analyzed gel electrophoresis sds page figure 3c separation proteins free ssdna shown chromatogram figure 3b after treating fab fragments maleimide dna gel electrophoresis analysis indicated species higher molecular weight compared unmodified fab fragments figure 3c these conjugates prepared different sequences dna labeled distinct fluorophores heterodimer could prepared dna functionalized supported membranes shown figure 3d the resulting structure analyzed fccs measure heterodimerization figure 3e comparing cross correlation amplitude doubly labeled control sample determined 4244% assembly yield obtained heterodimeric structure when expanded antibody fragments different specificities technique provides way colocalize two different receptors using convenient synthetic protocol ( 2 fab removal 2-mea reducing agent 3 fab removal 2-mea reducing agent 4 fab treated maleimide dna 5 highest molecular weight peak sec chromatography blue shading 6 intermediate molecular weight peak sec orange shading entry r table indicates reagent removed fccs analysis confirmed formation fab heterodimer using pooled fractions evaluation nonspecific interactions dna functionalized membranes living cells accessibility dna presented cells performed modification live jurkat cells surface ssdnas described previously cells incubated membranes functionalized ssdna sequences either complementary noncomplementary cell surface ssdna membrane identical composition dna functionalization upon washing cells bound membranes functionalized complementary ssdna in addition one layer cells visible sample containing complementary dna focus cells visible samples rinsing ( nonadherent jurkat cells functionalized ssdna attached membranes functionalized complementary dna strands few bound cells observed maleimide capped sample lacked dna ( b dna anchored ephrina1-yfp his10 construct stimulated mda mb-231 cells images epha2 stained antibody cell permeabilization imaged tirf microscopy ( c heterodimeric protein complexes egf inert fab fragment remain intact interaction mda mb-231 cells presentation functional ligand cell surface receptor confirmed membrane anchored dna useful anchor protein presentation live cells ephina1-yfp his10 stimulates epha2 receptor presented supported membrane linked nta3dna fluorescence signal yfp portion protein dna conjugate confirmed presence protein frap analysis confirmed lateral mobility anchored protein mda mb-231 cells incubated ephrina1-functionalized bilayers 1 h fixed formaldehyde solution stained anti epha2 antibody analysis total internal reflection fluorescence tirf microscopy illuminates interface cell substrate showed colocalization membrane bound epha2 receptors ephrina1 expected previous reports using biotin the ability direct molecules signaling clusters demonstrated using epidermal growth factor egf presented mda mb-231 cells egf typically soluble ligand presentation cells membrane surface results visible clustering ligand upon conjugation cy3-labeled dna figure s8 si hybridization conjugate dna functionalized membranes presentation mda mb-231 cells clustering egf phosphorylation egfr observed figure 4c fab fragment binding target cell membrane presentation heterodimer molecules resulted clustering evidence disruption receptor phosphorylation observed these observations demonstrate colocalization anchored molecules directed independently inherent propensity molecules colocalize we plan use directed dimerization study effect signaling cluster composition epha2 signaling epha2 observed interact receptors eph egfr families rtks provide extra stability ephrina1dna conjugate designed expressed purified ephrina1snaptag fusion conjugated molecule dna figure s9 si strategy also used studies egf ephrina1 dna conjugates presented mda mb-231 cells express egfr epha2 figure 5a size dna heterodimer well diffraction limit differences colocalization samples containing monomeric ligands samples containing dimeric ligands could observed figure 5b analysis fixed cells shows clear difference colocalization figure 5b see si figure s10 description data analysis monomer heterodimer presented samples since variations ligand distribution seen also expect see differences receptor distribution cells presented monomeric ligand presented dimeric ligand when staining cells antibody phosphorylated tyrosine 1173 py egfr egfr receptor colocalization measurements decrease likely caused incomplete antigen staining amount nonspecific binding colocalization ephrina1 ligand egfr receptor considerably increased cells presented heterodimer demonstrating egfr binding ligand recruiting ephrina1 molecule this observation suggests heterodimer able interact egfr receptor ligand receptor binding preserved slight decrease egf egfr colocalization observed heterodimeric sample relative monomeric control suggesting interaction somewhat inhibited additionally working purify intact complexes cell lysate immunoprecipitation alteration receptor localization cells ( mda mb-231 cells deposited supported membranes containing dna bearing monomeric dimeric ligand ( b tirf microscopy analysis demonstrates ligands appear segregated presented monomers colocalized presented dimers colocalization measured correlation coefficient ephrinal clusters described detail si ( c immunofluorescence staining ptyr-1173 residue egfr cells b shows receptor localization altered presentation ligands the scale bar represents 10 error bars depict standard error mean numbers inset example images denote actual correlation coefficient two channels shown particular image we demonstrated ability dna anchors extending supported membranes present functional protein ligands cells also shown strategy capable generating heterodimeric structures direct molecular composition cell membrane receptor clusters	we present a method based on self - assembling oligonucleotides to anchor proteins to a supported membrane surface . this anchoring method allows control of the surface density of multiple proteins . by incorporating additional recognition sequences into the dna linkers , defined heterodimers can be produced upon the addition of a heterospecific dna cross - linking strand . characterization by fluorescence cross - correlation spectroscopy ( fccs ) confirmed lateral mobility and the formation of specific heterodimers . we further demonstrate that proteins linked in this manner as either monomers or dimers can form functional interfaces with living cells .
prominent view cognitive emotional processes assumes conceptual knowledge emerges bottom perceptual processes conceptual modal symbolic systems an alternative view proposed theoretical framework theories grounded cognition 24 suggesting associative limbic sensorimotor functional components automatically reactivated access specific conceptual knowledge this theoretical view assumes disturbing motor processing induce recognition impairment perceptual level for instance strack et al shown participants holding pen lips inhibit smiling holding pen teeth facilitate smiling figure 1 produced significant emotional modulation respect funniness cartoons depending group inhibited facial muscles follows argue consistent grounded cognition theory motor disorders characterizing different psychopathologies parkinson disease tourette syndrome could sufficient induce disturbances emotion processing different neural structures identified playing important role grounded cognition for example type links motor systems action understanding previously developed literature mirror neurons first shown monkeys 6 7 recently among humans premotor parietal areas identified important neural structures mirror neuron system 68 cortical mirror neurons interpreted automatic neural processes involved basic implicit comprehension action individuals 6 7 similar line research wicker et al have shown mirror neurons level insula may support feeling perception disgust this finding suggests mirror neuron areas dedicated functional integration motor also emotional processes could widely spread across different high level cortical areas among high level cortical structures for example right hemisphere cortex seems particularly involved processing recognition emotional expressions lesion studies specifically implicate somatosensory cortex attempt shed light function anatomical structures adolphs et al carried quantitative study involving detailed analysis 108 subjects focal brain lesions results show major implication right somatosensory cortices including right anterior supramarginal gyrus lower sector ii insula left frontal operculum recognizing six basic emotional facial expressions lesser extent consistent previous studies lesions right visual related cortices also induced deficit recognizing specific facial expressions especially fearful expressions moreover adolphs et al found complementary results showing lesions include right inferior parietal cortex induced impairments recognition negative emotions especially fear sadness consequently proposed right somatosensory cortex generate representation feeling state sometimes used recognition it important note structures involved recognizing basic emotional facial expressions seem slightly different involved conceptual knowledge emotions showing involvement right somatosensory related cortices including ii insula supramarginal gyrus access conceptual knowledge investigated authors means task requiring sorting efe photographs piles according similarity emotion displayed it argued task necessarily require conceptual knowledge rather assessment perceptual similarity could sufficient perform given task these differences goals functions somatosensory cortices versus parietal temporal cortical areas illustrate difference feeling perceptual recognition specific emotional expression further studies psychology cognitive neuroscience carefully differentiate psychological tasks subcortical structures might also play central role integration sensorimotor limbic associative inputs yelnik colleagues shown different neural structures constituting basal ganglia instance caudate nucleus striatum course subthalamic nucleus integrate sensory motor associative limbic functional components figure 2 this suggests motor disorders induced subcortical dysfunctions level basal ganglia could either direct indirect effect emotion processes recognition efes impairment motor processing parkinson disease pd characterized degeneration dopaminergic neurons substantia nigra pars compacta leading motor well associative addictive disorders 1416 the motor disorders characterizing pd produced modulation neural activity striatal structures innervated neurons substantia nigra pars compacta dopaminergic depletion produced degeneration substantia nigra pars compacta induces functional hyperactivity subthalamic nuclei consequently leads motor disorders could modulated l dopa therapy moreover bilateral deep brain stimulation subthalamic nuclei stn dbs often used therapy patients stn dbs well documented efficient treatment severely disabled parkinson disease hereafter pd patients intractable motor complications although compelling evidence clinical efficiency stn dbs motor symptoms 18 19 still ongoing debate effects stn dbs behavioral emotional manifestations one hand biseul et al showed stn dbs may produce significant emotional impairment specifically recognition fear however hand dujardin et al reported extensive impact stn dbs pd patients concerning recognition emotional expressions these results raise hypothesis l dopa stn dbs therapies impact motor well emotional behavior however addition emotional troubles induced central disorders emotional disorders might indirectly induced peripheral dysfunction among different motor disorders which pd patients suffer amimia often appears consequence motor symptoms pd this motor problem may consequences subsequent emotional processes proposed elsewhere framework grounded cognition 2 3 22 23 the facial amimia suffered pd patients induces severe long term deficiencies temporarily holding pen one mouth course experiment we believe motor disorders may induce wide range emotional impairments could demonstrated even emotion recognition tasks as pd tourette syndrome ts characterized part motor disorders whereas pd patients often suffer facial amimia ts patients often facial tics more precisely ts neuropsychiatric syndrome defined chronic multiple motor vocal tics sometimes accompanied anxiety obsessive compulsive disorders ocd suggested mink basal ganglia frontocortical dysfunctions probably constitute root ts physiopathology see also review proposed neurophysiological neuropsychological data ocd highlight abnormalities frontostriatal regions may potentially mediate correct recognition emotional expressions albin mink suggest dopaminergic dysregulation could root tourette syndrome hypothesis based biochemical analyses postmortem striatum ts patients revealing significant elevation number dopamine uptake carrier sites 29 30 the hypothesis also derived animal data shows injection dopaminergic agonist increases production motor stereotypy similar ts treated animals moreover collectively dopaminergic sensitivity ts could sufficient induce motor dysfunction verbal also motor tics theories grounded cognition extended account emotion processing suggest motor disorders might produce deficits processing emotional information previously suggested parkinson disease that regards parkinson disease dopaminergic dysfunction basal ganglia might induce compromised processing motor functions consecutive consequences emotional information processing based embodiment theory motor disorders characterizing tourette syndrome motor hyperactivity tics parkinson disease dyskinesia sufficient produce emotional disturbance suggested previous findings see also review motor dysfunction peripheral level sufficient induce emotional modulation central level moreover recent debate shows consequences embodiment theory emotional processes could fast beyond scope consciousness 3335 however potential influence dopaminergic dysfunction emotional processes motor disorders could accompanied problems directly affecting central level concerning parkinson disease shown dopaminergic depletion important consequences motor level hyperactivity subthalamic nuclei however reported yelnik et al in words dopaminergic depletion could also major influence limbic associative functional components indirectly motor disorders peripheral level also directly level central nervous system subthalamic nuclei hyperactivity moreover dopaminergic depletion may functional consequences neural structures level basal ganglia specifically limbic components subcortical structures well related cortical areas this implies dopaminergic depletion could direct influence emotional processes occurring central level also indirect influence based embodiment theory example facial amimia observed peripheral level similar conclusions drawn tourette syndrome dopaminergic hypersensitivity proposed might important consequences emotional processes occurring level basal ganglia the pallidum subcortical neural structure potentially involved ts could direct implications emotional processes manner similar subthalamic nuclei pd pd patients dopaminergic modulation probably direct influence basal ganglia therefore subcortical limbic processes combined indirect influence well established motor disorders observed ts still theoretical framework embodiment theory however despite strong theoretical assumptions emotional disorders pd ts literature brought light controversial evidence concerning emotional impairments recommends carefully take account methodological considerations an examination literature emotional processing pd yields set controversial findings for instance sprengelmeyer et al reported recent untreated pd patients presented significant efe impairments specifically disgust compared healthy controls difference observed severe treated pd patients using innovative technique allowing take account difficulty recognizing one another efe authors reported significant impairments disgust efe however using experimental procedure recording accuracy categorizing efe together rating scale intensity efe dujardin et al they found pd patients less accurate healthy controls decoding angry sad disgusted efes moreover pd patients rated efes anger sadness disgust less intense healthy controls more surprisingly pd patients rated surprise efe intensely healthy control group generally last findings suggest parkinson disease patients may widespread emotional impairments previously reported literature experimental tasks habitually undertaken sensitive enough reveal impairments words reported interesting data showing patient severe amygdala lesion inducing strong deficit feeling fear nonetheless able recognize reliable manner fearful expressions looking specific perceptual details face opening eyes this experiment illustrates fact participants may use perceptual details even without clear emotional feeling different efes recognize efes order decrease influence perceptual strategies performance efe tasks advocate use rapid presentations emotional stimuli rapid presentation critical stimuli efes reduces use perceptual strategies mask existence specific emotional deficits go undetected studies longer presentation durations 21 36 37 examination tourette syndrome sprengelmeyer et al found ts patients ocd specific impairment recognizing disgusted faces they showed different distributions brain activation disgust inducing visual stimulation ocd patients compared control participants whereas activation threat inducing stimulation ocd participants induced similar pattern observed control participants failed replicate finding sprengelmeyer et al found disgust impairment one ts patient severe ocd however pd patients sensitivity task may sufficient show clear evidence emotional impairment sprengelmeyer et al parker et al ts participants exposed morphed stimuli one efe another one across emotion hexagon 6 basic efe produced ekman friesen however potential disadvantage repeated exposure morphed stimuli across hexagon significantly improves perceptual participant ability categorize efes might sufficient induce ceiling effect more importantly long repeated exposure durations 1000 5000 ms stimulus duration could enable participants use cognitive strategies based specific perceptual features perform task as pd experiments studies illustrate fact participants may use perceptual details even without clear emotional feeling different efes perform task assume motor disorders pd ts patients suffer probably imply important consequences emotional level disruption embodied processing emotional events so far based experimental designs used previous simulations assume absence reliable results showing deficits could probably due perceptual strategies potentially compensating emotional troubles patients therefore research show emotional deficits based implicit measures emotional feelings ii differentiate deficits induced dopaminergic dysregulation occurring central level embodied processing disorders occurring peripheral level	parkinson 's disease ( pd ) and tourette 's syndrome ( ts ) lead to important motor disorders among patients such as possible facial amimia in pd and tics in tourette 's syndrome . under the grounded cognition framework that shows the importance of motor embodiment in emotional feeling ( niedenthal , 2007 ) , both types of pathology with motor symptoms should be sufficient to induce potential impairments for these patients when recognizing emotional facial expressions ( efe ) . in this opinion paper , we describe a theoretical framework that assumes potential emotional disorders in parkinson 's disease and tourette 's syndrome based on motor disorders characterizing these two pathologies . we also review different methodological barriers in previous experimental designs that could enable the identification of emotional facial expressions despite emotional disorders in pd and ts .
two day old male whole body cyanosis tachypnea born 38 2 weeks gestation birth weight 4,000 g referred samsung medical center his percutaneous oxygen saturation 60% 70% response oxygen supply a grade 3/6 systolic murmur heard left sternal border vital signs blood pressure 70/40 heart rate 165 beats per minutes respiratory rate 42 breaths per minute temperature 37.2c echocardiographic findings demonstrated complete transposition great arteries tga large peri membranous ventricular septal defect vsd mild pulmonary stenosis ps peak pressure gradient 23 32 mmhg small patent ductus arteriosus pda additionally subpulmonic deviation outlet septum small asymmetric pulmonary valve pv fusion the pv size 5.86.1 mm z score 2.5 fig after procedure respiration rate stabilized percutaneous oxygen saturation 80% ambient conditions the patient relatively well five months age started become increasingly short breath eventually admitted operation body weight 7.4 kg underwent pulmonary root translocation lecompte maneuver after median sternotomy inverted shaped pericardiostomy performed situ material used right ventricular outflow tract rvot reconstruction pericardium harvested after pda division antegrade cold blood cardioplegia infused aortic root cannulation then pulmonary artery branches extensively dissected distal attachments pulmonary hila mobilized anterior right ventriculotomy the coronary artery pattern 1 ad 2 r cx prominent left anterior descending lad coronary artery planned lecompte maneuver without maneuver after transection proximal ascending aorta pulmonary artery root excised pv annulus left ventricle lv figs 2a 3a main pulmonary artery moved anteriorly lecompte maneuver 3b vsd position confirmed via right atrium right ventriculotomy a portion right ventricular muscle resected conal septum relieve lv exit aorta then defect pulmonary root closed bovine pericardial patch 6.0 polypropylene running suture end end anastomosis transected aorta vsd closed bovine pericardial patch 6.0 polypropylene running suture create lv aorta tunnel fig formation lv tunneling patch lv tunneling tried make patch straightened preservation rv volume the pv functional bicuspid valve fusion pv annulus size measured intraoperatively using hegar dilator 9 mm appropriate pv annulus size according patient body surface area z score 10.5 mm performed commissurotomy the rvot reconstructed excised pulmonary artery root situ autologous pericardial patch growth potential anterior side figs after operation patient extubated 3rd post operative day discharged early post operative complications 8th postoperative day echocardiographic findings 7 days operation showed minimal ps mean pg=13 mmhg pv size 6.8 mm z score 2.5 6 months operation showed mild ps mean pg=22 mmhg mature pv size 15.8 mm z score=+1.70 fig residual arterial septal defect vsd insufficiency left ventricular outflow tract exhibited time the patient well 9 months postoperatively new york heart association grade class i. the rastelli procedure first performed 1968 soon became standard surgical technique patients tga associated vsd ps in addition excellent relief ps rastelli procedure allows anatomic correction achieves good anatomic physiologic results short term however late results procedure critical limitations low long term survival inevitable reoperation obstructed conduit these problems come inability conduit grow lvot stenosis 57 overcome limitations procedure pulmonary root translocation prt introduced da silva et al with prt technique dissected pulmonary root implanted right ventricle outflow tract allow growth pulmonary artery additionally natural lvot constructed avoiding making incision mobilizing aorta long term follow data demonstrated high long term survival adequate pulmonary root growth inspired da silva performed prt five month old patient tga vsd ps operation great care taken avoid injury pv mitral valve removing pulmonary root unlike da silva et al employed lecompte maneuver the translocated pulmonary trunk close sternum resulted increased risk bleeding intervention additionally used situ autologous pericardium patch rvot reconstruction expected growth potential however major drawback possible formation aneurysmal dilatation pericardial hood case questions regarding adequate pv size pulmonary root translocation arisen however larger numbers patients longer follow data needed address point pulmonary root translocation lecompte maneuver candidate procedure aim preserving growth potential native pv	a five - month - old boy who had undergone previously transcatheter balloon atrioseptostomy at 3 days of age for complete transposition of the great arteries with ventricular septal defect and pulmonary stenosis underwent pulmonary root translocation with the lecompte maneuver . this operation has the advantages of maintaining pulmonary valve function , preserving the capacity for growth , and avoiding problems inherent to the right ventricular to pulmonary artery conduit . this patient progressed well for 9 months postoperatively and we report this case of pulmonary root translocation with the lecompte maneuver .
traditionally macrophages b cells thought cell types able present antigens cells thus elicit immune response the pioneering work steinman cohn showed third kind antigen presenting cell types dendritic cells dcs indispensable initiation adaptive immune response steinman cohn 1973 banchereau steinman 1998 migratory tissue resident dcs work interface peripheral tissues lymphoid organs these cells sentinels immune system sense translate environmental cues sampling processing extracellular intracellular antigens figure 1 dcs able pick antigens using various uptake mechanisms norbury 2006 savina amigorena 2007 key defining feature cell type antigen uptake processing dcs migrate lymph nodes present antigens stimulate cells figure 1 insert dcs armed numerous receptors detect danger signals surrounding environment these signals associated ongoing infection pathogen associated molecular patterns pro inflammatory cytokines cause dcs undergo phenotypic changes maturation activation maximize ability elicit proliferation cells mature dcs extraordinary capacity activate naive cells owing high expression various co stimulatory molecules ni o'neill 1997 however besides eliciting immune response dcs could also provoke immunological tolerance inducing deletion anergy thus dcs contribute limiting autoimmunity cools et al 2007 there several mechanisms maintenance peripheral tolerance one external stimuli reprogramme dcs towards less activated tolerogenic cell type dcs form heterogeneous cell population could classified plasmacytoid conventional dcs shortman naik 2007 dcs could also subdivided migratory dcs reside peripheral tissues lymphoid organ resident dcs constitute 50% lymph node dcs splenic thymic dcs villadangos schnorrer 2007 the molecular details regulation dc differentiation still poorly characterized although described suggested several cytokines transcription factors necessary dc development zenke hieronymus 2006 wu liu 2007 flt3 ligand critical development conventional plasmacytoid dc differentiation contrast gm csf promotes conventional dc development wu liu 2007 in addition humans treatment il-4 gm csf cytokine used ex vivo generation monocyte derived dcs sallusto lanzavecchia 1994 much less known transcriptional regulation dc development putative master transcription factors identified far zenke hieronymus 2006 a microarray study indicated nuclear proteins transcription factors including ppar lxr nuclear hormone receptors induced monocyte derived dc development le naour et al 2001 our global gene expression profiling also showed 20 48 nuclear receptors present human monocyte derived dcs l nagy et al unpublished results these findings indicate nuclear receptors likely functions differentiation function cell type nuclear hormone receptors ligand activated transcription factors modulate gene expression binding specific hormone response elements it well established ligands hormones i.e. retinoids metabolites vitamin vitamin glucocorticoids gcs nuclear receptors besides regulating development metabolism also impact immune system now picture altered findings activators receptors also modulate dc differentiation function first part review provide introduction function lipids dc biology summarize potential function nuclear hormone receptors dc differentiation function we focus rxr heterodimeric receptors ppar rar lxr vitamin receptor vdr also discuss potential function gc receptors dc function second part provide overview endogenous ligand production receptors taking place dcs in body several tissue compartments dcs likely exposed large amounts lipids an obvious one gut associated lymphoid tissue galt diet derived lipids fatty acids retinoids cholesterol abundant figure 1 small intestine the lamina propria important maintain peripheral tolerance towards commensal bacterial flora nagler anderson shi 2001 dietary lipid mediators might contribute type tolerance it well established atherosclerotic plaques contain macrophages cells however dcs also detected plaques bobryshev lord 1995 angeli et al 2004 microenvironment in addition several active lipid mediators might present could modulate migratory immunological properties cells figure 1 tissue resident dcs sense translate environmental cues sampling processing protein antigens however cells also present lipid glycolipid antigens cd1 cell surface molecules brigl brenner 2004 cd1s molecules critical presentation various bacterial glycolipid peptidolipid antigens willcox et al 2007 ways endogenous lipids recognized presented still poorly characterized tsuji 2006 an interesting aspect lipid antigen presentation extracellular lipid particles facilitate uptake pathogen derived cd1 ligands for example apoptotic bodies mycobacterium infected macrophages efficient vehicles lipid uptake uninfected dcs schaible et al 2003 addition cd1d ligand precursor delivered dcs apolipoproteins van den elzen et al 2005 these results underscore notion local lipid environment ability modify lipid presentation capacity dcs in addition lipid derived mediators also elicit intracellular signalling alters maturation immunogenicity antigen presenting cells human monocyte derived dc maturation induced oxldl exposure effect mediated lysophosphatidyl choline activation g protein coupled receptor coutant et al 2002 dcs also sense integrate lipid signals pg receptors example dc migration cytokine production could modulated pge2 ltb4 pgd also important modulator dc function harizi gualde 2005 briefly highlighted dcs sense lipid environment various cell membrane receptors increasing amount evidence suggest dcs could also survey lipid environment lipid sensing nuclear hormone receptors following section summarize potential function lipid activated nuclear receptors dcs three isotypes ppars /. receptors key physiological functions example ppar promotes fatty acid oxidation liver lefebvre et al 2006 ppar indispensable adipocyte differentiation generally stimulates lipid storage willson et al 2001 ppar important regulator skeletal muscle lipid oxidation barish et al 2006 recent findings indicated receptors especially ppar important functions dc biology figure 2 initially comprehensive microarray study indicated humans monocyte derived dcs elevated expression ppar le naour et al 2001 this finding consistent previous observation indicating il-4 positive regulator ppar human murine monocytes macrophages huang et al 1999 later confirmed several laboratories mrna also protein ppar induced human monocyte derived dcs gosset et al 2001 nencioni et al 2002 szatmari et al 2004 in addition found bona fide ppar target fabp4/ap2 highly upregulated upon ppar ligand treatment developing human dcs moreover ex vivo cultured blood derived conventional cd1c+ dcs also express ppar. finally human lymphoid tissues tonsils several ppar s100 double positive cells detected suggesting least sub population lymphoid tissue dcs express receptor szatmari et al 2004 murine splenic cd11c+ dcs also express ppar faveeuw et al 2000 nuclear receptor detected bone marrow derived murine dcs hammad et al 2004 the changes ppar expression various stages dc development still poorly characterized however described cd1a negative population monocyte derived dcs express ppar cd1a positive counterparts gogolak et al 2007 the effects ppar activators immunological function phenotype ex vivo cultured dcs investigated detail ppar-activated immature dcs enhanced phagocytic activity addition cells possess diminished migratory capacity angeli et al 2003 szatmari et al 2004 appel et al 2005 ppar-activated human dcs produce less il-12 tnf moreover cells secrete lower amounts mcp2 ip-10 rantes chemokines gosset et al 2001 nencioni et al 2002 figure 2 furthermore ppar-instructed dcs altered cell surface expression pattern co stimulatory molecules express less cd80 increased cd86 gosset et al 2001 nencioni et al 2002 szatmari et al 2004 these observations appeared consistent model ppar-activated dcs skew differentiation special dc subset reduced th1 activation capacity enhanced th2 activation propensity faveeuw et al 2000 gosset et al 2001 others suggested activation ppar pathway generally reduces inhibits immunogenicity developing human dcs nencioni et al 2002 appel et al 2005 recently murine dcs similar effect observed suggesting ppar activation negative effect stimulatory capacity dcs more importantly report ppar-deficient dcs used authors found ppar effects stimulatory capacity cells receptor dependent klotz et al 2007 however molecular mechanism negative regulation clear analogy one suggested mechanism activity sumoylation receptor recruitment co repressors promoter region nf-b binding sites various inflammatory genes pascual et al 2005 dcs suggested ppar ligand treatment interfered activation nf-b map kinase pathways appel et al 2005 interestingly besides essentially inhibitory activities ppar appears possess positive regulatory activities immune cells well our recent global gene expression profiling study revealed acute ppar ligand treatment 100 genes immediately induced early activated genes fall lipid metabolism category szatmari et al 2007 in contrast immune response related genes induced 24 h later suggesting ppar activation directly regulates lipid metabolism cells rather indirectly modifies immune phenotype dcs described previous section dcs our results indicated ppar ligand coordinately regulates cd1 gene family expression human monocyte derived dcs ppar-activated dcs express less cd1a nencioni et al 2002 szatmari et al 2004 elevated expression cd1d more importantly elevated expression cd1d coupled enhanced capacity activate cd1d dependent cell type inkt invariant natural killer cells szatmari et al 2004 the lack inkt cell activation implicated development autoimmune conditions suggesting inkt cells intimately linked sustaining immunological tolerance hammond kronenberg 2003 we also defined possible mechanism regulation ppar indirectly stimulated expression cd1d production trans retinoic acid atra natural ligand ra receptors rars szatmari et al 2006a confirming reported recently human cd1d promoter contains retinoid response element chen ross 2007 we also described ppar-activated dcs elevated expression abcg2 xenobiotic transporter these results suggested ppar activation modifies xenobiotic drug resistance human dcs szatmari et al 2006b we others described dcs express low levels ppar. consistent finding ppar ligand treatment marginal effect monocyte derived dc differentiation function gosset et al 2001 szatmari et al 2004 in contrast shown ppar present human epidermal dcs langerhans cells activation ppar pathway blocks activation migration skin dcs dubrac et al 2007 curiously dcs also express ppar szatmari et al 2004 potential role receptors dc function yet characterized another metabolite receptor liver x receptors lxrs sensor oxidized forms cholesterol zelcer tontonoz 2006 reported upregulated monocyte derived dc development moreover lxr ligand treated dcs reduced cell activation capacity geyeregger et al 2007 the natural ligands receptors poorly characterized polyunsatured fatty acids oxidized fatty acids cholesterol therefore much remains discovered receptor endogenous activation takes place nevertheless high affinity synthetic ligands receptors available probe function dcs ex vivo potentially vivo next sections describe potential function two receptors high affinity hormonal ligand dc biology activators gc vdrs profound immunosuppressive effects assumed lymphocytes main target compounds however several vitro vivo observations suggested gcs vitamin also diminished immunogenicity dcs effects might contribute impaired immune response anti inflammatory effects there recent reviews provide overview immunosuppressive effects gcs vitamin dcs abe thomson 2003 hackstein thomson 2004 van etten mathieu 2005 thus briefly discuss effects ligands dc biology the immunosuppressive effects gcs well documented several studies suggested among cell types dcs also affected gcs decrease co stimulatory molecule expression murine dcs therefore cells poor cell stimulatory capacity vitro vivo moser et al 1995 humans gc treated monocyte derived dcs reduced cell activation capacity moreover gcs interfere differentiation dcs monocytes piemonti et al 1999 rea et al 2000 figure 2 the anti inflammatory effects gcs well characterized molecular mechanisms still poorly defined hackstein thomson 2004 it shown gcs regulate immune function cells dcs parallelly coordinated activation gitr ligand cells induction gitr receptors plasmacytoid dcs this signalling dcs leads non canonical nf-b dependent induction indolamine 2,3-dioxygenase ido key enzyme catalyses initial rate limiting step degradation tryptophan negative modulator lymphocyte proliferation grohmann et al 2007 in addition gcs exert ido dependent protection model allergic airway inflammation the active form vitamin also immunosuppressive effects numerous studies shown regulation dc immunofunctions important part profound suppressive activity 1,25 dihydroxy vitamin d3 highly suppresses activation maturation dcs moreover cells diminished cell activation capacity penna adorini 2000 piemonti et al 2000 figure 2 vivo murine model also confirmed administration vdr agonist negatively modulates stimulatory capacity dcs consistent finding vdr deficient mice hypertrophy subcutaneous lymph nodes elevated number mature dcs griffin et al 2001 the ways vdr carries functions whether interferes positive signalling induces suppressor molecules directly simply inhibits dc differentiation and/or maturation clear it suggested vdr transcriptionally represses expression one components nf-b relb thus blocking activation dcs dong et al 2003 figure 2 extent mechanism known summary the data obtained date suggest activation gc vdr profound inhibitory immunosuppressive tolerogenic effects dcs immunophenotype pathways potentially amenable therapeutic exploitation next section we discuss function retinoids show much complex behaviour repressive activator functions dcs it well known retinoids derivatives vitamin ligands rar rxr receptors exert modulatory effect immune system vitamin deficiency causes immune dysfunction increases susceptibility individual infectious diseases thus contributing elevated child morbidity mortality underwood arthur 1996 it reported mouse splenic dcs less stimulatory bedford knight 1989 ra treatment however retinoid treated langerhans cells enhanced cell activation capacity meunier et al 1994 moreover ra promotes differentiation maturation monocytes dc like cells mohty et al 2003 compounds enhance dna binding activity nk-b thus promoting maturation dcs geissmann et al 2003 figure 2 it noted retinoids also provoke apoptosis developing dcs rarrxr heterodimers geissmann et al 2003 it also described ra pretreated dcs injected tumours mice showed increased accumulation draining lymph nodes it concluded enhanced dc migration due elevated matrix metalloproteinase production concurrently diminished expression inhibitors metalloproteinase darmanin et al 2007 moreover ra treated monocyte derived dcs produce elevated level tgf il-6 ra instructed dcs acquire several attributes characteristic mucosal dcs saurer et al 2007 our laboratory also investigated effects activation rars using synthetic retinoids human monocyte derived dc differentiation found cells enhanced inkt cell activation capacity consequence induction cd1d szatmari et al 2006a moreover gene expression profiling indicates large number genes regulated retinoids leading activation multiple pathways all trans ra agonist rar however isomeric form 9-cis ra activate rar rxr mangelsdorf evans 1995 therefore 9-cis ra pleiotropic effects modulate activity several nuclear receptors principle interestingly 9-cis ra exerts suppressive effect human monocyte derived dc differentiation probably activation pparrxr heterodimer zapata gonzalez et al 2007 we also tested effects synthetic specific activator rxr lg268 dc differentiation obtained complex phenotypic changes suggesting probably multiple nuclear receptor heterodimers affected szatmari l nagy unpublished results exposure retinoids complex phenotype dcs demonstrate next section ra profound effect lymphocyte homing activation well in review systematically analysed potential function activation various nuclear receptors dc development function it emphasized studies used high affinity synthetic ligands activation nuclear hormone receptors probing biological functions the whether dcs actively participating production nuclear hormone receptor ligands simply get endocrine paracrine mechanisms it noted serum large number compounds present biologically inactive precursors however activation oxidation hydroxylation inactive compounds converted active forms for example vitamin d3 must hydroxylated 1,25 dihydroxy vitamin d3 high affinity ligand vdr okuda et al 1995 vitamin retinol first gets oxidized retinaldehyde thereafter compound converted ra agonist rars duester 2000 similarly cortisone converted cortizole ligand gr seckl walker 2001 figure 3 additionally hydroxylation cholesterol position 27 leads 27-hydroxy cholesterol potent activator lxr receptors fu et al 2001 finally polyunsaturated fatty acids oxidized lipoxygenases oxidized compounds relatively potent ligands ppar receptor nagy et al 1998 huang et al 1999 the organic cellular localization steps enzymes catalyse reactions well characterized cell types most chemical transformations occur liver kidney significantly steps also found dcs the studied nuclear receptor ligand context dcs ra active form vitamin a. breakthrough study iwata et al 2004 discovered murine intestinal dcs produce release ra dc derived ra instructs gut homing tropism cells induction expression 47 integrin ccr9 receptors this study established dc derived nuclear receptor ligand able reprogramme local cells imprint cell tropism interestingly several recent publications suggest ra combination immunological mediators modulates differentiation various lymphocyte populations galt intestine ra blocks il-6- tgf-driven induction pro inflammatory il-17-producing th17 cells promotes differentiation tolerogenic regulatory treg cells mucida et al 2007 these findings confirmed others intestinal dc produced ra enhances tgf-dependent conversion peripheral cells foxp3-positive treg cells suggesting ra works mediator gut oral tolerance vivo benson et al 2007 coombes et al 2007 sun et al 2007 gut associated dcs also promote b cell gut tropism upregulation aforementioned receptors additionally enhance il-6-dependent iga secretion b cells mora et al 2006 collectively findings underscore dc derived ra prominent function regulation gut associated immune processes it mentioned ra could induce expression 47 ccr9 cells thus imprint gut tropism study effects ra lymphocytes cases dc cell co cultures used therefore formally possible ra also affects immunophenotype dcs reprogrammed dcs promote treg development b cell iga production another interesting point address factors regulate ra production enzymes responsible unique capacity intestinal dcs produce ra remarkable selectivity phenotype vivo in contrast non gut lymphoid tissue dcs unable generate ra iwata et al 2004 intestinal dcs express several enzymes might participate ra synthesis important ones retinaldehyde dehydrogenases raldhs catalyse retinaldehyde oxidation ra figure 2 dcs peyer patches mostly express raldh1 aldh1a1 contrast mesenteric lymph node dcs mostly express raldh2 aldh1a2 iwata et al 2004 a specialized sub population mesenteric lymph node dcs cd103 cells promote generation treg cells dcs show elevated expression raldh2 coombes et al 2007 interestingly observed ppar-instructed human monocyte derived dcs also produce ra moreover raldh2 rdh10 retinol dehydrogenase 10 enzymes upregulated cells szatmari et al 2006a it well established raldh2 indispensable embryonic ra production niederreither et al 1999 significantly recent report suggested rdh10 might catalyse first oxidation step retinol critical step embryonic ra generation sandell et al 2007 further investigations needed define kind mechanisms regulate ra production dcs enzyme rate limiting ra synthesis once issues clarified one would able define vivo contribution dc derived ra signalling various immunological processes described earlier also beyond dcs also able activate vitamins inactive form vitamin 25-hydroxy vitamin d3 converted 1alpha,25 dihydroxy vitamin d3 ex vivo differentiation human dcs this conversion catalysed 25(oh)d3 1 alpha hydroxylase present developing dcs addition enzyme upregulated maturation dcs fritsche et al 2003 hewison et al 2003 consistent findings production vdr ligand claimed negatively regulate early differentiation monocyte derived dcs of note dermal dcs able directly convert vitamin d3 1,25 dihydroxy vitamin d3 skin active form vitamin instructed local cells express ccr10 thus enabling migrate epidermis sigmundsdottir et al 2007 remarkably results suggested similar ra elicits gut homing specificity cells active form vitamin imprints skin homing specificity cells figure 4 human monocyte derived dcs also able convert inactive cortisone high affinity gr ligand cortisole result upregulation 11beta hydroxysteroid reductase in addition dc differentiation inhibited administration physiological concentration cortisone suggesting pathway enhances gc dependent negative modulation dc development freeman et al 2005 finally far ppar ligand concerned observed monocyte derived dc development bona fide ppar targeting fabp4/ap2 gene upregulated especially culture cells human serum instead fbs szatmari et al 2004 we extended finding observed genes whose expression upregulated synthetic ppar ligand treatment also showed elevated expression dcs cultured human serum containing medium szatmari et al 2007 these results suggested presence human serum ppar ligands generated accumulated dcs indeed recent paper suggested lysophosphatidic acid cardiolipin abundant components human serum lipid species might contribute activation ppar leslie et al 2008 these results underscore notion remarkably dcs actively participating production several ligands nuclear receptors moreover ligands likely released able locally modulate function immune cell types dcs indispensable initiation primary immune response well established cells able orchestrate entire immune response including regulation peripheral immune tolerance therefore importance identify characterize regulatory processes underpinning changes it becoming increasingly evident members nuclear hormone receptor superfamily involved regulation dc biology this group transcription factors also represents gateway manipulating dcs therapeutic use clinical practice tumour antigen loaded dcs intensively investigated tools elicit antitumour immune response ex vivo differentiated dcs may loaded tumour antigens injected back patients used ex vivo expansion antitumour lymphocytes improving anticancer immunotherapies appear largely depend dc immunogenicity survival migration regulated thus important find ways modulate antigen presenting migratory capacity viability dcs nencioni et al 2008 there several ways manipulate dcs ex vivo administration cytokine cocktails signal molecules modify dc function activation state demonstrated review natural synthetic ligands nuclear hormone receptors also modulate dc functions future important explore exploit benefit ligand treatment modulate dc immunogenicity vivo thus patients altered lipid profile receptors might overactivated adversely modify immune phenotype dcs as example described serum lipoproteins skewed dc development towards cd1a dc phenotype distinct cytokine chemokine production profile gogolak et al 2007 studies nuclear receptors used ex vivo dc models reports investigated tissue specific nuclear receptor knockout models griffin kumar 2003 klotz et al 2007 future great importance generate dc specific nuclear receptor deletion models these models almost certainly prove helpful define receptor specificity effects receptor agonists in addition systems help define vivo function receptors dcs the vivo approaches might also clarify controversies still exist field however emphasized concerning human immunotherapy ex vivo dc models also used thus important characterize vitro effects ligands nuclear hormone receptors small part major differences mice humans regarding dc functions murine models might always predictive human responses dcs heterogeneous cell population villadangos schnorrer 2007 data derived human monocyte derived dcs future would also important define function nuclear receptors ligands various subtypes dcs dc precursors finally activators nuclear receptors widely used clinical practice example ligands ppar rosiglitazone pioglitazone applied treat type ii diabetes willson et al 2001 addition gcs frequently used immunosuppressive agents defining exact functions activators various immune cell types could help exploiting potential therapeutic intervention various immunological diseases	dendritic cells ( dcs ) are sentinels of the immune system and represent a heterogeneous cell population . the existence of distinct dc subsets is due to their inherent plasticity and to the changing microenvironment modulating their immunological properties . numerous signalling pathways have impacts on dcs . it appears that besides cytokines / chemokines , lipid mediators also have profound effects on the immunogenicity of dcs . some of these lipid mediators exert an effect through nuclear hormone receptors . interestingly , more recent findings suggest that dcs are able to convert precursors to active hormones , ligands for nuclear receptors . some of these dc - derived lipids , in particular retinoic acid ( ra ) , have a central function in shaping t - cell development and effector functions . in this review , we summarize and highlight the function of a set of nuclear receptors ( ppar , ra receptor , vitamin d receptor and glucocorticoid receptor ) in dc biology . defining the contribution of nuclear hormone receptor signalling in dcs can help one to understand the regulatory logic of lipid signalling and allow the exploitation of their potential for therapeutic intervention in various immunological diseases .
liver central organ biotransformation particularly prone oral medication related toxicity due high concentrations drugs metabolites portal blood rather actual target area central nervous system it however difficult attribute liver damage specific medication clinical practice meyer 2000 the susceptibility individual drug induced liver injury dili depends multiple genetic epigenetic factors age gender weight alcohol consumption influence occurrence hepatic adverse effects krhenbhl kaplowitz 1996 older patients seem vulnerable women stronger tendency toxic liver reaction men meyer 2000 ethnic differences also reported evans 1986 genetic metabolic variability significant susceptibility factor drug induced liver toxicity enzyme polymorphisms cause slowing complete disruption enzyme function turn results inefficient processing drugs shenfield gross 1999 this may always result corresponding liver damage contribute increased toxicity substances the majority drugs almost psychotropic drugs metabolized enzyme cyp450 due genetically determined polymorphisms cyp450-isoenzymes individuals categorized poor intermediate extensive superextensive metabolizers miners birkett 1998 shenfield gross 1999 wilkinson 2004 poor metabolizer receives medication containing several substrates inhibitors isoenzyme risk toxic reaction increases owing slower drug metabolism as most psychotropic drugs substrate cyp2d6 ingelman sundberg 2005 cytochrome especially significant pharmacokinetic interaction approximately 5% 10% caucasians reduced nonexistent cyp2d6 activity therefore risk toxicity receiving psychotropic treatment transon et al 1996 griese et al 1998 ; a important consideration whether patients preexisting liver dysfunction higher risk hepatotoxic reactions although little information controlled studies exists indications patients preexisting liver disorders generally display increased risk drug induced hepatotoxicity it likely preexisting liver damage negatively affects ability liver regenerate case hepatotoxic reaction chang schiano 2007 possible symptoms tiredness lack appetite nausea vomiting fever feeling pressure upper right region abdomen joint muscle pain pruritus rashes jaundice latter symptom directly indicative liver involvement chang schiano 2007 diagnose asymptomatic toxic liver damage early this involves measurement glutamat oxalat transaminase got glutamat pyruvat transaminase gpt gamma glutamyl transferase -gt serum found normal indicates disruption liver function got gpt also well known enzyme aspartate aminotransferase ast alanine aminotransferase alt respectively it important consider possibility dili prescribing psychotropic drugs record detailed history medication taken patient particular attention paid length use dose time intake medication appearance symptoms the latency period involved vary days months liver damage may result causes viral autoimmune alcohol induced hepatitis acute morbus wilson diagnosis drug induced toxic liver damage often diagnosis exclusion norris et al 2008 ( 2014 developed practice guidelines diagnosing managing dili hepatic pattern damage classified predominantly hepatocellular predominantly cholestatic hepatocellular cholestatic mixture important patterns varying severity drugs also cause drug specific patterns liver damage revealing increased values transaminases got gtp and/or cholestasis -gt alkaline phosphatase zimmerman 1999 andrade et a. 2004 slight increase transaminases -gt levels to twice norm without rise bilirubin often clinical significance spite continued medication simply disappear this phenomenon often observed antiepileptic mood stabilizing therapy yatham et al 2002 these small functional changes must still checked case elevation liver enzyme levels medication must discontinued voican et al 2014 the prognosis dili generally good less severe forms heal quickly completely hayashi fontana 2014 it difficult obtain figures regarding hepatotoxic drug reactions systematic epidemiological analyses seldom done observations conducted long enough period true validity drug surveillance programs permit early detection adverse drug reactions adrs may minimize consequences the arzneimittelsicherheit der psychiatrie amsp study one program field psychiatry systematically evaluating severe adrs psychotropic medication inpatients the amsp produces database adrs registered participating psychiatric clinics austria germany switzerland details amsp methods see grohmann et al in present study used database analyze elevation liver enzymes particular focus sociodemographic data significance clinical manifestations well transaminase levels measured antidepressant ad monotherapy combination therapies the amsp program aims continuous detection severe adrs resulting psychotropic treatment these evaluated inpatient treatment study analyzed data 80 university municipal state psychiatric hospitals departments participating amsp program 1993 2011 information severe adrs collected clinicians regular basis psychiatrists drug monitors use standardized questionnaire document cases the drug monitors get touch ward psychiatrists regular intervals severe adverse drug reactions reported weekly meetings medical staff grohmann et al 2004 information collected details adverse events well patient demographics nonpsychotropic drug intake it includes alternative hypotheses causes adr relevant risk factors measures undertaken previous exposure drug senior doctors hospital involved review cases later discussed central regional case conferences take place 3 times per year participants comprise hospital drug monitors representatives national authorities regulating drugs drug safety experts pharmaceutical industry following discussions analyses adr probability ratings assigned sent relevant authorities pharmaceutical companies receive case questionnaires also stored amsp central database based amsp study guidelines grohmann et al 2004 recommendations hurwitz wade 1969 seidl et al the adr probability rating system defines following grades probability beginning grade1 adr possible risk adr known probability another cause drug question 50% grade 2 defined probable known reaction time course dosage specific drug grade 3 categorized definite meaning reexposure drug causes adr grade 4 signifies questionable sufficiently documented cases adr results pharmacodynamic interaction 2 drugs drug given rating possible probable definite according given facts furthermore drug use data collected twice per year hospitals participating amsp program number inpatients mean treatment duration patients per year also recorded documentation adrs occurs value one liver enzymes got ast gpt alt -gt alkaline phosphatase exceed 5 times upper normal values severe defined amsp based judgment hepatologic experts severe clinical symptoms and/or cholestasis the threshold 5 times upper limit normal got gpt values proposed literature avoid unnecessary withdrawal substances aithal et al 2011 maximal levels liver enzyme recorded amsp dili cases mean maximum values per drug evaluated analysis only drugs prescribed 2000 times within overall study population included analyses our retrospective analysis employs data extracted anonymized databank amsp drawn 80 participating hospitals 1993 2011 detailed information hospitals participating program found online www.amsp.de the informed consent participants required data analyzed derived anonymized databank the amsp drug surveillance program approved leading boards participating institute prior implementation ethics committee university munich formally approved evaluations based amsp databank incidence rates hepatotoxicity calculated percentage inpatients receiving specific ad ad subclass presented together 95% cis regarding low actual number cases significant number inpatients involved ci calculated employing exact method rather one approximate methods vollset 1993 the statistical program r used generate figures r core team 2014 incidence rates hepatotoxicity calculated percentage inpatients receiving specific ad ad subclass presented together 95% cis regarding low actual number cases significant number inpatients involved ci calculated employing exact method rather one approximate methods vollset 1993 the statistical program r used generate figures r core team 2014 a total 184234 inpatients treated antidepressants 147 inpatients 149 cases 2 inpatients suffered dili twice severe hepatic adr observed 0.08% within 27 149 cases only ads imputed remaining inpatients suffering toxicity ad combination psychotropic drugs the majority monitored inpatients treated antidepressants 56.5% suffering depression inpatients surveillance predominantly female 63.1% total 75.2% inpatients suffering dili were diagnosed depression followed 9.4% diagnosis schizophrenia table 1 thus dili patients differed significantly diagnostic distribution total ad population age sex distribution hand differ dili patients monitored ad patients age sex international classification diseases version 10 icd-10 diagnosis patients monitored period 19932011 suffering dili due ads total population surveillance 149 cases dili abbreviations dili drug induced liver injury ad antidepressant n number 147 inpatients 149 cases dili frequencies different single substances well classes ads given table 2 figures 1 2 incidence dili median dosages among drug classes n=149 cases dili 184.234 patients monitored overall respectively tcas amitryptilinoxid desipramine dibenzepin imipramine case milnacipran tianeptin multiple nominations possible drug induced liver injury dili per antidepressant ad classes subgroups percent exposed patients cases ad subgroups imputed alone dili substance classes imputed 3 times except agomelatine due delayed implementation imputed 2 times drug induced liver injury dili per antidepressant ad)/single substance percent exposed patients cases single ads imputed alone substance classes imputed 3 times included except agomelatine due delayed implementation imputed 2 times ad classes the subgroup tricyclic tetracyclic ads showed unfavorable profiles terms dili subgroup serotonin reuptake inhibitors ssris lowest rates dili cases well ssris alone cases as single drugs mianserine agomelatine clomipramine showed highest frequencies dili 0.36% 0.33% 0.23% respectively trazodone serotonin antagonist reuptake inhibitor serotonin norepinephrine reuptake inhibitors snris noradrenergic specific serotonergic antidepressant nassa obtained similar results mianserine added tricyclic tetracyclic ads according existing literature benkert et al nevertheless argued authors add towards nassa group due similar chemical structure 104 149 cases ads imputed solely responsible dili 96 cases registered one ad imputed 8 cases 2 ads imputed combination the drugs listed tricyclic antidepressants 9 cases dili amitriptylinoxid 1 case desipramine 1 case dibenzepine 6 cases imipramine 1 case the substances mentioned ads nefazodone 1 case bupropion 1 case the group monoaminooxidase mao inhibitors consisted tranylcypromine 3 cases moclobemide case the substances metioned tcas tricyclic antidepressants ads mao inhibitors prescribed 2000 times hence single drugs included analyses present study an exception made agomelatine due particular interest drugs hepatotoxicity the results agomelatine however interpreted caution introduced april 2009 therefore observation period agomelatine significantly shorter drugs observed since 1993 as presented table 2 differences median dosages drugs deemed responsible dili monitored inpatients treated ads within ssri subgroup escitalopram citalopram sertraline were prescribed double dosage compared monitored inpatients time dili appeared also within snri noradrenalin reuptake inhibitor nassa subgroups higher dosages compared median dosage patients monitored only maprotiline prescribed lower dosage moment dili substances subgroup prescribed higher dosages cases dili the prevalent drug class combination one ads antipsychotic drugs aps 31 cases within study first olanzapine implicated dili 6 cases followed clozapine 3 cases aps held responsible dili 1 2 cases haloperidol melperone chlorprothixene quetiapine perazine levomepromazine promethazine risperidone valproic acid responsible 3 dili cases followed carbamazepine galantamine pregabaline lamotrigine implicated one case maximum gamma gt transaminase glutamat oxalat transaminase got glutamat pyruvat transaminase gpt values per dili case evaluated time period 2003 2011 values agomelatine 2009 2011 agomelatine introduced 2009 as small deviations terms maximum got also known aspartate aminotransferase ast gpt also known alanin aminotranferase alt alkaline phosphatase values across participating institutions 5-fold increase enzyme values determined dili 2003 measurement liver enzymes done participating hospitals temperature 37c prior this measurement done 15 20c resulting lower values varying time periods different hospitals duloxetine clomipramine paroxetine mainly responsible high gpt values mirtazapine affected gpt values least terms got values duloxetine clomipramine performed worst mirtazapine least influence got values regarding -gt duloxetine performed best trimipramine clomipramine well venlafaxine increased -gt values figure 3a c the duration treatment dili occurred different among antidepressants mianserine taken 22 days average mirtazapine taken 40 days ( gamma glutamyl transferase gamma gt mean maximum values single substances imputed alone minimum 3 times except agomelatine due delayed implementation imputed 2 times ( b glutamat oxalat transaminase got also known aspartate aminotransferase ast mean maximum values single substances imputed alone minimum 3 cases except agomelatine due delayed implementation imputed 2 times ( c glutamat pyruvat transaminase gpt also known alanin aminotransferase alt mean maximum values single substances imputed alone minimum 3 cases except agomelatine due delayed implementation for inpatients preexisting liver damage mean maximum values -gt got gpt 240 202 285u l respectively dili diagnosed cases preknown liver damage presented maximum -gt got gpt mean values 525 402 and this indicates preknown liver damage inpatients doubled mean maximum values -gt transaminases subjects normal liver status time dili appeared study sample preexisting hepatic injury common risk factor far 59 cases followed substance abuse mostly alcohol 20 cases the common clinical symptoms nausea fatigue loss appetite abdominal pain a total 27 inpatients showed clinical symptoms majority show 8 cases ad treatment remained dosage reduced cases drug withdrawn dili assessed within 55 cases dili disappeared totally 85 cases dili improved within 9 cases only one case acute liver failure occurred 20-year old woman predamaged liver resulting overdose paracetamol time admission psychiatric ward transaminase values normal she medication 150 mg doxepine 3 days 10 mg olanzapine 6 days the patient liver enzymes increased rapidly clinical symptoms vomiting nausea epigastric pain set following laboratory analysis a hepato toxicity identified bilirubin 3.8mg dl gpt 8827u l got 7363u l lactate dehydrogenase as soon acute liver failure diagnosed patient transferred intensive care ward care transplantation consulting team the hepatotoxic effects doxepine olanzapine discribed previous literature knowledge severe case presented far a total 184234 inpatients treated antidepressants 147 inpatients 149 cases 2 inpatients suffered dili twice severe hepatic adr observed 0.08% within 27 149 cases only ads imputed remaining inpatients suffering toxicity ad combination psychotropic drugs the majority monitored inpatients treated antidepressants 56.5% suffering depression inpatients surveillance predominantly female 63.1% total 75.2% inpatients suffering dili were diagnosed depression followed 9.4% diagnosis schizophrenia table 1 thus dili patients differed significantly diagnostic distribution total ad population age sex distribution hand differ dili patients monitored ad patients age sex international classification diseases version 10 icd-10 diagnosis patients monitored period 19932011 suffering dili due ads total population surveillance 149 cases dili abbreviations dili drug induced liver injury ad antidepressant n number in 147 inpatients 149 cases 19 single substances solely held responsible dili cases dili frequencies different single substances well classes ads given table 2 figures 1 2 incidence dili median dosages among drug classes n=149 cases dili 184.234 patients monitored overall respectively tcas amitryptilinoxid desipramine dibenzepin imipramine case milnacipran tianeptin multiple nominations possible drug induced liver injury dili per antidepressant ad classes subgroups percent exposed patients cases ad subgroups imputed alone dili substance classes imputed 3 times except agomelatine due delayed implementation imputed 2 times drug induced liver injury dili per antidepressant ad)/single substance percent exposed patients cases single ads imputed alone substance classes imputed 3 times included except agomelatine due delayed implementation imputed 2 times as ad classes subgroup tricyclic tetracyclic ads showed unfavorable profiles terms dili subgroup serotonin reuptake inhibitors ssris lowest rates dili cases well ssris alone cases single drugs mianserine agomelatine and clomipramine showed highest frequencies dili 0.36% 0.33% 0.23% respectively trazodone serotonin antagonist reuptake inhibitor serotonin norepinephrine reuptake inhibitors snris noradrenergic specific serotonergic antidepressant nassa obtained similar results mianserine added tricyclic tetracyclic ads according existing literature benkert et al nevertheless argued authors add towards nassa group due similar chemical structure 104 149 cases ads imputed solely responsible dili 96 cases registered one ad imputed 8 cases 2 ads imputed combination the drugs listed tricyclic antidepressants 9 cases dili amitriptylinoxid 1 case desipramine 1 case dibenzepine 6 cases imipramine 1 case the substances mentioned ads nefazodone 1 case bupropion 1 case the group monoaminooxidase mao inhibitors consisted tranylcypromine 3 cases moclobemide case the substances metioned tcas tricyclic antidepressants ads mao inhibitors prescribed 2000 times hence single drugs included analyses present study an exception made agomelatine due particular interest drugs hepatotoxicity the results agomelatine however interpreted caution introduced april 2009 therefore observation period agomelatine significantly shorter drugs observed since 1993 as presented table 2 differences median dosages drugs deemed responsible dili monitored inpatients treated ads within ssri subgroup escitalopram citalopram sertraline were prescribed double dosage compared monitored inpatients time dili appeared also within snri noradrenalin reuptake inhibitor nassa subgroups higher dosages compared median dosage patients monitored observed dili occurred within tricyclic tetracyclic class only maprotiline prescribed lower dosage moment dili substances subgroup prescribed higher dosages cases dili the prevalent drug class combination one ads antipsychotic drugs aps 31 cases within study first olanzapine implicated dili 6 cases followed clozapine 3 cases aps held responsible dili 1 2 cases haloperidol melperone chlorprothixene quetiapine perazine levomepromazine promethazine risperidone valproic acid responsible 3 dili cases followed carbamazepine galantamine pregabaline lamotrigine implicated one case maximum gamma gt transaminase glutamat oxalat transaminase got glutamat pyruvat transaminase gpt values per dili case evaluated time period 2003 2011 values agomelatine 2009 2011 agomelatine introduced 2009 as small deviations terms maximum got also known aspartate aminotransferase ast gpt also known alanin aminotranferase alt alkaline phosphatase values across participating institutions 5-fold increase enzyme values determined dili 2003 measurement liver enzymes done participating hospitals temperature 37c prior measurement done 15 20c resulting lower values varying time periods different hospitals duloxetine clomipramine paroxetine mainly responsible high gpt values mirtazapine affected gpt values least terms got values duloxetine clomipramine performed worst mirtazapine least influence got values regarding -gt duloxetine performed best trimipramine clomipramine well venlafaxine increased -gt values figure 3a c the duration treatment dili occurred different among antidepressants mianserine taken 22 days average mirtazapine taken 40 days ( gamma glutamyl transferase gamma gt mean maximum values single substances imputed alone minimum 3 times except agomelatine due delayed implementation imputed 2 times ( b glutamat oxalat transaminase got also known aspartate aminotransferase ast mean maximum values single substances imputed alone minimum 3 cases except agomelatine due delayed implementation imputed 2 times ( c glutamat pyruvat transaminase gpt also known alanin aminotransferase alt mean maximum values single substances imputed alone minimum 3 cases except agomelatine due delayed implementation for inpatients preexisting liver damage mean maximum values -gt got gpt 240 202 285u l respectively dili diagnosed cases preknown liver damage presented maximum -gt got gpt mean values 525 402 and this indicates preknown liver damage inpatients doubled mean maximum values -gt transaminases subjects normal liver status time dili appeared study sample preexisting hepatic injury common risk factor far 59 cases followed substance abuse mostly alcohol 20 cases the common clinical symptoms nausea fatigue loss appetite abdominal pain a total 27 inpatients showed clinical symptoms majority show 8 cases ad treatment remained dosage reduced cases drug withdrawn dili assessed within 55 cases in study sample 149 liver enzyme elevations one case acute liver failure occurred 20-year old woman predamaged liver resulting overdose paracetamol time admission psychiatric ward she medication 150 mg doxepine 3 days 10 mg olanzapine 6 days the patient liver enzymes increased rapidly clinical symptoms vomiting nausea epigastric pain set following laboratory analysis a hepato toxicity identified bilirubin 3.8mg dl gpt 8827u l got 7363u l lactate dehydrogenase as soon acute liver failure diagnosed patient transferred intensive care ward care transplantation consulting team the hepatotoxic effects doxepine olanzapine discribed previous literature knowledge severe case presented far to date studies occurrence elevation liver enzymes psychotropic treatment generally based case reports a systematic drug surveillance program however increases methodological accuracy significantly several programs shown links adrs range psychotropic drugs grohmann et al 2004 2013 gallego et al 2012 lettmaier et al 2012 study this result regarding tcas accordance previous results amsp arzneimittel berwachungs programm der psychiatrie german drug surveillance psychiatry study group the amsp group published manuscript severe adrs ads year 2004 degner et al 2004 ads classified according receptors diverse action profiles tcas linked increased levels liver enzymes predominantly adrs provoke cholestatic liver damage prolonged cholestasis hepatocellular necrosis may also occur zimmerman 1999 intensive drug monitoring study arzneimittel berwachungs programm working group elevated liver values observed 13.8% inpatients taking tcas majority inpatients presented minor increase transaminases eg gpt ap one third cases observed grohmann et al 1999 2004 degner et al 2004 most tcas induce inhibit cyp-450-isoenzymes substrate enzymes however may affected interactions point interest due relatively restricted therapeutic index chou et al up 0.02% inpatients receiving long term therapy fluoxetine showed elevated liver enzymes while severe hepatotoxic reactions rare literature reported adrs linked fluoxetine paroxetine sertraline grohmann et al 1999 2004 ; many new ads inhibit cyp-450 enzymes example fluoxetine paroxetine inhibitors cyp2d6 combination tcas severe intoxications may occur involving 3 substances likelihood toxicity even higher gillman et al 2007 seen short term studies mirtazapine elevates liver enzymes 3 times norm 2% patients cases patients develop significant liver damage patients values even recovering spite continued medication hui et al 2002 biswas et al 2003 two cases documented however mirtazapine induced severe cholestatic hepatitis dodd et al 2001 hui et al 2002 within study sample mirtazapine perform worse snris especially terms gpt got values actually showed favorable profile study cases dili the prevalent drug class combination one ads aps cases concerning combination ad olanzapine clozapine a total 5% 10% patients slow metabolizers show high plasma levels high risk hepatotoxic reaction kevin et al 2007 there little information available newer generation aps regarding hepatotoxic side effects extreme hepatotoxicity seems occur rarely clozapine risperidone induced liver damage even acute liver failure associated clozapine documented macfarlane et al 1997 olanzapine seems trigger hypersensitivity reaction involvement liver mansur et al clozapine causes mild mostly temporary increase transaminases 37% patients grohmann et al 1989 ; our results extent consistent preexisting findings summarized recent review antidepressant induced liver injury published 2014 also indicated greater risk hepatotoxicity tcas agomelatine least potential dili ssris voican et el 2014 the latter review claimed aminotransferase surveillance gpt useful tool detecting dili ( 2014 duloxetine tcas clomipramine least favorable influence gpt values this agreement findings sample median dosage dili occurred higher overall median dosage 7 9 substances additionally compared existing findings nefazodone mao inhibitors often described highly responsible dili previous studies confirmed within results surveillance program single mao inhibitors well nefazodone rarely prescribed therefore could reliably compared drugs our findings suggest ssris less likely antidepressants examined study precipitate dili preknown liver damage inpatients risk doubled mean values -gt transaminases subjects healthy liver status time dili appeared data thus special attention given inpatients prescribing antidepressants potential adverse effects affecting liver given huge sample size observational naturalistic study present findings may contribute significantly existing literature help prevent antidepressant induced adverse hepatic events the findings present study reflect data obtained inpatients likely severely ill higher antidepressant dosages polypharmacy compared outpatients second detection dili dependent increased liver enzyme values hence blood examination tests regular blood tests taken time admittance hospital however standardized regimen laboratory testing admittance might influence detection dili especially cases asymptomatic drug induced liver dysfunction small differences surveillance habits liver enzymes across 80 hospitals participating amsp program may contribute aforementioned problem this leads lower incidence rate dili compared studies using gpt values 3 times got values 2-fold normal value indicative dili furthermore reporting bias ruled due nature surveillance program prevent discrepancies among reported cases the latter discussed examined systematic way regional international meetings within amsp group terms results agomelatine mentioned awareness possible liver adrs beginning surveillance ( product safety information might influenced detection agomelatine induced liver enzyme elevations due sensitization prior onset dili the findings present study reflect data obtained inpatients likely severely ill higher antidepressant dosages polypharmacy compared outpatients second detection dili dependent increased liver enzyme values hence blood examination tests regular blood tests taken time admittance hospital however standardized regimen laboratory testing admittance might influence detection dili especially cases asymptomatic drug induced liver dysfunction small differences surveillance habits liver enzymes across 80 hospitals participating amsp program may contribute aforementioned problem the amsp program focuses severe adrs grohmann et al 2004 least 5-fold increase liver enzymes this leads lower incidence rate dili compared studies using gpt values 3 times got values 2-fold normal value indicative dili furthermore reporting bias ruled due nature surveillance program prevent discrepancies among reported cases the latter discussed examined systematic way regional international meetings within amsp group terms results agomelatine mentioned awareness possible liver adrs beginning surveillance ( product safety information might influenced detection agomelatine induced liver enzyme elevations due sensitization prior onset dili since 1993 educational research grants given following pharmaceutical companies 3 local nonprofit associations amsp 1 austrian companies aesca pharma gmbh astrazeneca sterreichgmbh boehringer ingelheim austria bristol myers squibb gmbh csc pharmaceuticals gmbh eli lilly gmbh germania pharma gmbh glaxosmithkline pharma gmbh janssen cilag pharma gmbh lundbeck gmbh novartis pharma gmbh pfizer med inform servier austria gmbh wyeth lederle pharma gmbh 2 german companies abbott gmbh co. kg astrazeneca gmbh aventis pharma deutschland gmbh ge r n bayer vital gmbh co. kg boehringer mannheim gmbh bristol myers squibb ciba geigy gmbh desitin arzneimittel gmbh duphar pharma gmbh co. kg eisai gmbh esparma gmbh arzneimittel glaxosmithkline pharma gmbh co. kg hoffmann la roche ag medical affairs janssen cilag gmbh janssen research foundation knoll deutschland gmbh lilly deutschland gmbh niederlassung bad homburg lundbeck gmbh co. kg novartis pharma gmbh nordmark arzneimittel gmbh organon gmbh otsuka pharma frankfurt pfizer gmbh pharmacia upjohn gmbh promonta lundbeck arzneimittel rhone poulenc rohrer sanofi synthelabo gmbh sanofi aventis deutschland schering ag smithklinebeecham pharma gmbh solvay arzneimittel gmbh synthelabo arzneimittel gmbh dr wilmar schwabe gmbh co. thiemann arzneimittel gmbh troponwerke gmbh co. kg upjohn gmbh wander pharma gmbh wyeth pharma gmbh 3 swiss companies ahp schweiz ag astrazeneca ag bristol myers squibb ag desitin pharma gmbh eli lilly suisse s.a essex chemie ag glaxosmithkline ag janssen cilag ag lundbeck suisse ag mepha schweiz ag teva msd merck sharp dohme ag organon ag pfizer ag pharmacia sandoz pharmaceuticals ag sanofi aventis suisse s.a sanofi synthelabo sa servier sa smithklinebeecham ag solvay pharma ag vifor sa wyeth ahp suisse ag wyeth pharmaceuticals ag dr konstantinidis received honoraria affiris astrazeneca novartis pfizer servier served consultant astrazeneca speaker astrazeneca bristol myers squib janssen dr winkler received speaker honoraria angelini bristol myers squibb novartis pfizer servier dr greil member advisory board lundbeck received speaker fees astrazeneca lundbeck lundbeck institute myers squibb eli lilly glaxosmithkline lundbeck organon sepracor servier served consultant advisory boards astrazeneca bristol myers squibb eli lilly glaxosmithkline janssen lundbeck merck sharp dome msd novartis organon pfizer schwabe sepracor servier served speakers bureaus angelini astrazeneca bristol myers squibb eli lilly janssen lundbeck pfizer pierre fabre schwabe sepracor servier dr winkler received lecture fees bristol myers squibb csc pharmaceuticals novartis pfizer servier	background : drug - induced liver injury is a common cause of liver damage and the most frequent reason for withdrawal of a drug in the united states . the symptoms of drug - induced liver damage are extremely diverse , with some patients remaining asymptomatic.methods:this observational study is based on data of arzneimittelsicherheit in der psychiatrie , a multicenter drug surveillance program in german - speaking countries ( austria , germany , and switzerland ) recording severe drug reactions in psychiatric inpatients . of 184234 psychiatric inpatients treated with antidepressants between 1993 and 2011 in 80 psychiatric hospitals , 149 cases of drug - induced liver injury ( 0.08% ) were reported.results:the study revealed that incidence rates of drug - induced liver injury were highest during treatment with mianserine ( 0.36% ) , agomelatine ( 0.33% ) , and clomipramine ( 0.23% ) . the lowest probability of drug - induced liver injury occurred during treatment with selective serotonin reuptake inhibitors ( [ 0.03% ) , especially escitalopram [ 0.01% ] , citalopram [ 0.02% ] , and fluoxetine [ 0.02% ] ) . the most common clinical symptoms were nausea , fatigue , loss of appetite , and abdominal pain . in contrast to previous findings , the dosage at the timepoint when dili occurred was higher in 7 of 9 substances than the median overall dosage . regarding liver enzymes , duloxetine and clomipramine were associated with increased glutamat - pyruvat - transaminase and glutamat - oxalat - transaminase values , while mirtazapine hardly increased enzyme values . by contrast , duloxetine performed best in terms of gamma - glutamyl - transferase values , and trimipramine , clomipramine , and venlafaxine performed worst.conclusions:our findings suggest that selective serotonin reuptake inhibitors are less likely than the other antidepressants , examined in this study , to precipitate drug - induced liver injury , especially in patients with preknown liver dysfunction .
titanium alloys become popular metallic biomaterials dental applications excellent biocompatibility this attributed inert nature titanium surface due formation thin native titanium oxide layer also provides excellent corrosion resistance although titanium alloys virtually replaced metallic biomaterials dental implant applications currently little insight reasons excellent biocompatibility titanium surfaces a number studies pointed various factors contribute biocompatibility titanium modified titanium surfaces 36 while studies investigated proliferation differentiation osteoblast cell lines evidenced many instances gene expression corroborate biocompatibility emphasis physical factors roughness texture wettability substrate microstructural features some importance paid substrate composition whether ti ti alloy makeup surface modified layer recent work plausible role titanium oxide contributing outstanding biocompatibility observed studying titanium alloys noticed alp activity higher oxidized titanium alloys compared corresponding untreated materials 7 8 despite good understanding signaling pathways osteoblast differentiation the effect titanium oxide osteoblast differentiation fully researched even though fact thin native titanium oxide layer forms titanium alloys well known large amount research conducted popular biomaterials it still unclear present time whether osteoblast differentiation affected titanium oxide oxygen released titanium oxide a recent report suggests oxygen tension strong effect osteoblast differentiation may fact regulate process hypoxic cell cultures demonstrated lower level mineralization resulting chondrogenic tissue comparison higher levels oxygen cell cultures healing fractures also reported much earlier delayed absence oxygen in contrast reactive oxygen species ros reported suppress bone formation stimulate bone resorption osteoblast differentiation involves complex molecular pathway consisting various transcription factors well known many transitional stages comprise pathway process several signaling molecules play key roles overall skeletal development it currently unknown titanium oxide plays critical role step signaling cascade understanding manner titanium oxide affects osteoblast differentiation may critical titanium implantology terms reducing hospitalization time formulating efficient therapeutic procedures study hfob cells cultured 10 days oxide formed surface two titanium based alloys two different methods oxidation degree osteoblast differentiation measured quantification alp activity using commercial assay kit compare unoxidized titanium alloy surfaces effort determine titanium oxide indeed played role differentiation process various samples two titanium based alloys gamma tial -tial ti-48al-2cr-2nb at.% ti-6al-4v wt.% machined form 7 mm diameter cylindrical rods these disks approximate thickness 1 mm obtained using slow speed diamond saw buehler surfaces disks ground using 240 320 600 1200 grit silicon carbide paper ecomet 3 buehler these metal disks sonicated 0.8% alconox fisher pittsburgh pennsylvania 70% ethanol 10 minutes rinsed deionized water dried hot air blow dryer both -tial ti-6al-4v disks oxidized laboratory furnace cm furnaces inc air 500c 800c 1 h later placed 48-well cell culture plates corning the nomenclature followed paper follows -tial ti-6al-4v disks oxidized 500c 800c hereafter referred gti5 gti8 tiv5 tiv8 respectively untreated disks designated gti tiv atomic force microscopy afm used obtain average surface roughness values oxidized surfaces other -tial ti-6al-4v disk samples processed using micro arc oxidation mao mao process stainless steel beaker used cathode titanium disk either -tial ti-6al-4v used anode each sample mounted titanium holder specially designed allow complete exposure sample electrolyte a hoefer ps300-b high voltage power supply 300 v 500 operated galvanostatic mode order form titanium oxide film sample surface using mao process process conditions sample current 200 225 durations 3 4 minutes case utilized based earlier study after treatment samples rinsed distilled water dried blow dryer micro arc oxidized samples henceforth referred maogti -tial samples maotiv ti-6al-4v samples respectively oxides formed -tial ti-6al-4v result mao treatment applied process conditions mainly rutile anatase reported earlier 11 12 thermal oxidation alumina dominant oxide formed -tial 500c rutile dominant 800c 1316 ti-6al-4v thermal oxidation 500c produces combination oxide diffused ti(o rutile latter phase appears grow high temperatures 650c 800c the average roughness values surfaces extracted topography analysis using afm presented table 1 human osteoblast cells cell line hfob 1.19 atcc manassas virginia cultured 90% dulbecco modified eagle medium nutrient mixture f-12 ham dmem sigma aldrich st louis missouri 2.5 mm l glutamine 15 mm hepes without phenol red supplemented 0.3 mg ml g-418 calbiochem san diego california 10% fetal bovine serum fbs hyclone logan utah cells grown 25 cm plastic culture flasks corning corning new york incubated 33.5c confluence approximately 100% confluence cells washed three times phosphate buffer saline pbs solution 137 mm nacl 2.7 mm kcl 4.3 mm na2hpo4 1.4 mm kh2hpo4 harvested using 0.25% trypsin-0.53 mm edta gibco gaithersburg maryland 37c 5 min cells pelleted low speed centrifugation 3,300 rpm 5 minutes subcultured 1 3 ratio cells seeded 48-well plates becton dickinson lincoln park nj density 5 10 cells cm tiv tiv5 tiv8 gti gti5 gti8 maotiv maogti disks 7 mm diameter using commercial alkaline phosphatase colorimetric assay kit ab83369 abcam order evaluate osteoblast differentiation quantitatively thermally oxidized micro arc oxidized untreated -tial ti-6al-4v disks samples incubated 3 days 33.5c 7 days 39.5c allow osteoblast differentiation modifications suggested protocol made achieve efficient cell lysis including washing samples carefully three times pbs homogenizing 60 l assay buffer also triton x-100 80 l utilized lyse cells efficient measurement intracellular alp stop solution 20 l added terminate alp activity sample the solution well transferred 96-well plate becton dickinson lincoln park nj pnpp solution 50 l added well containing test samples background controls a standard curve generated determine concentration alp activity sample 40 l 5 mm pnpp solution diluted 160 l assay buffer generate 1 mm pnpp standard 0 4 8 12 16 20 l were added 96-well plate duplicate generate 0 4 8 12 16 20 nmol well pnpp standard alp enzyme solution 10 l added well containing pnpp standard all reactions stopped adding 20 l stop solution standard sample reaction except sample background control reaction since 20 l stop solution added background control prepared previously the background corrected subtracting value derived zero 0 standards standards samples sample background control the pnpp standard curve plotted sample readings applied standard curve get amount pnpp generated alp activity test samples calculated using equation alp activity u ml v amount pnpp generated samples mol v volume sample added assay well ml reaction time minutes three independent experiments performed alp assay since experiment three replicates total nine replicates per surface evaluated mao -tial thermally oxidized -tial untreated -tial mao ti-6al-4v thermally oxidized ti-6al-4v untreated ti-6al-4v control glass coverslips 10-day period culture the data alp assay presented mean standard deviation sd optical density differentiated cells different surfaces corresponding amount alkaline phosphatase detected each value represents mean three measurements cell differentiation performed specific surface mentioned factorial analysis variance anova ) was used assess significant interactions type metal -tial ti-6al-4v type surface treatment micro arc oxidization 200 3 min 200 4 min 225 3 min 225 4 min thermal oxidization 500c 800c all significant interactions graphically analyzed addition randomized block design performed reduce variance data furthermore contrast test performed compare type metal -tial ti-6al-4v surface treatments significant differences cell differentiation type metal surfaces tested confirmed using lsd fisher test sem images glass coverslips untreated ti-6al-4v -tial surfaces tiv gti micro arc oxidized ti-6al-4v -tial surfaces maotiv maogti thermally oxidized ti-6al-4v -tial surfaces tiv5 tiv8 gti5 gti8 shown figure 1 gti tiv figures 1(a 1(b exhibit smoother surface passive oxide layer formed instantaneously ti alloys in contrast rounded surface structures visible tiv5 suggesting clusters oxide granules gti8 tiv8 hand exhibited rougher surface comparison samples figures 1(e 1(f larger oxide granules present tiv8 figure 1(e compared gti8 figure 1(f conferring irregular appearance surface suggesting tiv8 oxide layer could possibly thicker mao surfaces ti-6al-4v maotiv figure 1(g demonstrated number large pores oxide surface typical similar treatments ti alloys 18 19 although pores also clearly visible surface maogti smaller average submicron range sem images shown figure 2 indicate hfob 1.19 cells grew normally surfaces untreated -tial ti-6al-4v disks cell attachment proliferation similar metal surfaces suggesting normal growth cell confluence attachment vitro conditions the osteoblast cells spread flattened glass coverslips exhibiting close contact detection cellular boundaries difficult fibrous networks corresponding fibrillar collagen main component bone ecm aid adhesion cells important proper assembly extracellular matrix visible lending testimony normal growth osteoblasts surfaces the ecm serves calcium phosphate reservoir provides support cells offers protection important homeostasis appears forming copiously included nodules mineralization sponge like morphology intimately associated fibrillar network scattered throughout samples the maturation ecm evidenced presence fibrous networks associated cells increase nodules mineralization thermally oxidized ti-6al-4v -tial alloys 500c cellular attachment proliferation similarly observed cell multilayer constituted elongated polygonal cells round shaped cells figure 2 along presence small rounded structures may correspond mineral nodules observed higher magnification figure 3 ) mineral nodules appeared close contact cells sponge like appearance thermally there cell debris indicative cytotoxicity oxide figure 3 agreement earlier report however thermally oxidized -tial alloys fibrous networks mineralized nodules observed elongated cells see figure 3 slender cytoplasmic projections filopodia extended cells directions micro arc oxidized ti-6al-4v -tial disks confirming biocompatibility substrate materials addition sheet like cytoplasmic protrusions extending cell body directions suggest ability cellular movement spreading cells substrate and/or fact cellular division mitosis may occurring the presence mineralized nodules suggests maturation ecm formation bone like tissue indicating osteoblast differentiation evidenced high degree alp activity taken together normal cell attachment proliferation surfaces exception tiv8 indicate excellent biocompatibility control untreated treated titanium alloy surfaces standard calibration curves used extrapolate values alkaline phosphatase alp activity experimental disks 10 days seeding based alkaline phosphatase assay the alp activity measured described section 2 plotted figure 4 various sample surfaces utilized experiment measure osteoblast differentiation it clear little alp activity observed untreated ti alloy samples positive controls glass coverslips indicate reasonable alp activity corresponding osteoblast differentiation surface treatments thermal oxidation mao the highest alp activity observed ti alloys subjected mao treatment exception must noted alp activity ti-6al-4v oxidized 800c rather low compared treated samples anova revealed significant interactions factors tested type metal treatment alp activity the interaction type metal -tial ti-6al-4v surface treatment micro arc oxidation 200 3 min 200 4 min 225 3 min 225 4 min thermal oxidation 500c 800c significant p 0.05 there also significant differences amount alkaline phosphatase detected among six surfaces studied 10 days incubation 33.5c 39.5c respectively additionally alkaline phosphatase activity lower positive control glass coverslips even much lower untreated titanium alloy surfaces comparison micro arc thermally oxidized alloys furthermore alp activity increased -tial ti-6al-4v alloys mao treatments samples exposed longer process times current density although qualitatively significant differences number osteoblast cells attached micro arc oxidized thermally oxidized surfaces collectively alp activity significantly higher cell cultures grew micro arc oxidized surfaces comparison thermally oxidized substrates see figure 4 surface roughness oxidized surfaces appear show correlation alp activity hfob adherence clearly excellent surfaces exception tiv8 may possibly due cellular response toxic compounds harmful ions vanadium oxide layer result thermal oxidation titanium oxide alone does pose problems cytotoxicity since cells attach proliferate surfaces alloys subject oxidation 500c also -tial oxidized 800c oxide formed predominantly composed titanium oxide form rutile anatase an earlier study showed normal cell attachment tiv8 2 days seeding cell debris result subsequent cell death longer periods incubation osteoblast differentiation hand occurred different extents substrates measured alp activity osteoblast differentiation well coordinated physiological process occurring three stages include cell proliferation ecm production maturation matrix mineralization correspondingly proliferative osteoprogenitors msx2 rp59 expressed first stage followed runx2 osx oc osteocalcin later stages process differentiation proliferation col 1 alp detected earlier followed secretion rgd containing proteins bone sialoproteins bsp osteopontin op culminating synthesis oc last stage differentiation bone morphogenetic proteins bmps various members tgf- family secreted osteoblast cells sequestered extracellular matrix ecm also reported critical osteoblast differentiation interaction type collagen 21 integrin activates mitogen activated protein kinase mapk pathway results phosphorylation activation cbfa1 turn stimulating differentiation osteoblasts lack expression runx2 osx may result formation demineralized bone although data suggests transcriptional factors act independently expression runx2 along cbf alkaline phosphatase found critical early stage differentiation osx becomes important later stage osteoblast differentiation present study cell attachment proliferation occur normally substrates except tiv8 alkaline phosphatase activity measurements indicate osteoblast differentiation varies depending nature substrate the presence mineral nodules ecm titanium sample surfaces provides physical evidence corroborate activity osteoblasts one functional stages maturation observed osteoblast cultures longer periods incubation ti-6al-4v and -tial thermally oxidized disks 500c showed irregular rounded mineralized structures surface similar cell morphology function observed mao surfaces alloys suggesting ability surfaces also promulgate differentiation the fact alp activity significantly lower untreated alloys tiv gti suggests titanium oxide formed surface alloys may strongly correlated differentiation osteoblasts it demonstrated earlier study oxide layer mao treated alloys consists titanium oxide peaks anatase rutile phases coating conditions applied study both anatase rutile shown beneficial enhancing nucleation subsequent hydroxyapatite ha precipitation thereby increasing bioactivity titanium surface the results present study also suggest incorporation calcium ca phosphorus p titanium oxide may favorable cell differentiation while ca p important observation increased alp activity mao treated surfaces ti alloys samples thermally oxidized 500c devoid ca p also show reasonably high alp activity compared control glass coverslips a recent study shown higher elemental oxygen concentration higher water wettability tio2 surfaces compared bare titanium surfaces resulting twofold increase alp activity mineralized nodule area it also appears topography bioengineered titanium surfaces affects gene expression phenotypic response osteoprogenitor cells higher alp activity surfaces containing titanium oxide may possibly correlated surface topography substrate may affect cell proliferation differentiation 31 32 thus may argued osteoblast differentiation depend solely ca p ions presence titanium oxide in contrast another research suggests cell cytotoxicity due tio2 resulting interaction tio2 nanoparticles lysosomal compartment independently known apoptotic signaling pathways in addition tio2 reported possess antibacterial characteristics stark contrast positive biocompatibility although clear study titanium oxide increases alp activity osteoblasts mechanism associated process still unknown it proposed bmp-2 controls alkaline phosphatase expression osteoblast mineralization wnt autocrine loop mesenchymal stem cells mscs among factors regulate msc growth differentiation are soluble factors cell substrate interactions although little known molecular mechanisms soluble substrate signals regulate msc function these authors showed commitment human mscs osteogenic adipogenic lineages vitro involves signaling mitogen activated protein kinase mapk pathways in particular found dexamethasone ascorbic acid -glycerophosphate induce msc differentiation regulating extracellular signal regulated kinase erk1/2 cascade furthermore blocking erk1/2 pathway inhibits osteogenic differentiation mscs leads adipogenesis thus mapk pathways generally activated growth factors cytokines integrin mediated cell adhesion play critical role directing msc commitment mapk pathways also activated physical stimuli regulate function variety cell types including bone cells bone proposed mature cells osteocytes osteoblasts responsible sensing responding mechanical stimuli it unknown whether progenitors give rise cells responsive mechanical signals various signaling pathways including bmp wnt notch regulate bone homeostasis it difficult present time determine affected titanium oxide extent upregulating alp activity while clearly demonstrated hypoxia suppresses osteoblast differentiation consequence bone formation mode tio2 increases alp activity clear cut one may speculate chemical reaction tio2 culture medium may somehow result release oxygen normoxia positive impact osteoblast differentiation however clear tio2 bioactive factor indeed upregulates alp activity although manner oxide indeed participates biochemical signaling cascade occurs differentiation require study information may vital future implantology accelerating fracture healing tissue regenerative processes dental orthopedic applications if titanium oxide indeed upregulates osteoblast differentiation manufacturers titanium based implants would find advantageous incorporate titanium oxide coating every surface layer contact tissue side implant clearly research needed interrogate empirical ability titanium oxide preferentially favor osteoblast differentiation least alp activity alp activity much higher oxidized surfaces titanium alloys compared untreated surfaces probably due presence titanium oxide.the higher alp activity micro arc oxidized surfaces attributed ca p content present thermally oxidized titanium alloys.the mechanism upregulation alp due titanium oxide needs study although clear tio2 bioactive factor osteoblast differentiation alp activity much higher oxidized surfaces titanium alloys compared untreated surfaces probably due presence titanium oxide the higher alp activity micro arc oxidized surfaces attributed ca p content present thermally oxidized titanium alloys the mechanism upregulation alp due titanium oxide needs study although clear tio2 bioactive factor osteoblast differentiation	titanium and titanium alloys are currently accepted as the gold standard in dental applications . their excellent biocompatibility has been attributed to the inert titanium surface through the formation of a thin native oxide which has been correlated to the excellent corrosion resistance of this material in body fluids . whether this titanium oxide layer is essential to the outstanding biocompatibility of titanium surfaces in orthopedic biomaterial applications is still a moot point . to study this critical aspect further , human fetal osteoblasts were cultured on thermally oxidized and microarc oxidized ( mao ) surfaces and cell differentiation , a key indicator in bone tissue growth , was quantified by measuring the expression of alkaline phosphatase ( alp ) using a commercial assay kit . cell attachment was similar on all the oxidized surfaces although alp expression was highest on the oxidized titanium alloy surfaces . untreated titanium alloy surfaces showed a distinctly lower degree of alp activity . this indicates that titanium oxide clearly upregulates alp expression in human fetal osteoblasts and may be a key bioactive factor that causes the excellent biocompatibility of titanium alloys . this result may make it imperative to incorporate titanium oxide in all hard tissue applications involving titanium and other alloys .
periodontitis chronic inflammatory disease characterized increased expression various cytokines inflammatory mediators resulting extensive osteoclast formation bone loss these cytokines affect bone remodeling play vital role physiological pathological regulation bone the level bone mass essential execute various functions maintained balanced act bone formation bone resorption this process highly co ordinated regulated two specialized cells osteoblasts bone forming cells osteoclasts bone resorbing cells these cells controlled various hormones inflammatory mediators cytokines growth factors recent addition regulators multifactorial cytokine opg detected gcf opg key physiological inhibitor osteoclastic bone resorption glycoprotein belongs tumor necrosis factor receptor tnf super family it decoy receptor receptor activator nuclear factor kappa b ligand rankl inhibits cell cell signaling marrow stromal cells precursors osteoclast thus prevents bone resorption rankl precursor production osteoclasts opg expressed various cell types like osteoblasts osteoclastic stromal cells cells b cells chondrocytes follicular dendritic cells however also found organs like kidney liver heart lung spleen thyroid lymph nodes thymus brain placenta it also found periodontal dental tissues like gingiva periodontal ligament internal external enamel epithelium well mesenchyme dental papilla tooth development moreover prominent expression opg cartilaginous primordia developing maxilla mandible hyoid bone reported further opg reported preventive role rheumatoid arthritis associated bone erosion joints deficiency inflamed joints rheumatoid arthritis confirms finding recently opg isolated gingival tissue gcf levels decreasing progression periodontal diseases suggesting opg levels gcf may become modulator periodontal disease especially alveolar bone resorption however till date studies correlation opg levels gcf periodontal health disease nonsurgical periodontal therapy srp hence light aforementioned facts clinico biochemical study designed estimate levels opg gcf subjects clinically healthy periodontium gingivitis slight periodontitis moderate severe periodontitis moderate severe periodontitis subjects scaling root planing srp this study conducted period august september 2007 involved 64 subjects 32 females 32 males aged 30 39 years selected outpatient section department periodontics government dental college research institute bengaluru karnataka india essential ethical clearance study obtained institutional ethical review board government dental college research institute rajiv gandhi university health sciences karnataka india those volunteered briefed study procedure consent form signed acceptance specific conditions excluded participation study pregnant lactating postmenopausal women ii patients diabetes mellitus ischemic heart disease conditions contributing atherosclerosis malignant tumors rheumatoid arthritis bone disorders and/or cancer chemotherapy antiresorptive drugs like bisphosphonates disese hve opg concentration less inflammation iii smokers alcoholics iv subjects received treatment anti inflammatory drugs antibiotics steroids contraceptives last six months v receiving periodontal treatment the subjects categorized groups group comprising 16 patients based modified gingival index mgi clinical attachment loss cal radiographic evidence bone loss group healthy consisted 16 subjects clinically healthy periodontium evidence disease the score obtained assessing gingival status using mgi zero crestal bone loss determined radiograph group ii gingivitis consisted 16 subjects whose gingivae showed clinical signs inflammation evidence cal zero group iii slight periodontitis consisted 16 subjects showed clinical signs gingival inflammation cal 1 2 mm radiographic evidence bone loss group iv moderate severe periodontitis consisted 16 subjects showed clinical signs gingival inflammation cal 3 mm radiographic evidence bone loss group v treatment group consisted group iv subjects treated nonsurgically gcf samples collected sites six eight weeks treatment constitute group v figures 15 clinical picture patient group healthy showing cal 0 mm mesiolabial aspect 11 radiographic picture area clinical picture patient group ii gingivitis showing cal 0 mm mesiolabial aspect 11 radiographic picture area clinical picture patient group iii slight periodontitis showing cal 1 2 mm mesiolabial aspect 21 radiographic picture area clinical picture patient group iv moderate severe periodontitis showing cal 3 mm mesiobuccal aspect 46 radiographic picture area clinical picture patient group v moderate severe periodontitis treatment radiographic picture area treatment sampling protocol followed described previously earlier studies group briefly clinical radiological examinations group allocation sampling site selections performed one examiner pb samples collected subsequent day second examiner mvrp this done ensure blinding sampling examiner prevent contamination gcf blood associated probing inflamed sites only one site per subject selected sampling site healthy group sampling predetermined mesiobuccal region maxillary right left first molar wherever adequate sample obtainable gingivitis sites 1 6 mm cal identified using williams graduated periodontal probe followed radiographical confirmation bone loss assigned sampling subsequent day a standardized volume 1 ml gcf collected predetermined test site using calibration color coded 1 5 ml calibrated volumetric microcapillary pipettes extracrevicular approach unstimulated plastic vials used store gcf containing micropipettes stored 70c assay figures 6 7 the microcapillary pipettes aspirator tube collection gcf using extra crevicular positioning microcapillary pipette appropriate dilution gcf samples sandwich type elisa development kit elisa enzyme linked immunosorbent assay employed quantitative determination human opg figures 8 9 duoset human opg elisa kit contents opg elisa kit 96 well plate kit prepared previous day incubated overnight per manufacturer kit development instructions the kit utilizes capture antibody coated microtiter plate immobilization bind human opg standards sample then 100 l diluted sample standards added appropriate wells covered adhesive strips followed incubation two hours room temperature later 100 l working dilution streptavidin horseradish peroxidase hrp substrate solution added well washing plate three times wash buffer addition incubated 20 minutes room temperature finally 50 l stop solution added well stop enzyme reaction color generated read 450 nm the concentration opg tested samples calculated using standard curve plotted using optical density values standards figure 10 opg capture antibody preparation statistical software program applied analyze data obtained the kruskal wallis man whitney u test wilcoxon signed rank tests carried compare opg levels among groups the spearman rank correlation test used correlate opg levels study groups clinical parameters the sampling protocol followed described previously earlier studies group briefly clinical radiological examinations group allocation sampling site selections performed one examiner pb samples collected subsequent day second examiner mvrp this done ensure blinding sampling examiner prevent contamination gcf blood associated probing inflamed sites only one site per subject selected sampling site healthy group sampling predetermined mesiobuccal region maxillary right left first molar wherever adequate sample obtainable gingivitis sites highest clinical signs inflammation selected periodontitis sites with 1 6 mm cal identified using williams graduated periodontal probe followed radiographical confirmation bone loss assigned sampling subsequent day standardized volume 1 ml gcf collected predetermined test site using calibration color coded 1 5 ml calibrated volumetric microcapillary pipettes extracrevicular approach unstimulated plastic vials used store gcf containing micropipettes stored 70c assay figures 6 7 the microcapillary pipettes aspirator tube collection gcf using extra crevicular positioning microcapillary pipette after appropriate dilution gcf samples sandwich type elisa development kit elisa enzyme linked immunosorbent assay employed quantitative determination human opg figures 8 9 duoset human opg elisa kit contents opg elisa kit 96 well plate kit prepared previous day incubated overnight per manufacturer kit development instructions the kit utilizes capture antibody coated microtiter plate immobilization bind human opg standards sample then 100 l diluted sample standards added appropriate wells covered adhesive strips followed incubation two hours room temperature later 100 l working dilution streptavidin horseradish peroxidase hrp substrate solution added well washing plate three times wash buffer addition incubated 20 minutes room temperature finally 50 l stop solution added well stop enzyme reaction color generated read 450 nm the concentration opg tested samples calculated using standard curve plotted using optical density values standards figure 10 the kruskal wallis man whitney u test wilcoxon signed rank tests carried compare opg levels among groups the spearman rank correlation test used correlate opg levels study groups clinical parameters the highest mean opg concentration noted group 162.47 51.17 pg/l lowest group iv 10.92 1.91 pg/l intermediate values group ii 41.39 16.64 pg/ l group iii 23.40 1.99 pg/ l group v 15.63 4.68 pg/ l mean opg concentration study groups graph comparing opg levels among study groups results kruskal wallis test nonparametric carried evaluate difference opg levels 5% level significance p 0.05 suggested mean concentration opg differed significantly among groups tested table 2 kruskal wallis test comparing mean gcf opg levels groups multiple comparison using mann whitney u test carried find pair pairs groups differed significantly p 0.05 suggested opg levels gcf decreased progressively health severe periodontitis table 3 pairwise comparison using mann whitney u test gcf opg group iv moderate severe periodontitis group v treatment group iv compared using wilcoxon signed rank test table 4 difference concentration opg statistically significant p 0.05 indicating srp opg levels increased considerably gcf 10.92 pg/l 15.63 pg/l wilcoxon signed rank test comparing gcf opg concentration treatment spearman rank correlation test done observe correlation gcf opg concentration clinical variables mgi cal when opg levels gcf tested correlation disease severity measures mgi group ii mgi cal groups iii iv v negative correlation found gcf opg concentration shown table 5 kruskal -wallis test comparing cal opg concentrations kruskal wallis test done compare mean opg concentration gcf different cal levels treatment significant reduction cal treatment proportional statistically significant p 0.05 increase opg levels gcf shown table 6 results spearman rank correlation r test comparing gcf opg cal within groups summary mean rank group highest differs significantly group ii iii iv v. results indicate gcf opg concentration decreases periodontal health disease periodontitis chronic inflammatory disease characterized increased expression various cytokines inflammatory mediators resulting extensive osteoclast formation bone loss these cytokines affect bone remodeling play vital role physiological pathological regulation bone opg key physiological inhibitor osteoclastic bone resorption glycoprotein belongs tnf super family it decoy receptor rankl inhibits cell cell signaling marrow stromal cells precursors osteoclasts thus prevents bone resorption rankl precursor production osteoclasts opg expressed various cell types like osteoblasts osteoclastic stromal cells cells b cells chondrocytes follicular dendritic cells moreover also found organs tissues like kidney liver heart lung spleen thyroid lymph nodes thymus brain placenta it found also periodontal dental tissues like gingiva periodontal ligament internal external enamel epithelium well mesenchyme dental papilla tooth development there prominent expression cartilaginous primordia developing maxilla mandible hyoid bone correlated opg concentration gcf explained possible role periodontal disease progression however till date studies documented compared opg levels gcf subjects healthy diseased periodontium srp hence present study undertaken determine potential role opg novel bone marker periodontal disease modulator achieve objective opg levels gcf were quantified compared healthy gingivitis slight periodontitis moderate severe periodontitis subjects moderate severe periodontitis subjects treatment study the mean concentrations opg gcf found decrease progressively 162.47 51.171 pg/l healthy subjects 8.12 pg/ l periodontitis subjects whereas gingivitis mean concentration opg 60.50 pg/ l the results present study respect general trend accordance mogi et al reported decreasing opg levels gcf progression periodontal disease when pairwise comparison done healthy gingivitis group gingivitis slight periodontitis group slight periodontitis moderate severe periodontitis group moderate severe periodontitis group treatment group healthy slight periodontitis group healthy moderate severe periodontitis group healthy moderate severe periodontitis group treatment differences statistically significant gcf opg concentration the mean rank obtained moderate severe periodontitis 12.50 pg/l much lower healthy 72.50 pg/ l gingivitis 52.44 pg/l slight periodontitis 44.16 pg/l groups this suggests opg levels gcf decrease progressively health periodontitis present study influence age sex subjects opg levels was minimized selecting subjects within narrow age group 30 39 years including equal number male female subjects group further study comprised five groups healthy gingivitis slight periodontitis moderate severe periodontitis moderate severe periodontitis treatment compared previous study mogi et al 2004)where four groups namely healthy controls slight periodontitis moderate periodontitis severe periodontitis subjects included provision evaluate effect periodontal therapy opg levels gcf confirm role opg modulation periodontal disease the levels opg reported earlier study expressed amount opg pg/l site levels higher study the mean opg levels study half concentration opg levels previous study reasons variations levels opg may due difference study population environmental factors volume bone present time gcf collection due reasons the numerical values opg earlier study comparable study the variability opg concentration group could due different stages disease process time collection gcf the levels opg low gingivitis group group ii compared healthy group could due near conversion gingivitis lesion periodontitis lesion detectable clinically either manual probing radiography slight periodontitis group opg concentration less healthy gingivitis groups the moderate severe periodontitis subjects treated srp strict measures oral hygiene instituted eight weeks treatment gcf samples collected group iv group v the mean concentration opg gcf moderate severe periodontitis group increased 10.92 pg/l treatment treatment level 21.25 pg/l respectively statistically significant recently similar results reported gingival biopsies quantified opg mrna mrna messenger rna rankl healthy chronic periodontitis patients srp most samples group v treatment fall group iii slight periodontitis group iv could due modulation periodontal disease opg protects bone preventing osteoclastogenesis accelerated rankl study mean mgi scores periodontitis subjects treatment 2.27 1.34 respectively commensurate cal levels opg levels gcf summary study shows opg concentration gcf decreases progression periodontal disease further accompanied decrease opg levels directly correlated stage periodontal disease amount bone loss cal further treatment aimed arresting progression periodontal disease resulted statistically significant rise levels opg gcf proportionally confirming active role periodontal attachment gain the results present study therefore provide site specific information changes opg levels result periodontal disease treatment the source opg gcf seems neighboring tissues including alveolar bone gingiva periodontal ligament periodontal tissues further concentration opg gcf increased periodontal therapy thus increasing gcf opg concentration study mean concentration opg group iv moderate severe periodontitis group 10.92 pg/l lower concentration described earlier study based findings hypothesized decreased opg levels due progressive periodontal disease could act risk factor development periodontal disease however needs confirmed conducting longitudinal prospective studies involving larger sample size the present study shows opg concentration gcf decreases proportionally progression periodontal disease gingival inflammation cal further treatment aimed arresting progression periodontal disease resulted statistically significant increased levels gcf opg proportionally confirming active role periodontal attachment gain therefore results present study provide site specific information changes opg levels result periodontal disease treatment thus within limits present study conclude opg considered novel bone marker modulation periodontal disease	background : initial research indicated that higher concentration of osteoprotegerin ( opg ) is associated with healthy periodontium ( protective ) and its concentration decreases as the periodontal disease progresses . however , till date , there are no studies to investigate the levels of opg in gingival crevicular fluid ( gcf ) after the treatment of periodontitis . hence , the present study was carried out to assess its concentration in gcf to find out their association if any , and to explore its possible use as a novel bone marker of the host modulation of periodontal disease.materials and methods : sixty - four subjects were divided into 4 groups ( 16 each ) , based on clinical attachment loss ( cal ) and radiological parameters ( bone loss ) ; healthy ( group i ) , gingivitis ( group ii ) , slight periodontitis ( group iii ) , and moderate - to - severe periodontitis ( group iv ) . moderate - to - severe periodontitis subjects , after nonsurgical periodontal treatment , ( srp ) constituted group v. gcf samples were collected to estimate the levels of opg using enzyme - linked immunosorbent assay ( elisa ) . the kruskal - wallis , man - whitney u test , and wilcoxon signed - rank tests were carried out to compare opg levels among groups . the spearman rank correlation test was used to correlate opg levels between the study groups and the clinical parameters ; p < 0.05 was considered significant.results:the highest mean opg concentration in gcf was obtained for group i ( 162.47 51.171 pg/ l ) and the least for group iv ( 10.92 1.913 pg/l ) , suggesting a negative correlation between opg concentration and cal . opg concentrations in gcf after the treatment of group iv increased from 10.92 1.913 pg/l to 15.63 4.679 pg/l.conclusion : opg concentration in gcf was inversely proportional to cal and not an active progression factor for periodontal disease . further , after the treatment of moderate - to - severe periodontitis subjects ( group iv ) , opg concentrations increased . hence , it can be concluded that opg could be considered as a novel bone marker the host modulation of periodontal disease .
jugular foramen paragangliomas rare slow growing encapsulated hypervascular tumors arise jugular foramen temporal bone 1 jugular foramen paraganglioma known occur predominantly age 50 60 female male ratio reported 5:1 1 2 incidence multiple lesion reported 25 50% familial cases compared less 10% sporadic cases 1 jugular foramen paragangliomas locally invasive expanding within temporal bone via pathways least resistance air cells vascular lumens skull base foramina eustachian tube 3 4 significant intracranial extracranial extension may occur well extension within sigmoid sinus inferior petrosal sinuses 3 5 clinical course jugular foramen paragangliomas reflects slow growth paucity symptoms often results significant delay diagnosis 1 3 6 common presenting symptom known pulsatile tinnitus followed hearing loss 2 7 complete surgical resection ideal management jugular foramen paragangliomas 2 5 7 9 radiation therapy utilized alternative treatment modality certain candidates including elderly medically inoperable patients also indicated recurred tumor surgical resection residual tumors gross total removal extensive tumor could carried 10 gamma knife surgery recently introduced used primary tool cases without significant cervical extension patients recurrent tumors intracranial area 10 identify clinical characteristics effective surgical approach the authors made retrospective analysis patterns clinical presentation surgical approaches treatment outcomes 9 patients jugular foramen paraganglioma underwent surgical treatment the patient group consisted 4 men 5 women underwent surgery single surgeon 1986 2005 mean age time diagnosis 40.8 yr ranging 26 60 yr follow period 29 month 264 months mean follow period 93 months five cases occurred right side remaining 4 cases left one case bilateral lesion detected review clinical records performed analyzing initial clinical symptoms signs audiological examinations neurological deficits radiological features surgical approaches extent resection treatment outcomes postoperative complications the extent jugular foramen paraganglioma classified according fisch classification based radiological findings most common initial symptom time first outpatient visit hoarseness observed 4 patients followed pulsatile tinnitus noted 3 cases table 1 sudden sensorineuronal hearing loss 2 patients facial palsy 2 patients neck mass 1 patient also reported all patients except 2 cases least one low cranial nerve palsy evaluation most common neurologic deficit presentation 10th nerve palsy followed 9th nerve 12th nerve 7th nerve order the extent jugular foramen paragangliomas classified according fisch classification radiologic findings mri seven patients classified type c fig 1 remainnig 2 patients type fig size tumor varied small 1.51 cm large 4.59 cm angiography all tumors least one main feeding vessel ascending pharyngeal artery common feeding vessel successful embolization feeding vessel achieved cases fig complete resection achieved 6 patients regular outpatient follow without sign recurrence all type tumors resulted partial resection 1 7 type c tumors partially resected the residual tumor 2 cases type jugular foramen gangliomas portion intracranial extension in one type tumor case case 5 1 cm sized residual tumor suspected postoperative mri first operation 1999 the patient received gamma knife radiosurgery gks remnant tumor continuously observed mri outpatient however patient undergo revision operation cooperation neurosurgery department 2006 tumor mass grew large 4 cm tumor still remained second operation revision operation neurosurgery department performed 2007 still resulting small portion residual tumor the remaining tumor observation currently remaining two partial resection cases however patients refused undergo burden major surgery twice first operation infratemporal approach gamma knife surgery performed alternative planned staged operation neurosurgery department tumor completely shrunken one case tumor stabilized without growing case no mortality encountered follow period ranging 17 275 months mean 71 months in 4 cases patient showed h b grade iv palsy returned h b grade ii palsy months since infratemporal fossa approach inevitably encounters facial palsy due transposition facial nerve facial palsy grade better h b grade ii three patients received arytenoid adduction 2 cases due unilateral vocal cord palsy one case due decreased vocal cord mobility case left vocal cord palsy developed patient undergo arytenoid adduction since symptom due vocal cord palsy prominent most common initial symptom time first outpatient visit hoarseness observed 4 patients followed pulsatile tinnitus noted 3 cases table 1 sudden sensorineuronal hearing loss 2 patients facial palsy 2 patients neck mass 1 patient also reported all patients except 2 cases least one low cranial nerve palsy evaluation most common neurologic deficit presentation 10th nerve palsy followed 9th nerve 12th nerve 7th nerve order the extent jugular foramen paragangliomas classified according fisch classification radiologic findings mri seven patients classified type c fig 1 remainnig 2 patients type fig size tumor varied small 1.51 cm large 4.59 cm angiography tumors least one main feeding vessel ascending pharyngeal artery common feeding vessel successful embolization feeding vessel achieved cases fig complete resection achieved 6 patients regular outpatient follow without sign recurrence all type tumors resulted partial resection 1 7 type c tumors partially resected residual tumor 2 cases type jugular foramen gangliomas portion intracranial extension in one type tumor case case 5 1 cm sized residual tumor suspected postoperative mri first operation 1999 patient received gamma knife radiosurgery gks remnant tumor continuously observed mri outpatient however patient undergo revision operation cooperation neurosurgery department 2006 tumor mass grew large 4 cm tumor still remained second operation revision operation neurosurgery department performed 2007 still resulting small portion residual tumor the remaining tumor observation currently remaining two partial resection cases however patients refused undergo burden major surgery twice first operation infratemporal approach gamma knife surgery performed alternative planned staged operation neurosurgery department tumor completely shrunken one case tumor stabilized without growing case no mortality encountered follow period ranging 17 275 months mean 71 months in 4 cases patient showed h b grade iv palsy returned h b grade ii palsy months since infratemporal fossa approach inevitably encounters facial palsy due transposition facial nerve facial palsy grade better h b grade ii three patients received arytenoid adduction 2 cases due unilateral vocal cord palsy one case due decreased vocal cord mobility in case left vocal cord palsy developed patient undergo arytenoid adduction since symptom due vocal cord palsy prominent our collected data showed differences previous reports jugular foramen paraganglioma previous reports jugular foramen paraganglioma is known occur predominantly age 50 60 female male ratio reported 5:1 1 2 however female male ratio 5:4 tumors detected mean age 40.8 yr data even though age detection distributed widely focused certain age group our data showed significant preference certain sex age site terms incidence most common initial presenting symptom time first visit outpatient hoarseness whereas common presenting symptom known pulsatile tinnitus followed hearing loss previous reports 2 7 lower cranial nerve dysfunction relatively common glomus jugulare tumors includes dysphagia hoarseness aspiration tongue paralysis shoulder drop voice weakness 3 5 7 our result consistent 7 9 patients showed least one low cranial nerve palsy emphasizing importance neurologic evaluation low cranial palsy time first visit emphasis also given fact patients without pulsatile tinnitus excluded suspicion jugular foramen paraganglioma facial nerve paralysis known occur less commonly signals advanced disease related poor facial nerve prognosis outcome 3 5 7 facial palsy present 2 cases data cases advanced jugular foramen paragangliomas facial nerve function restored initial facial nerve palsy operation cases imaging evaluation mri 7 patients type c tumors remaining 2 cases type tumors it correlates fact jugular foramen paragangliomas slow growing lack symptoms results late diagnosis tumor 1 3 6 successful embolization surgical removal tumor without massive bleeding achieved cases ascending pharyngeal artery common feeding vessel reported previously 11 since tumor hypervascular nature angiography crucial identify main feeding vessels embolize prior surgery decreases chance massive bleeding intraoperatively 11 complete surgical resection ideal management jugular foramen paragangliomas 2 5 7 9 cases 6 7 type c tumors resected completely observation without sign recurrence all type tumors resulted partial resection 1 7 type c tumors partially resected gks partial resection tumor reported effective 10 recurrence observed 1 3 cases data we recommend combined approach cooperation neurosurgery department implemented first place cases jugular foramen ganglioma intracranial extension rather planning staged operation showed single stage resection reconstruction offered greatest likelihood complete tumor removal preserving local tissue use reconstruction 12 combined approach include infratemporal fossa suboccipital middle fossa anterior craniofacial translabrynthine approach these approaches combined depending location tumor 12 13 combined approach expose tumor better single approach since better operative view tumor obtained two different angles result better chance complete removal tumor 13 the widened view also prevents excessive effort remove unvisualized portion tumor might cause injuries nerves there problem seal larger defect combined approach compared single approach advances reconstruction technique defect decreased concerns problem 12 13 combined approach also much better maintain compliance patient treatment cases all patients staged operation planned refused undergo secondary operation due decreased compliance first operation cases infratemporal approach sufficient complete resection tumor cases intracranial extension present aid embolization no mortality encountered permanent postoperative complications occurred cases observed results skilled surgical technique infratemporal fossa approach considered safe effective approach removal jugular foramen paraganglioma without intracranial extension low cranial involvement present cases suggesting neurologic examination low cranial nerve crucial surgical aspect concluded infratemporal fossa approach provides safe satisfactory way remove jugular foramen paraganglioma combined approaches strongly recommended instead staged operation treating jugular foramen paraganglioma intracranial extension	objectivesjugular foramen paraganglioma is a locally invasive , benign tumor , which grow slowly and causes various symptoms such as pulsatile tinnitus and low cranial nerve palsy . complete surgical resection is regarded as the ideal management of these tumors . the goal of this study is to identify the clinical characteristics and most effective surgical approach for jugular foramen paraganglioma.methodsretrospective analysis of 9 jugular foramen paraganglioma patients who underwent surgical resection between 1986 and 2005 was performed . clinical records were reviewed for analysis of initial clinical symptoms and signs , audiological examinations , neurological deficits , radiological features , surgical approaches , extent of resection , treatment outcomes and complications.resultsmost common initial symptom was hoarseness , followed by pulsatile tinnitus . seven out of 9 patients had at least one low cranial nerve palsy . seven patients were classified as fisch type c tumor and remaining 2 as fisch type d tumor on radiologic examination . total of 11 operations took place in 9 patients . total resection was achieved in 6 cases , when partial resection was done in 3 cases . two patients with partial resection received gamma knife radiosurgery ( gks ) , when remaining 1 case received both gks and two times of revision operation . no mortality was encountered and there were few postoperative complications.conclusionneurologic examination of low cranial nerve palsy is crucial since most patients had at least one low cranial nerve palsy . all tumors were detected in advanced stage due to slow growing nature and lack of symptom . angiography with embolization is crucial for successful tumor removal without massive bleeding . infratemporal fossa approach can be considered as a safe , satisfactory approach for removal of jugular foramen paragangliomas . in tumors with intracranial extension , combined approach is recommended in that it provides better surgical view and can maintain the compliance of the patients .
pattern drinking india undergone change occasional ritualistic use social event these developments raised concerns health social consequences excessive drinking leading dependence last decade there rapid increase number city bars nightclubs india result undocumented rise alcohol abuse amongst sections society the percentage drinking population aged less 21 years increased 2% 14% past 15 years according studies southern state kerala alcohol drugs information center india non governmental organization what particular concern important indicator health risks signature pattern alcohol consumption india frequent heavy drinking more half drinkers fall criteria hazardous drinking characterized bingeing solitary consumption point intoxication the present study carried look demographic factors associated alcohol dependence syndrome problems alcohol related co morbidities prevented appropriate preventive measures the study conducted de addiction clinic department psychiatry mamata medical college associated mamata general hospital khammam andhra pradesh period july 2008 february 2009 all subjects fulfilling inclusion exclusion criteria study period included study all male subjects presenting de addiction clinic mamata general hospital alcohol related problems potential candidates study enrolled study fulfill following inclusion criteria patient age 18 years abovepatient fulfills criteria alcohol dependence according diagnostic statistical manual mental disorders fourth edition dsm iv patient age 18 years patient fulfills criteria alcohol dependence according diagnostic statistical manual mental disorders fourth edition dsm iv subjects following included study concurrent presence substance dependence according dsm iv nicotinepresence significant illness requiring intensive medical surgical management concurrent presence substance dependence according dsm iv nicotine presence significant illness requiring intensive medical surgical management patients fulfilling selection criteria admitted obtaining informed consent demographic details history general physical examination mental status examination recorded semi structured proforma designed study all male subjects presenting de addiction clinic mamata general hospital alcohol related problems potential candidates study enrolled study fulfill following inclusion criteria patient age 18 years abovepatient fulfills criteria alcohol dependence according diagnostic statistical manual mental disorders fourth edition dsm iv patient age 18 years patient fulfills criteria alcohol dependence according diagnostic statistical manual mental disorders fourth edition dsm iv subjects following included study concurrent presence substance dependence according dsm iv nicotinepresence significant illness requiring intensive medical surgical management concurrent presence substance dependence according dsm iv nicotine presence significant illness requiring intensive medical surgical management patients fulfilling selection criteria admitted obtaining informed consent demographic details history general physical examination mental status examination recorded semi structured proforma designed study a total 68 male patients registered de addiction clinic department psychiatry mmc mamata general hospital khammam period july 1 2008 february 28 2009 whereas total 63 patients met dsm iv criteria alcohol dependence 7 excluded study met criteria another drug dependence the remaining 56 patients offered admission management 16 patients refused come admission the mean age presentation study 37.2 8.51 years mean age presentation various studies similar design this study found 62% patients married time presentation figure 1 western studies the marital status patient commonly found separated divorced ranging 43% 60% respectively one large study 2713 alcohol dependent patients however reports higher rate married patients controls 57% the differences possibly due cultural differences sample current study came predominantly rural population mostly nuclear families this reflects population catered hospital study took place urban center huge rural catchment area 32 80% table 1 patients education less high school level most studies shown patients similar clinical settings education less high school table 2 showing marital status individuals type background family the educational status individuals rate various forms employment 85% involving mostly unskilled skilled work previous studies reported equal percentage patients unemployed gainfully employed the current study higher rates patients employed mostly involved work require much education hence comparison becomes difficult table 3 the majority patients study belonged lower middle middle socio economic class other studies reported patient population belonging lower middle lower class table 4 mean age first drink alcohol form amount taken 18.9 years table 5 the mean age getting intoxicated alcohol first time i.e. feeling effects alcohol taking equivalent 80 90 ml alcohol one setting within brief period approximately 1 2 h 19.8 years a study among patients reported mean age first consumption 15.4 years regular consumption 23.1 years the collaborative study genetics alcoholism coga group found mean age onset alcoholism 25 years table 5 the mean age onset alcohol abuse 24 years onset alcohol dependence according dsm iv 28.3 years a study powell et al found mean age onset drinking 17.3 years age problem level drinking 30.4 years majority patients presence withdrawal symptoms 95% tolerance 95.5% table 6 dsm iv indicates diagnoses substance dependence characterized regard presence physiological component coga study found distinction predicated physiological complications alcohol related emotional psychiatric symptoms depression anxiety withdrawal symptoms tolerance study patients key informants asked enumerate reasons seeking current treatment tables 7 8 based compilation various reasons could grouped certain categories analysis financial strain due alcohol use commonly attributed current treatment seeking patients 70% key informants 92.5% though patients mostly denied first reason this followed presence family conflicts concern physical health 65% followed seeking treatment due social pressure 35% experiencing withdrawal symptoms 25% psychological reasons 22.5% feelings guilt low mood etc most patients 2 reasons seeking treatment comparable reasons provided key informats unique effort study incorporate clinical parameters assessment seems yield similar severity status studies reported similarly reasons admission current treatment decision patient common reason 73 76% patients reasons included medical condition 12% employer pressure 8% stopped short analysis reasons seeking treatment informants reasons seeking treatment mean age first drink 18.9 years age onset alcohol dependence 28.3 years the alcohol dependence syndrome common low socio economic class people education high school level measures improve education socio economic standards rural areas urgently needed control alcohol abuse related co morbidities	aims : to study the demographic factors associated with alcohol dependence syndrome so that the problems of alcohol related co morbidities can be prevented with appropriate preventive measures.materials and methods : the study was conducted in de - addiction clinic of the department of psychiatry , mamata medical college , khammam , andhra pradesh from july 2008 to february 2009 . patient who fulfills criteria for alcohol dependence , according to diagnostic and statistical manual of mental disorders , fourth edition were included.results:mean age ( standard deviation ) at first drink was 18.93 ( 3.81 ) years and at onset of alcohol dependence was 28.28 ( 6.55 ) years . the most common reason being given by the patients was financial strain ( 70% of the patients ) due to alcohol use and its consequences . educational qualification of 12th standard or above was seen only in 7.5% . alcohol dependence syndrome was more common in unemployed , unskilled and semi - skilled patients . majority of patients ( 80% ) belonged to lower socio - economic class.conclusion:alcohol dependence syndrome and its related co morbidities can be minimized to a great extent if the educational and socio - economic standards are improved in countries like india where there is increase in alcohol consumption as a life style choice .
data sets described obtained encode project website www.encodeproject.org comparative regulation/. all data sets processed using uniform processing pipeline identical alignment filtering criteria standardized idr peak calling using spp human worm macs2 fly ( 32 tf gene families binding dataset least two species names abbreviated cross enrichment indicates enrichment motifs one species datasets another 13 families observed cross enrichment red 7 families blue ) we observed cross enrichment additional 12 green also matching motifs two cases marked asterisk known fly motif matches human motif worm motif matches we discovered motif worm datasets match literature derived known motifs human fly ( c three motifs highly similar enriched human prdm1 worm blmp-1 datasets enrichments box fraction motif instances inside bound regions dividing fraction shuffled motif instances additional motifs known discovered datasets included supplementary information ( fly worm stage alignment expression using fly worm orthologs ( fly worm stage alignment using proximal genes chipd tf binding sites the stage mapped data exhibit two sets collinear patterns two species distinct diagonals bottom diagonal expression worm embryos larvae matched fly embryos larvae respectively worm adults matched fly early embryos fly female adults possibly due orthologous gene expression eggs species worm dauers matched fly late embryo l1 l3 stages similar position dauer stages worm lifecycle worm l1 l4 stages upper diagonal worm middle embryos matched fly l1 stage worm late embryos matched fly prepupae pupae stages worm l4 male larvae matched fly male adults this collinear pattern may attributable fly genes two mode expression profiles many one fly worm orthologous gene pairs details a comparison go enrichment orthologous tf pairs contexts human vs worm b human vs. fly c worm vs. fly shown plus signs mark orthologous tf pairs white pluses indicating significant enrichment ortholog pair ( orthologous factors enriched matching go terms non orthologous factors red dash line represents hot threshold black dashed line represent enrichment 1x black line represents best fitting line scatter plot r 0.0045 b scatterplot density number tf peaks per kb rather total number peaks region shows similar trend ( c barplot fraction regions high igg enrichment hot non hot rgb regions using threshold 1.5x teytelman et al ( fraction hot red non- hot blue regions high igg enrichment plotted function threshold black line represents enrichment igg input 1x grey dashed line represents enrichment cutoff 1.5x used b teytelman et al ( e comparison igg igg input rna pol ii enrichment rna polii input shows different trend teytelman et al ( e nearly 99.967% uniformly processed rna polii binding sites ip input rations 2x median enrichment ~20x ( identify hot region context first analyzed number size distribution target binding regions factor binding sites concentrated for target case simulation randomly select equivalent number random binding regions matched size distribution next factor assayed target case evaluated number size observed binding sites simulated equivalent number size distribution target binding sites restricting placement simulated binding regions we collapsed simulated binding sites factors binding regions verifying cluster similar number simulated binding regions target binding regions we identify regions 5% hot 1% xot occupancy threshold based simulated data ( b binding regulatory factors covers different fractions genomes fly human worm coverage shown constitutively hot regions chot red hot regions yellow non hot regions rgb green ( histone marks hot regions represented points smoothed show density proximal b distal sites show similar trends histone mark enrichment flanking regions enhancer calls specific developmental stage c e cell type labeled set bar graphs match hot regions cell type hot regions another cell type each set six bar graphs represents set hot regions called constitutively hot specific five cell types constitutive hot chot regions significantly enriched promoters remaining regions overlapping enhancer regions the number ffls stage normalized number tfs corresponding stage specific network though sets tfs may differ number tfs stage stays roughly the pairwise co association strengths orthologous tfs shown human worm orthologs b human fly orthologs c for pair species specific orthologs across multiple samples co association strength measured fraction significant co binding events experiments shown intervalstats the co association strength human worm orthologs human x axis plotted co association strength worm axis lines depict 1 solid 1.5 dashed standard deviations mean score factors blue represent enrichments due paralogous tfs human tend highly co associated co association strength human x axis plotted co association strength fly axis tf orthologs assayed multiple developmental stages cell lines the maximal co association contexts selected comparative analyses e f	summarydespite the large evolutionary distances , metazoan species show remarkable commonalities , which has helped establish fly and worm as model organisms for human biology1,2 . although studies of individual elements and factors have explored similarities in gene regulation , a large - scale comparative analysis of basic principles of transcriptional regulatory features is lacking . we mapped the genome - wide binding locations of 165 human , 93 worm , and 52 fly transcription - regulatory factors ( rfs ) generating a total of 1,019 data sets from diverse cell - types , developmental stages , or conditions in the three species , of which 498 ( 48.9% ) are presented here for the first time . we find that structural properties of regulatory networks are remarkably conserved and that orthologous rf families recognize similar binding motifs in vivo and show some similar co - associations . our results suggest that gene - regulatory properties previously observed for individual factors are general principles of metazoan regulation that are remarkably well - preserved despite extensive functional divergence of individual network connections . the comparative maps of regulatory circuitry provided here will drive an improved understanding in the regulatory underpinnings of model organism biology and how these relate to human biology , development , and disease .
searched pathology database royal north shore hospital sydney australia colorectal carcinomas undergoing surgical resection calendar years 20042009 period center performed centralized pathological testing two quaternary referral hospitals dedicated colorectal surgery units four community hospitals therefore patient cohort represents true snapshot colorectal carcinoma cases encountered community whole tissue microarrays containing duplicate 1 mm cores created immunohistochemistry four mismatch repair proteins mlh1 msh2 pms2 msh6 brafv600e using clone ve1 springbioscience pleasonton ca performed using previously described methods brafv600e mutation specific immunohistochemistry slides stained using leica bondiii autostainer leica microsystems mount waverley vic australia used according manufacturer protocol the slides dewaxed bond dewax solution ar9222 leica microsystems hydrated bond wash solution ar9590 leica microsystems heat induced epitope retrieval performed 60 min manufacturer alkaline retrieval solution er2 vbs part ar9640 leica microsystems slides incubated primary antibody dilution 1 80 30 min room temperature antibody detection performed using biotin free bond polymer defined detection system ds9713 leica microsystems according manufacturer protocol if tissue microarray staining clearly interpretable eg good internal controls mismatch repair markers repeated whole sections follow obtained examination hospital medical records records surgeons private rooms archival public death notices obituaries state new south wales australia patients followed death last date follow 7 years definitive surgery the survival four immunohistochemical phenotypes determined function cumulative survival time kaplan meier method multivariate cox regression employed explore effect mismatch repair braf immunohistochemistry phenotype survival using model included gender age diagnosis tumor anatomic location tumor histologic grade presence absence lymphovascular space invasion peritumoral lymphocyte reaction status american joint committee cancer tnm seventh edition tumor stage this study approved northern sydney local health district human research ethics committee protocol 1201 035 briefly mean age 74 years range 17100 years 52.1% females one thousand one hundred forty eight 80.5% mismatch repair proficient comprising 1057 74.1% mismatch repair proficient braf wild type 91 6.4% mismatch repair proficient brafv600e mutant one hundred eighty four cases 12.9% mismatch repair deficient brafv600e mutant 94 6.6% mismatch repair deficient braf wild type follow mean 5.29 years 75th centile 3.21 years 353 patients died survival curves correlating immunohistochemical staining pattern survival kaplan meier cox regression methods presented figure 1 along photomicrographs representative staining patterns the 5-year survivals progressively deteriorated mismatch repair deficient braf wild type 73.6% mismatch repair deficient brafv600e mutant 70.1% mismatch repair proficient braf wild type 65.4% mismatch repair proficient brafv600e mutant 49.7% pairwise comparisons mismatch repair proficient braf wild type colorectal carcinomas baseline group univariate cox regression modeling revealed overlapping 5-year survival figures tumor groups except mismatch repair proficient brafv600e mutant tumors showed statistically significant worse outcome hazard ratio death 1.79 95% ci=1.242.60 p<0.01 multivariate analysis the poor prognosis mismatch repair proficient brafv600e mutant tumors negated hazard ratio 1.10 95% ci=0.691.76 p=0.68 dominant effect stage age overall survival however better prognosis mismatch repair deficient brafv600e mutant tumors became significant hazard ratio 0.57 95% ci=0.35093 p=0.03 compared baseline group mismatch repair proficient braf wild type tumors table 1 the use molecular markers predict outcome colorectal carcinoma particularly mismatch repair deficiency microsatellite instability braf mutation area active research briefly studies indicated mismatch repair deficiency associated good outcome in contrast presence braf mutation usually found marker poor prognosis although studies found braf mutation predict outcome unselected population discrepancy appears strong association braf mutation poor prognostic factor mismatch repair deficiency good prognostic factor somatic hypermethylation pathway therefore recently several groups used combination mmr braf mutation status determined molecular means predict outcome colorectal cancer using approach mismatch repair deficient braf wild type colorectal carcinomas have consistently found good prognosis whereas mismatch repair proficient brafv600e mutant colorectal carcinomas emerged poor prognostic group studies this combined mismatch repair braf prognostic algorithm tested recently lochhead et al used molecular techniques determine microsatellite instability braf mutation status 1253 colorectal carcinoma patients compared majority tumors mismatch repair proficient braf wild type mismatch repair proficient braf mutant colorectal carcinomas demonstrated poor prognosis hazard ratio colon cancer specific mortality 1.6 95% ci=0.122.28 mismatch repair deficient braf mutant colorectal carcinomas demonstrated good prognosis hazard ratio 0.48 95% ci=0.270.87 mismatch repair deficient braf wild type demonstrated good prognosis hazard ratio 0.25 95% ci=0.120.52 the results study although based cause rather cancer specific survival essentially confirmatory lochhead et al significant advantage use molecular techniques immunohistochemistry approach readily available virtually diagnostic surgical pathology laboratory centers universal lynch syndrome screening is already undertaken mismatch repair deficiency immunohistochemistry mlh1 pms2 msh2 msh6 would simply matter performing immunohistochemistry five markers rather four estimated additional disposable costs us$10 minimal extra labor costs we note poor prognosis mismatch repair proficient braf mutant tumors found univariate analysis p<0.01 fell away multivariate analysis dominant effect stage age overall survival however given ease braf status determined conjunction mismatch repair deficiency routine clinical setting established indication combined mismatch repair deficiency braf testing triage formal genetic testing lynch syndrome study makes argument potential use prognostic marker colorectal cancers date four five independent studies investigating brafv600e mutation specific immunohistochemistry colorectal carcinoma determined highly sensitive specific presence brafv600e mutation one study suggesting limited utility it would reasonable conclude local factors tissue processing techniques staining methods affect performance antibody laboratories including found robust reliable marker however caution introduction braf immunohistochemistry performed appropriate quality control measures including use controls validation accuracy testing individual laboratories previous studies brafv600e mutation specific immunohistochemistry colorectal carcinoma concentrated utility triaging formal genetic testing lynch syndrome microsatellite unstable tumors other studies concentrated prognostic predictive power combined braf mismatch repair deficiency assessment determined molecular means this first study demonstrate braf determination immunohistochemistry alone interpreted conjunction mismatch repair deficiency status also identifies subgroups colorectal carcinomas different overall survivals significantly poor prognostic group mismatch repair proficient brafv600e mutant tumors summary results suggest addition brafv600e immunohistochemistry mismatch repair deficiency immunohistochemistry identifies distinct prognostic subgroups colorectal carcinomas including poor prognostic group mismatch repair proficient brafv600e mutant tumors results confirmed large independent cohorts strong argument could made perform routine brafv600e immunohistochemistry time mismatch repair deficiency assessment colorectal carcinomas facilitate universal screening lynch syndrome mismatch repair deficient tumors also identify poor prognosis mismatch repair proficient brafv600e mutant group	immunohistochemistry has recently been validated for the detection of the brafv600e mutation across a range of tumor types . in colorectal carcinoma , the presence of the brafv600e mutation can be used to virtually exclude lynch syndrome in mismatch repair - deficient tumors . in mismatch repair - proficient tumors , brafv600e mutation assessed by molecular methods has been proposed as a poor prognostic factor . we investigated whether combined brafv600e and mismatch repair status assessment by immunohistochemistry alone can be used as a prognostic marker in the routine clinical setting . we performed immunohistochemistry for brafv600e , mlh1 , pms2 , msh2 , and msh6 on 1426 consecutive unselected colorectal carcinomas . ninety - one ( 6.4% ) carcinomas were mismatch repair - proficient and brafv600e mutant , and these tumors demonstrated a significantly worse 5-year survival of 49.7% compared with mismatch repair - proficient braf wild type ( 74.1% of tumors , 65.4% survival ) , mismatch repair - deficient brafv600e mutant ( 12.9% of tumors , 70.1% survival ) , and mismatch repair - deficient braf wild type ( 6.6% of tumors , 73.6% survival ) . the poor survival was confirmed by univariate analysis ( p<0.01 ) but fell away in multivariate analysis ( p=0.68 ) because of the strong effect of tumor stage and age on overall survival . we conclude that in addition to its utility in screening for lynch syndrome , reflex brafv600e and mismatch repair assessment by immunohistochemistry can be used as a powerful predictor of all - cause survival .
natural sources radioactivity environment called naturally occurring radioactive materials categorized terrestrial cosmic origin humans exposed internal external radiation natural sources internal exposure occurs intake terrestrial radionuclides inhalation ingestion inhalation exposure dose results existence dust particles air including radionuclides u th decay series the biggest contribution inhalation exposure comes short half life decay products radon ingestion exposure dose mostly results u th series radionuclides k drinking water foodstuff in addition cs important fission product released environment result nuclear activities radionuclide rapidly passes foodstuffs creates dose effect the aim study determine exposure dose ra th k cs radionuclide concentrations fruits vegetables produced elaz region turkey frequently consumed local residents the significance study first study determine background radiation levels food products region provide data future studies case nuclear accident chernobyl nuclear accident nuclear fallout determine level contamination the province elaz located eastern anatolian region longitude 38304021e latitude 38173911n its surface area 9,151 km average altitude 1,067 m. region divided 11 administrative regions total population 540,000 fig 1 approximately 50 province consists grasslands 28 agricultural land 12 forest 10 dams lakes a continental climate prevails winters cold snowy summers hot arid the province rich mineral resources mining activities include copper fluoride chalcopyrite zinc lead chrome manganese molybdenum iron wolfram .fig samples fruits vegetables produced frequently consumed region provided public market soil foreign materials samples were removed suitable consumption divided small pieces washed distilled water they kept room temperature 3 months without allowing contamination totally oven dried 105 c the temperature oven increased 250 c continued samples reduced ash the ashed samples homogenized transferred plastic container 5 cm height 5 cm diameter finally samples sealed stored period 1 month counting order allow equilibrium ra short lived decay products the activity concentrations ra th k cs radionuclides vegetable fruit samples determined using gamma spectroscopic system comprising 2 2 nai(tl well type detector detector surrounded cylindrical lead shield thickness diameter length approximately 3.5 13.7 15.5 cm respectively energy calibration detector performed using co 37 kbq ra 370 kbq point sources ra th k cs activity concentrations vegetable fruit based detection 609.3 583 1461 662 kev energy gamma rays transmitted bi tl k cs respectively ( 1)1\documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$a({\rm{bq}}\,{\rm{kg}}^ 1 \frac{c}{{m_{{\rm{s \varepsilon p_{\gamma \end{document}where c gamma ray count number per second detector efficiency specific gamma ray p absolute transition probability gamma decay ms mass sample kg ingestion dose occurring intake radionuclides depends consumption rate foodstuff concentration radionuclide involved ( 2 3 13 14]2\documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ h_{\text{t r \mathop \sum \nolimits \left u^{i c_{\rm{r}}^{i \right)g_{\text{t r \end{document}where foodstuff group \documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ u^{\it \end{document \documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$c_{\rm{r}}^{i \end{document annual consumption rate kg radionuclide activity concentration bq kg respectively coefficients \documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ g_{\text{t r \end{document dose conversion coefficient r radionuclide sv bq dose conversion coefficients ra th k cs radionuclides adult members society 4.5 10 2.3 10 6.2 10 1.3 10 sv bq respectively 13 15 16 samples fruits vegetables produced frequently consumed region provided public market soil foreign materials samples were removed suitable consumption divided small pieces washed distilled water they kept room temperature 3 months without allowing contamination totally oven dried 105 c the temperature oven increased 250 c continued samples reduced ash the ashed samples homogenized transferred plastic container 5 cm height 5 cm diameter finally samples sealed stored period 1 month counting order allow equilibrium ra short lived decay products the activity concentrations ra th k cs radionuclides vegetable fruit samples determined using gamma spectroscopic system comprising 2 2 nai(tl well type detector detector surrounded cylindrical lead shield thickness diameter length approximately 3.5 13.7 15.5 cm respectively energy calibration detector performed using co 37 kbq ra 370 kbq point sources ra th k cs activity concentrations vegetable fruit based detection 609.3 583 1461 662 kev energy gamma rays transmitted bi tl k cs respectively ( 1)1\documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$a({\rm{bq}}\,{\rm{kg}}^ 1 \frac{c}{{m_{{\rm{s \varepsilon p_{\gamma \end{document}where c gamma ray count number per second detector efficiency specific gamma ray p absolute transition probability gamma decay ms mass sample kg ingestion dose occurring intake radionuclides depends consumption rate foodstuff concentration radionuclide involved ( 2 3 13 14]2\documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ h_{\text{t r \mathop \sum \nolimits \left u^{i c_{\rm{r}}^{i \right)g_{\text{t r \end{document}where foodstuff group \documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ u^{\it \end{document \documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$c_{\rm{r}}^{i \end{document annual consumption rate kg radionuclide activity concentration bq kg respectively coefficients \documentclass[12pt]{minimal \usepackage{amsmath \usepackage{wasysym \usepackage{amsfonts \usepackage{amssymb \usepackage{amsbsy \usepackage{mathrsfs \usepackage{upgreek \setlength{\oddsidemargin}{-69pt \begin{document}$$ g_{\text{t r \end{document dose conversion coefficient r radionuclide sv bq dose conversion coefficients ra th k cs radionuclides adult members society 4.5 10 2.3 10 6.2 10 1.3 10 sv bq respectively 13 15 16 table 1 shows natural manmade radionuclide activity concentrations measured samples vegetables fruits frequently consumed elaz surrounding region minimum detectable activity values vegetable fruit samples calculated 0.02 bq th cs 0.03 bq ra 0.1 bq k. average activity concentrations ra th k cs vegetable samples 0.64 bq kg sd 0.26 0.65 bq kg sd 0.14 13.98 bq kg sd 1.22 0.54 bq kg sd 0.04 respectively the activity concentrations ranged 0.11 0.99 bq kg ra 0.470.84 bq kg th 2.1444.77 bq kg k 0.170.79 bq kg cs average concentrations ra fruits 1.52 bq kg sd 0.34 values ranged 0.73 2.81 bq kg th concentrations ranged 0.26 1.96 bq kg average 0.98 bq kg sd 0.23 the average activities k cs radionuclides 18.66 bq kg sd 1.13 0.59 bq kg sd 0.16 respectively k concentrations ranged 1.34 35.49 bq kg.table 1activity concentrations vegetables fruitsidspeciesscientific nameactivity concentrations vegetables fruits bq kgfresh weight ra th k csvegetables f1bell pepper capsicum annuum l.bdlbdl7.21 0.910.48 0.04 f2parsley petroselinum crispum mill ) hillbdlbdl44.77 1.90bdl f3scallion allium cepa l.bdl0.84 0.1729.41 1.85bdl f4pumpkin cucurbita moschata duchesne ex poir.bdlbdl2.14 1.36bdl f5leek allium ampeloprasum 0.64 0.37bdl10.02 1.15bdl f6radish raphanus sativus l.0.11 0.040.47 0.053.43 0.340.17 0.01 f7kale brassica oleracea acephalabdl0.64 0.245.78 1.57bdl f8capsicum capsicum annuum l.bdlbdl5.78 0.63bdl f9cabbage brassica oleracea capitata0.95 0.09bdl26.95 0.95bdl f10tomato solanum lycopersicum l.0.45 0.080.64 0.0910.73 0.70bdl f11eggplant solanum melongena l.0.99 0.19bdl16.57 1.600.79 0.06 f12lettuce lactuca sativa l.bdlbdl30.93 1.410.72 0.05 f13spinach spinacia oleracea l.0.80 0.33bdl9.84 0.92bdl f14peppermint mentha spicata l.0.60 0.36bdl2.22 1.05bdl f15garden cress lepidium sativum l.0.54 0.61bdl3.97 1.90bdlaverage0.64 0.260.65 0.1413.98 1.220.54 0.04fruits f16melon cucumis melo l.1.01 0.130.48 0.1335.49 0.990.53 0.04 f17pear pyrus spp.bdl1.96 0.3313.62 1.60bdl f18quince cydonia oblonga mill.2.81 0.451.14 0.3123.01 1.400.64 0.27 f19grapes vitis vinifera l.bdl0.26 0.121.34 0.63bdl f20watermelon citrullus lanatus thunb matsum nakaibdlbdl34.44 0.88bdl f21apple malus domestica borkh.0.73 0.451.04 0.264.04 1.25bdlaverage1.52 0.340.98 0.2318.66 1.130.59 0.16 bdl detection limit activity concentrations vegetables fruits bdl detection limit effective dose values exposed due radionuclides taken body consumption fruit vegetable samples shown table 2 primarily average activity concentration bq kg radionuclide multiplied food consumption rate annual activity intake value determined bq unit food consumption rate taken 73 kg fruits vegetables the effective dose value determined multiplying annual activity intake value effective dose coefficient effective dose values fruit samples radionuclides ra th k cs higher vegetable samples average effective exposure dose consumption vegetable samples 2.12 sv sd 0.86 11.04 sv sd 2.3 6.33 sv sd 0.55 0.51 sv sd 0.04 respectively ra th k cs effective dose values ra th k cs ranged 0.36 3.25 7.89 14.10 0.97 20.26 0.16 0.75 sv respectively average effective doses consumption fruit samples 4.99 sv sd 1.13 16.56 sv sd 3.91 8.44 sv sd 0.52 0.56 sv sd 0.16 respectively ra th k cs dose values ranged 2.40 9.23 sv ra 4.37 32.91 sv th 0.6116.06 sv k.table 2dose coefficients committed effective dose values ra th k csradioisotopesactivity intake bq)effective dose coefficient sv bq)committed effective dose sv y)rangeaveragevegetables ra47 190.0450.36 0.133.25 0.622.12 0.86 th48 100.237.89 0.8414.10 2.8511.04 2.3 k1021 896.2 10 0.97 0.6220.26 0.866.33 0.55 cs39 31.3 10 0.16 0.010.75 0.060.51 0.04fruits ra111 250.0452.40 1.489.23 1.484.99 1.13 th72 170.234.37 2.0232.91 5.5416.56 3.91 k1362 836.2 10 0.61 0.2916.06 0.458.44 0.52 cs43 121.3 10 0.56 0.16 dose coefficients committed effective dose values ra th k cs table 3 shows committed effective dose values reported countries regions 3 1821 total adult effective dose vegetables fruits frequently produced consumed elaz region ra th k cs radionuclides calculated 20 sv sd:3.75 30.55 sv sd:5.72 respectively summary study found adults living study region intake radiation dose approximately 50.55 sv fruit vegetable consumption radiation dose 50.55 sv lower world average value 290 sv presents risk public health dose values obtained present study reflect reported values general.table 3average effective dose values elaz region comparison literatureregion countrycommitted effective dose sv y)referencesvegetablesfruitsfoodstuffnorth america110asia110europe110korean110jos plateau nigeria(0.22,164)accra metropolitan area ghana4,640rize turkey22763elaz turkey2030.55present study average effective dose values elaz region comparison literature ra th k cs radionuclide concentrations vegetables fruits produced frequently consumed elaz region turkey determined study found radiation dose due consumption vegetables fruits less world average poses threat public health the results lower committed effective dose values reported various regions countries	determining radioactivity levels in foodstuffs is of great importance for the protection of human health . in addition , the literature includes few studies related to this subject in turkey . in this study , gamma spectroscopic system was used in order to measure 226ra , 232th , 40k and 137cs activity concentrations in vegetables and fruits produced in elaz region . the average activity concentrations in vegetables was calculated as 0.64 0.26 bq kg1 for 226ra , 0.65 0.14 bq kg1 for 232th , 13.98 1.22 bq kg1 for 40k , and 0.54 0.04 bq kg1 for 137cs . the average activity concentrations in fruits were 1.52 0.34 , 0.98 0.23 , 18.66 1.13 and 0.59 0.16 bq kg1 , respectively for 226ra , 232th , 40k and 137cs . total committed effective dose value was determined as 20 and 30.55 sv y1 , respectively for vegetables and fruits . the findings were compared with previous data reported for turkey and other regions of the world .
spontaneous pneumomediastinum pneumopericardium may defined presence free air gas mediastinal structures pericardial sac without apparent precipitating cause free air enter mediastinal tissues rupture alveoli laceration tracheobronchial tree gastrointestinal tract passage extraluminal gas thorax neck retroperitoneum chest wall posteroanterior chest radiographs typically reveal radiolucency left heart border mediastinal pleura although pneumomediastinum often asymptomatic may cause pain neck chest dysphonia shortness breath although severe complications develop patients course spontaneous pneumomediastinum usually benign self limited we report rare case spontaneous pneumomediastinum pneumopericardium subcutaneous emphysema young adult review literature a 20-year old male admitted hospital acute respiratory distress due severe pain neck chest inspiration spontaneous cough drinking cup coffee he current history trauma aspiration foreign body drug abuse the blood pressure 150/100 mmhg pulse 80 beats min respirations 22/min the crepitus palpitation remarkable along left side neck anterior chest wall the chest evaluation demonstrated symmetric clear breath sounds regular heart beats without murmur hamman sign an arterial blood gas analysis room air followed ph 7.432 pao2 79.7 mmhg paco2 45.9 mmhg sao2 96.4% the hemoglobin 12.5 g dl hematocrit 38% white cell count 13,200/mm platelet 231,000/mm the chest neck radiographs showed pneumomediastinum pneumopericardium subcutaneous emphysema neck prevertebral space evidence pneumothorax figure 1 the radiograph gastrografin swallowing reveal definite evidence leakage esophagus structural abnormalities figure 2 the chest ct scan showed pneumomediastinum extensive emphysema lower neck region extension prevertebral soft tissue space pneumopericardium but neither definite lung lesion structural abnormalities bronchi esophagus figure 3 on 7th hospital day neither symptoms respiratory distress pain neck chest the follow radiographs ct scan chest showed complete resolution pneumomediastinum pneumopericardium subcutaneous emphysema figure 4 spontaneous pneumomediastinum rare usually self limited disease commonly seen young men parturient women an increased pressure gradient intra alveolar interstitial spaces enhances air leakage small alveolar openings ruptured alveoli perivascular adventitia yielding interstitial emphysema however visceral layers deep cervical fascia contiguous mediastinum air usually decompresses neck preventing physiologically tamponade pneumothorax elevated pressure deep cervical fascia favors dissection along blood vessels planes neck dissection free air pericardial space common complication barotrauma neonates rare adults apposition pericardial layers tight alveolar rupture occurs presence elevated intra alveolar pressure damage alveolar walls causes elevated alveolar pressure include airway obstruction e.g. mucous plugging asthmatic person foreign body mechanical ventilation particularly large ventilatory volume high end expiration pressure blunt trauma coughing emesis valsalva maneuver e.g. parturition causes damage alveolar walls include pneumonitis emphysema lung fibrosis acute respiratory distress syndrome causes pneumomediastinum would associated use heroin marijuana cocaine nitrous oxide other causes pneumomediastinum include trauma gas producing infections head neck abdomen surgery upper digestive tract well dental surgery however patient ventilator may occur mechanism causes cases pneumomediastinum gas dissecting medially interstitial emphysema lung gas probably enters pericardium along venous sheaths collagenous support pericardial reflections weak they may experience dyspnea dysphagia neck throat pain dysphonia physical examination may show respiratory distress neck crepitus decreased cardiac dullness hamman sign mediastinal crunching sound synchronized systole rarely signs pericardial tamponade low grade fever present one third mild leukocytosis one half cases posteroanterior chest radiographs typically reveal radiolucency left heart border mediastinal pleura other findings may include highlighting aortic knob continuous diaphragm sign pneumopericardium usually manifested single band gas may outline left ventricle right atrium if enough air pneumopericardium completely surround heart create halo sign esophagogram also performed detect possible esophageal tear emesis retching precipitating event there pathognomic electrocardiographic changes pneumomediastinum although low voltage axis shifts described analgesics bed rest treatment coughing appropriate breathing 100% oxygen enhance reabsorption free air increasing gradient nitrogen alveoli tissues pain typically resolves within 1 2 days follow chest radiograph within 12 24 hours necessary detect progression complications pneumothorax if progression occurs patient may require needle aspiration chest tube placement dangerous provide questionable benefit in adult pneumopericardium pericardial drainage performed hemodynamic embarrassment conclusion spontaneous pneumomediastinum pneumopericardum rare disease occurs young healthy adult without underlying cause absolute bed rest high concentration oxygen supply found definite benefit	spontaneous medialstinal emphysema ( pneumomediastinum ) and pneumopericardium may be defined as the presence of free air or gas in the mediastinal structures and in the pericardial sac without an apparent precipitating cause . it most frequently occurs in young healthy adults without serious underlying pulmonary disease.although pneumomediastinum and pneumopericardium is often asymptomatic , it may cause pain in the neck and chest , dysphonia and shortness of breath . treatment is supportive unless the patient has a history of trauma from foreign body aspiration . the course of spontaneous pneumomediastinum and pneumopericardium is usually benign and self - limited.a case of spontaneous pneumomediastinum , pneumopericardium and subcutaneous emphysema in a 20-year - old male is reported in this paper .
since great impact patients quality life school performance work productivity comorbid conditions asthma considered important health problem allergic rhinitis defined allergic reaction often ige dependent offending allergens dust mites insects animal dander pollens symptoms include rhinorrhea nasal obstruction nasal nasopharyngeal itching sneezing postnasal drip often allergic rhinitis accompanied allergic conjunctivitis ocular symptoms itchy watery eyes resulting term allergic rhinoconjunctivitis according length duration allergic rhinitis classified intermittent symptoms present 4 days week 4 weeks persistent symptoms present 4 days week least 4 weeks forms symptom severity used classify allergic rhinitis mild moderate severe forms a number pharmacological treatments allergic rhinitis exist example oral topical antihistamines leukotriene receptor antagonists intranasal glucocorticoids cromoglycic acid mast cell stabilizers azelastine new generation antihistamine applied topically nasal spray eye drops it used treatment allergic rhinitis hay fever allergic conjunctivitis although azelastine regarded effective possible first line treatment allergic rhinitis common side effects bitter taste drug local irritation reactions rare side effects fatigue headache occur cromoglycic acid antiallergic drug inhibits degranulation mast cells thereby blocking release inflammatory mediators thus cromoglycic acid prevents development allergic reactions rather reducing acute symptoms onset action four seven days due short half life cromoglycic acid thought safe medication adverse events might occur usually mild sneezing sensation burning due good safety profile cromoglycic acid prescribed treating rhinitis children pregnant women general many allergic rhinitis patients still unsatisfied control symptoms complain incomplete relief symptoms suffer unwanted side effects 5 6 therefore surprising increasing interest use alternative complementary medicine cam treating rhinitis exists thus demonstrated 40% american population uses cam 17% uses treating otorhinolaryngologic diseases however far general recommendation use cam given aria guidelines ambiguous study results available the present two individual studies compared treatment allergic rhinitis ectoine containing nasal spray eye drops azelastine containing products study 1 treatment ectoine containing nasal spray cromoglycic acid containing nasal spray study 2 ectoine natural amino acid derivate produced bacteria living extreme harsh environmental conditions serves osmoregulatory compatible solute 9 10 ectoine works via mechanism called preferential exclusion 11 12 if present together proteins lipids ectoine expelled surfaces thereby increasing hydration surface stabilizing lipid layers its membrane stabilizing well inflammation reducing capacities makes ectoine interesting candidate treatment allergic rhinitis these studies served investigate efficacy safety ectoine containing nasal spray eye drops patients allergic rhinitis the current paper describes two noninterventional studies carried ectoine containing nasal spray eye drops assessing efficacy comparison azelastine nasal spray eye drops study 1 nct02131051 cromoglycic acid nasal spray study 2 nct02131038 the ectoine eye drops contain iso osmotic solution 2% ectoine 0.35% hydroxyethyl cellulose ectoine nasal spray hypertonic solution 2% ectoine additional ingredients eye drops sodium chloride sodium dihydrogen phosphate dihydrate sodium monohydrogen phosphate dihydrate water additional ingredients nasal spray sodium chloride water study 1 nasal spray eye drops used whereas nasal spray used study 2 the azelastine eye drops contain 0.5 mg ml azelastine hydrochloride one drop administering 0.015 mg azelastine hydrochloride azelastine nasal spray contains 1 mg ml azelastine hydrochloride one puff administering 0.14 mg azelastine hydrochloride additional ingredients eye drops benzalkonium chloride preservative sodium edetate hypromellose sorbitol sodium hydroxide water additional ingredients nasal spray sodium edetate hypromellose citric acid sodium chloride sodium hydrogen phosphate water study 2 the spray contained 20 mg ml cromoglycic acid corresponding 2.8 mg sodium cromoglycic acid per puff in addition following ingredients present formulation benzalkonium chloride preservative 0.014 mg puff sodium edetate sodium chloride sodium dihydrogen phosphate sodium monohydrogen phosphate sorbitol water day 0 visit 1 patients were asked participate study upon signing informed consent form patient information allocated one study groups without washout period antiallergic medications used last two days prior inclusion recorded physician patients treated either ectoine containing nasal spray eye drops azelastine containing nasal spray eye drops patients ectoine group apply one eye drop per eye one puff nasal spray per nostril four times per day patients azelastine group apply one eye drop per eye one puff nasal spray per nostril twice per day the treatment period 7 days patients asked document symptoms together possible comedication adverse effects daily patient diaries evening therefore patients assessments started products applied already following treatment patients came back visit 2 day 7 symptom scores evaluated tolerability efficacy compliance possibly comedications antiallergic others assessed male female patients aged 1870 proven allergy acute symptoms nose eye sum nasal score 15 sum oral score 6 allowed take part study exclusion criteria pregnant nursing women drug addicts persons unable give consent study participation patients intolerance ingredients study treatments previous eye nose surgery concomitant treatment antiallergic drugs diseases might influence output study according physicians judgment single nasal nasal obstruction rhinorrhea sneezing ocular symptoms eye itching tearing conjunctivitis scored 8 point scale ranging symptoms 0 severe symptoms 8) efficacy tolerability compliance judged using scale ranging 0 good 8 bad thus general judgment either well tolerate efficient products given patients documented patient diaries both scoring values based patients personal opinion feeling products whereas efficacy tolerability assessed patients physicians further analysis carried mann whitney u test wilcoxon test friedman test unavailable data treated missing values substituted last value carried forward method this study designed crossover study without washout period within first week half patients received ectoine nasal spray whereas half received cromoglycic acid containing nasal spray thus patients started one week treatment ectoine nasal spray received cromoglycic acid containing nasal spray within second week vice versa simplification reasons patients starting treatment ectoine termed group and the ectoine nasal spray applied least 5 times per day whereas cromoglycic acid spray applied 4 times day thus patients take ectoine product least 5 times day could upgrade dosing felt medication sufficient patients attend visits investigator day 0 v1 day 7 2 days v2 day 14 2 days v3 during visits investigator assessed nasal nasal obstruction sneezing rhinorrhea ocular symptoms eye itching tearing conjunctivitis well palate itching turbinate hyperplasia end study v3 efficacy in addition investigator assessment patients document daily ocular nasal symptoms well judgment tolerability efficacy patient diary evening based design patients scoring started study medication applied male female patients diagnosed allergy moderate severe acute symptoms nasal obstruction sneezing rhinorrhea allowed take part study exclusion criteria intolerance ectoine cromoglycic acid pregnancy previous nose surgeries ongoing treatment additional antiallergic drugs single nasal symptoms nasal obstruction rhinorrhea sneezing ocular symptoms eye itching tearing conjunctivitis well symptoms palate itching turbinate hyperplasia scored 8 point scale ranging symptoms 0 severe symptoms 8) efficacy tolerability compliance judged using scale ranging 0 good 8 bad thus general broad judgment well tolerate efficient products given patients documented patient diaries both scoring values based patients personal opinion feeling products whereas efficacy tolerability assessed patients physicians compliance solely judged physicians pollen score order reflect current pollen exposure data online hexal pollen calendar used grade pollen exposure mild moderate severe 1 2 3 scores course study statistics safety analyses performed entire study population whereas efficacy analysis performed patients completed treatment further analysis carried mann whitney u test wilcoxon test friedman test unavailable data treated missing values substituted last value carried forward method both studies conducted accordance declaration helsinki investigations carried understanding consent participants this noninterventional trial taking place two german ear nose throat ent practices starting june 2010 completed september 2010 48 patients took part study 43 included final analysis 31 females 12 males mean age patients 35 years groups comparable regard clinical aspects nasal symptom scores assessed single symptoms sum nasal symptoms tnss the mean symptom score nasal obstruction decreased significantly 45.95% ectoine group 49.23% azelastine group v1 v2 p 0.001 groups the documentation patient diaries also reflected significant decrease 18.39% ectoine group p 0.003 17.83% azelastine group p 0.044 mean values decreased 56.88% ectoine group 52.50% azelastine group p 0.001 groups the patient documentation showed clear decrease symptom rhinorrhea however significant values decreased 28.75% ectoine group p 0.054 19.45% azelastine group p 0.133 the symptom sneezing decreased significantly v1 v2 values decreased 59.52% ectoine group 59.84% azelastine group p 0.001 groups the patient documentation also reflected symptom decrease significant ectoine group 25.61% p 0.475 significant azelastine group 39.47% p 0.001 nasal itching decreased significantly v1 v2 values decreased 76.40% ectoine group p 0.001 69.31% azelastine group p 0.001 according patient documentation nasal itching scores decreased 27.12% ectoine group p 0.068 42.38% p 0.002 azelastine group the sum nasal symptom scores nasal obstruction rhinorrhea sneezing nasal itching showed significant decrease v1 v2 assessed physicians sum scores ectoine group decreased 20.71 3.52 8.52 4.74 decrease 58.85% p 0.001 sum scores azelastine group decreased 21.73 3.34 9.32 6.24 decrease 57.11% p 0.001 data depicted figure 2 according patients assessment see figure 3 values decreased 23.05% ectoine group p 0.076 33.14% azelastine group p 0.02 ocular symptom scores also assessed single symptoms sum ocular symptoms toss the symptom conjunctivitis clearly decreased v1 v2 reflected decline 48.15% ectoine group p 0.058 46.07% azelastine group p 0.013 patients documentation scores conjunctivitis decreased 34.09% ectoine group p 0.218 whereas increase 14.77% observed azelastine group p 0.885 there significant decrease symptom scores eye itching ectoine group mean decreased 48.15% p 0.008 whereas values azelastine group decreased 46.07% p 0.002 corresponding decreases assessed patients 17.65% ectoine group p 0.604 5.33% azelastine group p 0.14 tearing a statistical decrease scoring symptom tearing also observed v1 v2 ectoine group values decreased 52.46% p 0.003 whereas values azelastine group decreased 40.43% p 0.039 the patient documentation symptom tearing also showed clear decrease values 5.56% p 0.886 ectoine group 18.63% p 0.357 azelastine group the toss sum conjunctivitis eye itching tearing decreased significantly v1 v2 groups p 0.001 ectoine p 0.009 azelastine starting mean values v1 9.43 3.14 ectoine group 9.5 4.22 azelastine group decreased 45.96% 5.10 4.38 ectoine group 44.98% 5.23 4.36 azelastine group decreases toss values assessed patients significant figure 4 data shown palate itching nasal ocular symptoms clear decrease symptom palate itching observed v1 v2 ectoine group values decreased 2.52 2.71 1.19 1.72 p 0.024 azelastine group values decreased 3.36 2.68 1.5 1.92 p 0.018 values patients documentation reach statistical significance azelastine group scoring decreased 3.81 2.5 2.15 2.13 p 0.001 ectoine group values decreased 1.76 2.1 1.67 2.15 p 0.854 correlation pollen count nasal symptoms in order normalize nasal symptoms nasal constriction rhinorrhea sneezing pollen burden quotient sum score pollen counts determined values quotients decreased significantly 8.97 3.98 5.23 3.59 ectoine group p 0.002 9.73 3.59 5.76 5.26 azelastine group p 0.011 thus confirming decrease nasal symptoms pollen season upon treatment the physicians assessment efficacy products similar v2 values 2.48 good ectoine group 2.64 good satisfactory azelastine group significant difference groups general tolerability assessed good good groups 1.33 ectoine group 1.45 azelastine group compliance comparably good values 1 groups values patients assessments efficacy tolerability shown figures 5 6 the patients evaluations resulted comparable values efficacy tolerability without statistical differences treatment groups comparison reduction symptoms groups order calculate reduction symptoms v1 v2 different treatment groups differences mean v1 v2 values compared via mann whitney u test shown table 3 statistical differences ectoine azelastine group thus confirming substances worked comparably well the calculation performed patient data statistical difference shown except symptom palate itching adverse events aes total 8 aes occurred study see table 5 2 aes occurred ectoine group whereas 6 aes occurred azelastine group this noninterventional trial taking place german ear nose throat ent practice starting may 2009 completed september 2009 50 patients 33 females 17 males average age 34 years took part study both treatment groups homogeneous clinical point view nasal obstruction both patient groups started comparable mean nasal obstruction score 5.80 group 5.64 group b physician assessment the symptom scores decreased 3.2 group 3.44 group b week decrease 2.52 group 2.92 group b observed 2 weeks decreases significant groups p values 1 week 2 weeks p 0.001 similarly patient scores symptom nasal obstruction decreased 4.08 group 3.60 group b day 0 2.84 group p 0.009 3.24 group b p 0.464 day 7 2.52 group p 0.004 2.56 group b p 0.041 day 14 the symptom rhinorrhea decreased significantly p 0.001 groups v1 v2 v1 v3 according physician assessment values decreased 5.12 2.40 v2 1.88 v3 group 4.96 2.68 v2 2.76 v3 group b. according patients evaluation scoring rhinorrhea decreased 3.12 2.32 d7 p 0.104 2.04 d14 p 0.010 group a. group b values decrease 3.80 3.08 d7 p 0.115 2.28 d14 p 0.001 the symptom sneezing also decreased significantly p 0.001 v1 v2 v1 v3 groups baseline scores group 5.72 decreased 2.56 v2 1.80 v3 whereas values group b decreased 5.68 2.80 v2 2.6 v3 according patients evaluation scoring symptom sneezing decreased 3.16 2.44 p 0.20 day 7 2.12 p 0.265 day 14 group whereas values decreased 4.04 2.64 p 0.018 day 7 2.40 p 0.001 day 14 group b. reflect development sum nasal symptoms total nasal score nasal obstruction rhinorrhea sneezing calculated results depicted figures 8 9 according physician assessment tnss scores decreased significantly groups v1 v2 p 0.001 v1 v3 p 0.001 scores assessed patients showed decreases tnss d1 d7 significant whereas significant decreases tnss scores d1 d14 shown group p 0.001 group b p 0.001 investigate development ocular symptoms treatment period the single symptoms eye itching tearing conjunctivitis redness eyes assessed investigator patients details scores listed tables 6 7 according investigator assessment all observed ocular symptoms improved significantly v1 v3 group whereas symptoms eye itching tearing improved significantly group b. patients assessment ocular symptoms showed symptoms eye itching eye redness improved significantly group whereas decreases symptom scores day 1 day 14 significant group b. development sum ocular symptoms eye itching conjunctivitis tearing assessed investigator depicted figure 10 it could confirmed ocular symptoms decreased significantly v1 v2 p 0.001 group 1 p 0.008 group b well v1 v3 p 0.001 group 1 p 0.003 group b the development total ocular symptom score assessed patients shown figure 11 a significant decrease symptom score observed group day 1 day 14 p 0.026 in addition nasal ocular symptoms development symptom palate itching determined investigator patients shown table 8 significant decreases symptom palate itching in contrast patients assessment symptom showed small decreases symptom significant additionally development turbinate hyperplasia determined investigator shown table 8 treatment resulted significant improvement symptom within first week treatment still significantly improved two weeks treatment no differences groups could determined symptom table 9 correlation pollen count nasal symptoms order rule results might influenced existence pollens the quotient tnss values pollen count scores confirmed significant decrease tnss values v1 v2 p 0.001 v1 v3 p 0.001 data shown good satisfactory score 2.68 1.89 group 2.96 1.72 group b v2 score 3.12 2.11 group 2.80 2.06 group b v3 similarly patients assessment efficacy good satisfactory day 7 group 2.76 1.89 group b 2.96 1.81 day 14 group 2.56 2.00 group b 2.44 2.16 without statistical differences groups following 1 week treatment tolerability judged good group 1.24 1.30 good 2.40 1.53 group b. following crossover groups tolerability treatment judged satisfactory 3.0 2.16 group good 0.88 1.05 group b. changes tolerability groups highly significant p 0.001 thus indicating tolerability significantly better following 7-day treatment ectoine containing nasal spray comparison 7-day treatment cromoglycic acid nasal spray those differences tolerability scoring also clearly visible patients assessment tolerability whereas tolerability judged good ( 1.30 1.48 within first days treatment group scoring second week decreased mean score 2.65 1.89 corresponding good satisfactory group b showed opposite development tolerability scoring 2.35 1.68 good within first 7 days improved mean score 0.97 1.24 good within second half treatment details patients tolerability assessment depicted figure 12 summary patients judged tolerability significantly better treatment ectoine containing nasal spray compared treatment cromoglycic acid nasal spray p 0.001 the compliance assessed good physician values statistically different groups see table 10 in contrast 13 patients complained burning sensation treatment cromoglycic acid nasal spray the correlation observed aes burning sensation displeasing smell dehydration effect judged probable the current studies investigated efficacy safety ectoine containing nasal spray eye drops comparison commonly applied pharmacological treatments allergic rhinitis two noninterventional trials although paper covers results two separate studies summarized one document indication similar studies aimed compare ectoine containing products topical medications study cromoglycic acid one first studies ectoine products dosage slightly higher study comparing ectoine azelastine products placebo controlled randomized trial ectoine nasal spray eye drops conducted study 2 confirmed dose 4 uses per day sufficient show significant superiority placebo treatment dosage chosen study 1 both studies demonstrated allergic rhinitis successfully safely treated ectoine containing products thus offering potential new treatment strategy allergic rhinitis sufferers although study design forbids randomization patients use placebo blinding study medication still reflects realistic standard clinical practice thus patients included independently prior medication washout period kept order ensure homogeneity patients show certain degree symptoms inclusion reflected minimum tnss values additionally symptom scores correlated pollen count scores order include objective measures analysis importantly sites specialized area ear nose throat practice chosen warrant precise assessment symptoms specialized physicians homogeneous patient population although believe valuable results drawn noninterventional trials one drawback study design fact one include placebo group study population hand demonstrated double blind randomized placebo controlled trials clearly limitations disadvantages particularly patients awareness placebo arm lead modifications results due patients expectations interpretations this confirmed comparison open controlled study designs neuroleptic studies indicating results well performed open studies earn attention study 1 shown ectoine azelastine products resulted clear decrease symptoms allergic rhinitis study period 7 days according physicians evaluation symptoms nasal obstruction rhinorrhea sneezing nose itching conjunctivitis azelastine group the mean decrease tnss 58.85% ectoine group 57.11% azelastine group thus demonstrating strong clinical relevance similarly mean decreases toss 45.96% ectoine group 44.98% azelastine group therewith reflect strong clinical relevance study 2 also demonstrated significant decrease symptom scores upon treatment within first week study tnss values decreased 50.96% group 45.21% group b decreases within entire study period 2 weeks 62.74% group 49.14% group b according physician assessment nasal obstruction often caused enlargement nasal turbinates located lateral walls side nose thus significant improvement turbinate hyperplasia assessed physician underlined efficacy treatments reducing nasal obstruction comparison physicians assessment symptoms this might likely due fact starting symptom values assessed patients lower physicians values this turn least partly accredited fact patients first assessments symptoms documented end first treatment days whereas physicians documented baseline symptoms first site visit prior start treatment recent placebo controlled study environmental challenge chamber showed 3 hours application ectoine nasal spray eye drops symptoms decreased ~20% this decrease reflects roughly difference first assessment physicians first patient diary entry in addition physicians able carry ranking symptoms based experience many patients thus judgment might considered objectively hand symptoms itching eyes nose palate measured scientifically valid method thus prone personal perception difficult assessed physicians together patients taken together an overestimation physician underestimation patients likely study 1 patients assessment showed azelastine group decreases significant symptoms nasal obstruction sneezing nasal itching for ectoine group values decreased significantly symptom nasal obstruction whereas clear significant decrease symptoms nasal itching sneezing rhinorrhea observed total decreases tnss 24.68% ectoine group 35.26% azelastine group thus confirming clinical relevance treatment clear decreases ocular symptoms tearing eye itching assessed patients groups however values reach significance the symptom conjunctivitis clearly significantly decreased ectoine group whereas became slightly worse azelastine group total toss assessed patients decreased 19.57% ectoine group 11.81% azelastine group although ocular treatment applied study 2 ocular symptoms allergic rhinitis clearly improved upon treatment ectoine cromoglycic acid nasal spray according physicians assessment toss values decreased 59.09% group 39.32% group b 1 week treatment 73.74% group 45.47% group b 2 weeks treatment it surprising local nonpharmaceutical nasal treatment might also influence ocular symptoms recent studies suggest crosstalk nose eyes the mechanism influence symptoms via nasolacrimal duct fully understood thought via mucosal connection possibly via nose eye reflex the patients assessment ocular symptom development study 2 confirmed significant decrease symptom eye itching two weeks treatment groups a significant reduction symptom eye redness observed group group b. however ocular symptom scores generally rather small study treatment aimed mainly reduce nasal symptoms studies needed evaluate efficacy treatments ocular symptoms interestingly another published study azelastine eye drops cromoglycate eye drops placebo eye drops showed superiority active treatments versus placebo without significant differences two active treatments future study comparing treatment ectoine eye drops pharmacological eye drop formulations would desirable current studies showed ectoine nasal spray eye drops safely applied patients allergic rhinitis patients judged tolerability products similarly good azelastine products significantly better cromoglycic acid nasal spray low numbers aes reflected good safety profile used treatments the crossover design study 2 bears difficulties washout period crossover carried however symptoms assessed daily basis effects following one treatment one week analyzed separately results following two treatments clear improvements symptoms were already observed one week treatment time span seems sufficient evaluate effects either treatment b. efficacy safety azelastine studied huge range clinical trials last decades one use historical data bring results current study broader context results comparator studies see table 11 addition results placebo groups comparator studies used order rank current results thus comparable data confirmed superiority azelastine versus placebo treatment values indicate effects azelastine usually 2 3-fold higher placebo however comparing actual values current study studies rather difficult design e.g. randomized versus nonrandomized placebo controlled versus placebo controlled differences length treatment differences scaling symptoms dose azelastine concentration number daily applications available studies differs enormously in addition studies used nasal spray assessed solely nasal symptoms whereas current study one studies acknowledging also ocular symptoms allergic rhinitis taken together results current study 1 showed effects ectoine containing products almost comparable azelastine well studied drug proven superiority placebo treatment commonly prescribed allergic rhinitis cromoglycic acid common drug treating allergic rhinitis although thought effective intranasal steroids antihistamines shown reduce nasal ocular symptoms therefore reasonable therapy option particular good safety profile makes interesting treatment option children pregnant women published studies identical current study design study 2 terms treatment duration analysis end points general comparisons cromoglycic acid studies drawn several studies confirmed cromoglycic acid superior placebo patients allergic rhinitis thus schuller colleagues investigated efficacy cromolyn sodium comparison nedocromil sodium placebo treatment period 8 weeks demonstrated cromolyn resulted clear improvement nasal symptoms particularly symptom stuffy nose placebo controlled study confirmed cromoglycate acid nasal spray provided significant relief nasal symptoms within 2 weeks treatments significant symptoms sneezing nasal congestion clearly visible significant symptoms rhinorrhea nasal pruritus taken together ectoine containing nasal spray eye drops demonstrated promising alternatives pharmacological drugs good efficacy good safety profile as ectoine nasal spray eye drops act purely physically nasal ocular mucosa makes products particularly interesting patients reservations pharmacological therapy an additional study children adolescents seasonal allergic rhinitis data yet published confirmed safety ectoine containing nasal spray eye drops pediatric population further studies undertaken investigate onset action compare commonly applied pharmacological drugs quick relief symptoms crucial patients understood advantageous comparing example azelastine intranasal corticosteroids therefore assessed ectoine products controlled ramdomised study carried using controlled environmental exposure chamber showed quick onset action ectoine nasal spray eye drops confirmed efficacy reducing nasal ocular symptoms additional studies applying ectoine eye drops needed elucidate impact ocular symptoms allergic rhinitis	objectives . allergic rhinitis is a common disease with increasing prevalence and high impact on economic burden and comorbidities . as treatment with pharmacological drugs is not always satisfactory due to side effects and incomplete efficacy , alternative treatment strategies are needed . ectoine is an osmolyte with membrane stabilizing and inflammation reducing capacities . nasal spray and eye drops containing ectoine are promising new treatment regimens for allergic rhinitis sufferers . design and methods . the current two noninterventional trials evaluated the efficacy and safety of ectoine containing nasal spray and eye drops for treating allergic rhinitis in comparison with either azelastine or cromoglycic acid containing products . nasal and ocular symptom developments as well as judgment of tolerability and efficacy were assessed both by investigators and patients over a time period of one to two weeks . results . both trials confirmed that ectoine containing products reduced nasal and ocular symptoms in allergic rhinitis patients . results clearly demonstrated good safety profiles of the ectoine products comparable to those of azelastine and even better to those of cromoglycate products . conclusion . ectoine containing nasal spray and eye drops are interesting new treatment strategies for sufferers of allergic rhinitis , combining both good efficacy and absence of side effects .
understanding modes action natural compounds toxicants important least two reasons ecological evolutionary standpoint knowing mode action compounds critical understanding function compound nature for example high activity phytotoxins plant pathogens specific molecular targets found green plants fungi provides strong evidence compounds evolved virulence factors pathogens duke dayan 2011 practical standpoint natural compounds often source pesticides new modes action dayan et al 2012 new modes action needed combat increasingly rapid evolution pest resistance currently used pesticides particularly herbicides duke 2012 there 20 molecular targets herbicides currently used duke 2012 natural phytotoxins many effective modes action used commercial herbicides duke dayan 2011 exploitation natural product mode action may may involve use natural products chemical scaffold design synthetic compounds mode action for example allelochemical leptospermone chemical basis design structurally similar triketone herbicides inhibit hydroxyphenylpyruvate dioxygenase hppd beaudegnies et al 2009 last commercial herbicide mode action introduced duke 2012 however phytochemical ryanodine gave clue new insecticide mode action targeting ligand gated calcium channels insect muscles structurally unrelated insecticides developed commercialized lahm et al 2009 the modes action natural phytotoxins unknown especially compounds thought involved plant plant interactions allelochemicals there many papers purporting show mode action herbicides natural phytotoxins turned wrong there detailed sure procedure determination mode action phytotoxin although papers give researchers start using simple physiological assays e.g. dayan et al 2000 dayan watson 2011 dayan zaccaro 2012 omics methods genomics paired transcriptomics proteomics well metabolomics physionomics offer new approaches narrowing search molecular target toxicant robust technology first three approaches become available past decade evidenced fact virtually papers cited review published past 10 years similar strategies generally used utilization approaches mode action research genomics underpins transcriptomics proteomics genes fixed treatment toxin change this however reverse genetics determination gene function analysis phenotypic effects gene expression important annotation sequenced genes affecting plant gene expression phytotoxins valuable endeavor the simplest method use omics methods probe mode action phytotoxin simply examine effect compound profiles mrna proteins metabolites physiological processes different doses different times administering dose look hint molecular target this approach productive complexities responses toxicant level seldom reveal initial target even mode action known approach always point unambiguously target the rigorous approach generate complete database responses library toxicants known molecular targets then detailed response compound unknown target compared responses plants compounds known targets if omics data fit known modes action may suggest new molecular target few labs industrial ones capacity generate analyze large databases known modes action short review discuss commonly used omics approaches study mode action giving advantages limitations profiling global transcriptional response toxicant determined readily microarray next generation sequencing technologies become available relatively recently transcription profiling used extensively combinations methods determine mode action pharmaceuticals e.g. bharucha kumar 2007 gobert jones 2008 pan et al 2008 inhibition enzyme involved critical biochemical pathway protein receptor e.g. d-1 protein photosystem ii psii chemical inhibitor result compensation alteration transcription genes encoding enzymes directly affected pathway well genes encoding proteins associated stress inactivation xenobiotic compounds chemical alterations genomic information coupled microarray technology next generation sequencing allows us readily examine relative effect inhibitor every gene genome get maximal information the first plant species information available arabidopsis thaliana accordingly first papers global transcriptional responses phytotoxins used species studies e.g. lechelt kunze et al 2003 manfield et al 2004 baerson et al 2007 das et al 2010 relatively small genome a. thaliana reduces amount complexity data must analyzed the genomes plant species becoming available increasing rate annotations genomes becoming robust argued even though a. thaliana good plant species discovery new herbicide target sites knocking genes good elucidating mode action new phytotoxins sensitive using functional genomics metabolomics gressel 2009 time small genome superior gene annotation rapidity experiments done a. thaliana make best model organism mode action transcriptome fingerprinting the transcriptome response differentially affected different doses phytotoxin effects change time so uniform method treatment must used generating transcriptome response library phytotoxins different modes action treatment i50 and/or i80 concentrations required 50 80 inhibition growth dose toxicant sampling various times beginning exposure still different compounds act different rates due several factors including target sites metabolic inactivation rates uptake rates translocation rates complicate things even more phytotoxins act primarily meristems e.g. mitotic inhibitors others act almost exclusively green photosynthesizing tissues e.g. ps ii inhibitors fedtke duke 2005 so perfect way uniform method building transcriptome response library phytotoxins known molecular target sites a good example difficulties work transcriptional responses a. thaliana allelochemical benzoxazolin-2-(3h)-one boa baerson et al 2005 original intent work provide indications mode action compound dose response experiment i50 i80 concentrations boa root growth 10-day old a. thaliana seedlings determined transcriptome responses seedlings determined whole transcribed genome microarrays two doses 24 hr treatment time doses almost 200 genes representing 12 functional categories genes involved metabolism cell rescue defense accounted half affected genes many genes encode detoxification enzymes also induced set structurally diverse xenobiotic compounds different modes action non phytotoxic xenobiotics protect plants herbicides safeners similar effects transcription genes involved phytotoxin detoxification a. thaliana baerson et al ( 2005 study clear indication association genes affected boa particular mode action separating effects genes closely associated target site resulting metabolic perturbation defense pathways daunting task genes affected time points show earlier effects cascade non specific responses likely enriched directly associated primary response early work examined effects herbicides limited number genes studies glombitza et al ( 2004 examined effects two herbicide classes 267 a. thaliana genes pasquer et al ( 2006 studied effect herbicides three chemical classes wheat gene expression using microarray 600 barley cdnas truly determine action phytotoxin transcriptome microarray composed global genome plant studied must used there number papers transcriptional responses herbicides known modes action the earliest paper use global gene chip probe mode action herbicide lechelt kunze et al gene a. thaliana encoding putative fatty acyl coa reductase involved long chain fatty acid alcohol biosynthesis regulated two herbicides flufenacet benfuresate inhibit long chain fatty acid elongases mode action ( 2004 found several genes a. thaliana closely associated cell wall assembly involved mode action cellulose synthesis inhibiting herbicide isoxaben zhu et al 2008 determined transcriptome responses glyphosate resistant r -susceptible soybean near isogenic varieties the resistance imparted transgene encoding glyphosate resistant target site enzyme 5-enolpyruvylshikimate-3-phosphate synthase epsps 1 4 24 hr treatment 3 170 311 genes affected times respectively variety 1 4 24 genes affected respectively r variety the genes affected variety would pointed clearly epsps target site glyphosate effect transcription epsps time point gene shikimate pathway affected 3-deoxy arabino heptulosonate-7-phosphate synthesis first enzyme pathway this effect seen 4 hr three genes associated aromatic amino acid metabolism slightly affected many unrelated genes the results paper would probably useful discovery target glyphosate already known however support view glyphosate target site epsps major transcriptome effects glyphosate r variety similar paper 2007 using imidazolinone herbicide- inhibitors acetolactate synthase als susceptible resistant via mutation csr1 2 encodes subunit als a. thaliana found many genes affected herbicide plants whereas significant changes transcriptome treated r plants nevertheless results would pointed branched chain amino acid pathway site target type herbicide ( 2010 reported transcriptional responses glyphosate compared elicited series als inhibitor herbicides a. thaliana brassica napus quite different one could differentiate two modes action well stress treatments three classes als inhibitors used two sulfonylureas one imidazolinone one triazolopyrimidine results suggested method could differentiate effects compounds molecular target even compounds chemical family they also reported herbicidal inhibitors ps ps ii phytoene desaturase auxin transport gibberellin biosynthesis distinctive transcriptional signatures transcriptional responses phytotoxins known modes action include work zhu et al ( 2007 two psii inhibiting herbicides atrazine bentazon raghavan et al kelley et al 2006 found strong transcriptional response gh3 primary auxin responsive gene soybeans auxinic herbicides dicamba clopyralid the gene significantly affected heat drought salt stress virus infection jamers de coen 2010 found strong transcriptional effects chlamydomonas reinhardtii genes associated oxidative stress alga treated subtoxic levels paraquat herbicide causes effect rapid generation reactive oxygen species there papers transcriptional responses plants allelochemicals phytochemicals ( 2005 main transcriptome responses upregulation stress genes associated metabolic detoxification xenobiotics 2011 attempted learn mode action juglone 5-hydrox-1,4-napthoquinone transcriptome profiling the major effects genes related cell growth cell wall formation detoxification xenobiotics abiotic stress epigenesis the mechanism action l dopa probed microarray golisz et al 2011 the authors concluded two mechanisms 1 disruption amino acid metabolism 2 regulation metal ion homeostasis especially iron ( 2008 probed transcriptome response a. thaliana fagomine gallic acid rutin putative allelochemicals buckwheat fagopyrum esculentum most responses consistent stress effects target sites compounds identified the natural phytotoxin cantharidin strongly affected transcription genome a. thaliana compound inhibits 19 serine threonine protein phosphatases plant bajsa et al 2011a b these enzymes strongly influence many signaling pathways thus 10 genes a. thaliana genome significantly affected within 24 hr exposure cantharidin dose reduced chlorophyll levels 30 a large number genes down- regulated pattern genes affected changed dramatically time treatment seen hierarchical clustering microarray data fig 1 similar results found endothall commercial herbicide close chemical analogue cantharidin also inhibits serine threonine protein phosphatases bajsa et al the natural phytotoxin coronatine analog hormone methyl jasmonic acid meja influenced 35 genes regulated meja tomato uppalapati et al just found cantharidin analysis transcriptome responses coronatine revealed major effects signaling via jasmonic acid ethylene auxin pathways coronatine meja concluded share similar identical activities impact multiple hormone pathways.fig 1hierarchical clustering microarray data heat map analysis arabidopsis thaliana genes changed expression 2 10 24 hr treatment 200 cantharidin ( 2011a hierarchical clustering microarray data heat map analysis arabidopsis thaliana genes changed expression 2 10 24 hr treatment 200 cantharidin previously unpublished data experiments reported bajsa et al ( 2011a phytotoxic trichothecene deoxynivalenol produced plant pathogen fusarium graminearum distinct effects transcription barley gardiner et al 2010 transcripts abc transporters udp glucosyltransferases cytochrome p450s glutathione transferases regulated biochemical studies supported view upregulated genes involved detoxification transcriptome responses particular compound vary considerably depending duration method treatment dose(s used therefore experiments done one dose sampling done several times exposure since microarray methods provide quantitatively linear results rt qpcr reverse transcription quantitative real time pcr methods used verify obtain accurate data genes interest identified microarray methods e.g. baerson et al 2005 thus extraction rna entire plant root shoot may dilute clear response would obtained target tissue(s cell type(s analysis biosynthetic pathways addition individual genes may provide clearer hints mode action toxicant for example although profound effects array ergosterol synthesis inhibiting fungicides genes encoding enzymes ergosterol synthesis pathway saccharomyces cerevisiae analysis pattern effects entire pathway provided signature differentiated class ii ergosterol synthesis inhibitors fungicide modes action kagan et al 2005 ) 2effects class ii b iii c sterol biosynthesis inhibitors putative methionine biosynthesis inhibitor cyprodinil expression levels genes ergosterol pathway standard errors shown b standard deviations shown c d. genes listed x axis left right order appear pathway dashed horizontal lines graphs indicate level expression change seen relative control arrows indicate gene(s encoding enzymes targeted inhibitor class reproduced kagan et al ( 2005 effects class ii b iii c sterol biosynthesis inhibitors putative methionine biosynthesis inhibitor cyprodinil expression levels genes ergosterol pathway standard errors shown b standard deviations shown c d. genes listed x axis left right order appear pathway dashed horizontal lines graphs indicate level expression change seen relative control arrows indicate gene(s encoding enzymes targeted inhibitor class reproduced kagan et al ( 2005 whole transcribed genome microarray huge leap forward transcriptome analysis redman et al 2004 however high throughput next generation sequencing cdna mrna rna seq offers another leap forward morozova marra 2008 wang et al 2009 marioni et al the number copies transcripts different genes determined sequencing cdna fragments sufficient length identify genes these methods allow one count directly relative number times gene transcribed sample statistical robustness this method much precise microarray methods allows one transcriptomics experiments plant species microarray chips exist dynamic range method greater 8,000-fold whereas microarray hundred fold wang et al 2009 result rna seq methods much accurate highly poorly expressed genes microarray a downside method many millions cdnas must sequenced determine definitive effects weakly transcribed genes however method provides opportunity obtain accurate expression level estimates obtained microarray methods recently expense approach prohibitive past years cost become competitive microarray we seen papers use method probe mode action phytotoxins there danger rna based data result false conclusions influence phytotoxin proteins resulting transcriptional effects gene expression also dependent factors transcription post transcriptional processes cause protein levels change independently mrna we unaware transcriptome information leading discovery target site phytotoxin numerous cases resulted better understanding mode action phytotoxins e.g. zhu et al 2008 transcriptional pattern complex determinning gene(s might associated primary target phytotoxin challenging even rna seq stated duke et al ( 2009 transcriptional profiling useful creating list candidate targets pathways unmatched technologies information provide foundation development hypothesis concerning putative primary cellular target targets phytotoxin identification proteins separated two dimensional gels 2d page mass spectrometric methods allowed scientists determine effects phytotoxins hundreds proteins there thousands proteins plant cells method global transcriptional analysis nevertheless effects relative abundance proteins closer actual physiological effects transcriptional responses papers analysis proteome responses plants herbicides couple papers available use method probe effects putative allelochemicals natural phytotoxins 2012 examined effects low high doses herbicides paraquat psi energy diverter diuron psii inhibitor norflurazon phytoene desaturase inhibitor proteome green alga chlamydomonas reinhardtii significant effects up- regulation found 149254 proteins depending herbicide for example although norflurazon effect abundance target enzyme phytoene desaturase enzymes plastidic isoprenoid pathway e.g. 1-deoxy xylulose 5-phosphate synthase geranylgeranyl reductase upregulated enzymes tetrapyrrole pathway case diuron the amounts d1 protein molecular target light harvesting complex protein increased whereas levels proteins involved photosynthetic electron transport decreased heat map analysis effects three herbicides proteins associated photosynthesis showed distinct patterns up- regulation associated herbicides fig 3heat map showing proteins functionally related photosynthetic machinery significantly changed chlamydomonas reinhardtii response paraquat pq diuron dr norflurazon nf high h low l concentrations statistical evaluation performed g test fold changes presented log 2 values reproduced nestler et al ( 2012 permission heat map showing proteins functionally related photosynthetic machinery significantly changed chlamydomonas reinhardtii response paraquat pq diuron dr norflurazon nf high h low l concentrations statistical evaluation performed g test fold changes presented log 2 values reproduced nestler et al ( 2012 permission proteomic analysis roots medicago truncatula treated als inhibiting herbicides flumetsulam metsulfuron methyl revealed proteins affected meristematic 81 non meristematic 51 tissues holmes et al 2006 there two trends 1 increased accumulation proteins involved cell division redox mediation meristematic tissues 2 increases proteins involved pathogen responses decreases metabolic proteins tissues kelley et al 2006 found four proteins strongly affected two auxinic herbicides dicamba clopyralid soybeans although detected 2-d gel protein probed immunoblot analysis since transcription gene strongly upregulated see transcriptomics section they tentatively identified malate dehydrogenase md gamma glutamyl hydrolase superoxide dismutase sod sod stress protein would expected upregulated phytotoxins many modes action md upregulation associated general plant stress the upregulation gh3 gene protein suggested biomarker auxinic herbicide damage sublethal treatments vitis vinifera protoporphyinogen oxidase ppo)-inhibiting herbicide flumioxazin caused abundance 33 proteins change castro et al 2005 the herbicide regulated proteins associated pathogenesis oxygen stress photorespiration whereas levels enzymes carbon fixation sugar metabolism reduced the authors speculated reductions proteins may due enhanced degradation proteins process found indirect effect ppo inhibitor herbicides proteomic analysis maize revealed microtubule disrupting herbicide amiprophos methyl changed amount 28 proteins allowing detection 15 additional proteins disappearance 13 proteins 2-d gels wang et al 2011 some proteins affected root leaves mesocotyl cold acclimation protein ubiquitin ubiquitin like protein maturase k cytochrome p450 monoxygenase mesocotyl ferredoxins 2,4 dienoyl coa reductase root atp dependent protease they concluded profile affected proteins could used marker phytotoxins acting mode action the effects long chain fatty acid elongase inhibiting herbicide dimethenamid herbicide safener cloquintocet mexyl proteome roots leaves coleoptiles triticum tauschii analyzed zhang et al proteins increased safener involved predominately xenobiotic detoxification mainly coleoptiles root no multidrug resistance associated proteins mrp detected 2-d gels enhanced safener induced transcription one mrp found rt qpcr the effects crude extracts allelopathic mexican plant species proteome bean tomato roots revealed alterations 11 16 proteins depending source extract test plant species cruz ortega et al 2004 in relatively early studies -amylase inhibitor like protein glutathione transferase identified affected levels increased provided clues understanding physiological mechanisms allelochemical induced stress we found studies effects single allelochemicals proteome ( 2011 identified 25 differentially expressed proteins chinese medicinal achyranthes species treated growth promoting extracts soil species growing proteins associated stress secondary plant metabolism signal transduction synthesis degradation nutritive material well synthesis degradation nucleic acids protein affected this paper identify target site actual active compounds extract also identified proteomics using ms analysis 2-d gel spots level precision transcriptomics whether using microarrays second generation sequencing for example transcriptional clue gh3 gene regulated auxinic herbicides could verified 2-d gel analysis verified sensitive immunochemical method kelley et al 2006 problems proteomics outlined zhang riechers 2008 still largely exist they include lack template based replication process pcr rna this means visualizing analyzing low abundance proteins gels impossible methods used reproducibility problem 2-d gels abdallah et al 2012 additionally proteomics limited gene transcript information available identify sequenced peptides the complexity posttranslational modification proteins regulation difficulty encountered rna another drawback proteomics limited soluble proteins excluding many membrane bound proteins trimpin brizzard 2009 general correlation transcriptomes proteomes good least partly actually translated rna part total rna usually analyzed transcriptomics methods using polysomal rna transcriptional studies may reduce lack correlation skadsen jing 2008 recently developed gel free proteomics methods itrag isobaric tags relative absolute quantitation protein tagging methods coupled lc ms ms may become powerful tools tackling problems improving 2-d gel based proteomics bindschedler cramer 2011 abdallah et al 2012 less complicated lable free gel free lc ms methods also available abdallah et al 2012 we found literature using newer proteomics methods probe mode action phytotoxins compared number genes and/or proteins single plant species much smaller number metabolites molecular weight less 500 especially primary metabolites required growth development if one includes secondary metabolites plant species combined 100,000 different compounds dixon 2001 plant species contain less thousand primary metabolites perhaps many secondary metabolites latter often exclusive single closely related group plant species herbicides potent phytotoxins kill plants interfering secondary plant metabolism metabolomic approaches understanding mode action concentrate relatively small number primary metabolites however effects phytotoxins concentrations secondary compounds might useful generating fingerprint modes action modern chromatographic separation instrumentation coupled mass spectrometry and/or nmr allows separation tentative identification compounds relative ease one problem approach concentrations even primary metabolites orders magnitude apart vary dramatically cell types different tissues some metabolic intermediates tight regulation exceed low concentrations toxic plant higher concentrations examples toxic intermediates include sphingoid bases protoporphyrinogen ix -ketobutyric acid abbas et al 2002 duke 2012 short review these details found extensive reviews dealing metabolomics e.g. aliferis chysayi tokousbalides 2011 one approach metabolomics generate one dimensional 1d proton nmr h nmr spectral fingerprints crude extracts hoping resulting information provide clues mode action comparing fingerprints phytotoxins known modes action e.g. ott et al 2003 aliferis chysayi tokousbalides 2006 for obvious reasons method inferior actually identifying quantifying compound two dimensional 2d ) nmr correlation spectroscopy cosy analyses crude extracts provide chemical data method inferior chromatographic separation followed mass spectroscopy lc nmr advantages nmr alone limited detection limits compared ms coupled chromatography use gc ms lc ms ms samples provided perhaps definitive information metabolomics thus far generated herbicide modes action grossmann et al 2010 2012a b there relatively studies use metabolomic approaches mode action discovery confirmation phytotoxins the review aliferis jabaji 2011 gives details use metabolomics profile modes action pesticides including herbicides the first use nmr fingerprinting mode action herbicides metabolite analysis aranibar et al four modes action fingerprinted using artificial neural networks classification h nmr data crude extracts maize this work later expanded 19 modes ott et al 2003 mode action phytotoxin 5s,8r,13s,16r)-(1)-pyrenophorol probed avena sterilis using h nmr fingerprinting metabolites aliferis chysayi tokousbalides 2006 the fingerprint correspond herbicides diuron glyphosate mesotrione norflurazon oxadiazon paraquat in lemna minor later claimed compound caused effects metabolome similar glyphosate results suggested similar mode action aliferis et al 2009 yet check dramatic elevation shikimic acid telltale marker inhibition epsps target site glyphosate duke et al 2003 identification individual metabolites would confirmed whether claim correct metabolomic studies effects glyphosate a. thaliana using lc pda lc ms gc tof ms bttcher et al 2008 lemna pausicostata using combination gc ms lc ms ms grossmann et al 2012b large increases shikimate effects amino acid profiles predominant early effects glyphosate ( 2008 showed commercial formulation glyphosate used extracts contained significant amounts formulation chemicals would discerned methods separate mixtures components h- nmr analysis complex mixtures without separation rapid provide clues mode action compound profile match phytotoxin known mode action ( 2006 used direct infusion fourier transform ion cyclotron resonance mass spectrometry ft icr ms another method separate identify quantify metabolites discriminate metabolite profiles four modes action a. thaliana compounds mode action gave similar results however overlap responses compounds different modes action using gc ms kluender et al ( 2009 examined effects psii inhibiting herbicide prometryn metabolites green alga scenedesmus vacuolatus results 14-h time course showed development impairment energy metabolism associated catabolic processes reductions carbohydrate synthesis perhaps complete study effects phytotoxins plant metabolomes trenkamp et al they examined effects glufosinate glyphosate sulcotrione foramsulfuron benfuresate experimental cell wall biosynthesis inhibitor ae944 analysis polar metabolites revealed clear differences profiles generated compounds six different modes action for herbicides results matched would expected mode action herbicide e.g. sulcotrione ae944 cases apparent connection effects metabolites mode action e.g. benfuresate since benfuresate acts lipid synthesis one might expect see effects polar metabolites would point mode action another example use metabolomics probe secondary effects phytotoxin cheng et al ( 2011 examined metabolome soybean response herbicide lactofen herbicides mode action induce host defenses disease soybean duke et al 2007 lc ms analysis herbicide induced metabolites led discovery two new phytoalexins ( 2007 examined effects phytotoxic constituents roots ligularia macrophylla growth lemna paucicostata separately using chromatography coupled ms metabolomics methods described duke et al ( 2010 2012a b effects active eremophilane compounds 6-angeloyloxy-10-hydroxyfurnoeremophilane metabolome l. paucicostata examined fig this method generates relative concentration values 200 identified metabolites 300 unknown compounds results compared cluster analysis proprietary database 150 metabolic profiles previously characterized standard compounds l. paucicostata 60 different modes action grossmann et al 2012b strong increases certain sugars abscisic acid l dopa tryptophan decreases allantoin aminoallantoins flavonoids cystathionine observed response furanoermophilane 2010 found metabolic profile saflufenacil correspond closely ppo inhibitors this mode action confirmed vitro enzyme assays determining compound causes rapid dramatic increases protoporphyrin ix vivo.fig nodes metabolites indicate significance changes p 0.01 dark 0.01 p 0.05 middle 0.05 p 0.1 light levels we thank klaus grossmann basf se limburgerhof germany charles cantrell usda ars oxford ms usa nicole christiansen metanomics berlin germany previously unpublished data metabolite profile lemna paucicostata treated 6-angeloyloxy-10-hydroxyfurnoermophilane ligularia macrophylla nodes metabolites indicate significance changes p 0.01 dark 0.01 p 0.05 middle 0.05 p 0.1 light levels we thank klaus grossmann basf se limburgerhof germany charles cantrell usda ars oxford ms usa nicole christiansen metanomics berlin germany previously unpublished data method used conjunction physionomics study mode action cinmethylin older herbicide unknown mode action grossmann et al it structural analogue potent natural phytotoxin 1,4-cineole romagni et al 2000 in addition effects isa caused higher levels tryptophan tyrosine phenylalanine concentrations strongly reduced the tyrosine degradation product l dopa 3,4-dihydroxyphenylalanine increased five fold plastohydroquinone levels reduced these effects similar hppd inhibitor topramezone differed isa cause decrease isopentenyl pyrophosphate tocopherol cluster analysis metabolite changes compared effects phytoene desaturase hppd non mevalonate isoproenoid synthesis inhibitors common effects cinmethylin isa compounds grossmann et al cinmethylin two isas methiozolin iso1 clustered distinctly differently herbicide classes feeding treated plants 4-hydroxyphenylpyruvate 4-hpp direct tyrosine derivative alleviated growth inhibition(grossmann et al tyrosine amino transferase enzyme converts tyrosine 4-hpp inhibited vitro cinmethylin isos this paper aware used omics methods discover new molecular target site.fig 5mode action classification cluster analysis metabolite changes lemna paucicostata 48 72 hr treatment herbicides affecting isoprenoid synthesis phytoene desaturase pds hydoxyphenylpyruvate deoxygenase hppd non mevalonate isoprenoid synthesis inhibitor modes action contrast results cinmethylin methiozolin iso1 see fig 7 structures 6effects tyrosine downstream products tyrosine amino transferase 4-hyroxyphenylpyruvate homogentisate growth inhibition lemna paucicostata cinmethylin methiozolin iso1 grossmann et al 2012a permission mode action classification cluster analysis metabolite changes lemna paucicostata 48 72 hr treatment herbicides affecting isoprenoid synthesis phytoene desaturase pds hydoxyphenylpyruvate deoxygenase hppd non mevalonate isoprenoid synthesis inhibitor modes action contrast results cinmethylin methiozolin iso1 see fig 7 structures grossmann et al 2012a permission effects tyrosine downstream products tyrosine amino transferase 4-hyroxyphenylpyruvate homogentisate growth inhibition lemna paucicostata cinmethylin methiozolin iso1 grossmann et al 2012a permission recent paper grossmann et al 2012b provides considerable metabolomic information using protocols number known modes action well new information phytotoxic phenylalanine analog phe1 changes several metabolites including increases tryptophan levels led researchers hypothesize compound inhibits iaa synthesis supplying plants iaa several intermediates iaa synthesis reversed growth inhibition phe1 great extent the enzyme(s iaa synthesis likely target site(s yet isolated ( 2011 used method probe mechanism action potent fungal phytotoxin ascaulitoxin aglycone produced plant pathogen ascochyta caulina the metabolic profile correspond 60 modes action elaborated method however caused distinct changes amino acid contents indicated might inhibit conversion pyruvate alanine synthesis and/or interconversion glutamate glutamine aspartate asparagine physionomics based upon profiles physiological responses effectors grossmann 2005 grossmann et al 2012b grossmann 2005 first proposed term physionomics colleagues used approach successfully conjunction metabolomics study mode action several compounds see this procedure similar past approaches herbicide discovery companies discovery phytotoxin modes action however physiological profiles different modes action quantified clearer comparisons unknown modes actions methods grossmann 2005 grossmann et al scientists public sector proposed batteries physiological assays identify mode action phytotoxins e.g. dayan et al 2000 these physiological assays physionomics approach provide first clue mode action many cases eliminate need complicated expensive omics approaches.fig 7physionomic profiles four compounds apparently phytotoxic due inhibition tyrosine amino transferase bioassay abbreviations dark l light vlcfa long chain fatty acid ros reactive oxygen species symptoms observed tissue desiccation root growth inhibition n necrosis meristematic area wr intensified green leaf pigmentation reproduced permission grossmann et al ( 2012a physionomic profiles four compounds apparently phytotoxic due inhibition tyrosine amino transferase bioassay abbreviations dark l light vlcfa long chain fatty acid ros reactive oxygen species symptoms observed tissue desiccation root growth inhibition n necrosis meristematic area wr intensified green leaf pigmentation reproduced permission grossmann et al omics approaches mode action discovery point way molecular target phytotoxin target sites partially validated genetic means determination defect gene encoding putative target site generates phenotype including omics profile however short term blockage biochemical signaling pathway phytotoxin likely cause similar omics profile caused genetic defect target one might expect mutation lethal compensatory mechanisms would developed a. thaliana this includes characterized classical mutants generated mutagen ethyl methane sulfonate ems http://www.arabidopsis.org/ dna insertion lines krysan et al 1999 however ultimately target site must validated showing binds phytotoxin inhibited vitro natural phytotoxins complicated compound protoxin must metabolically activated form active inhibitor vivo examples microbial phytotoxin hydantocidin must phosphorylated inhibit adenylosuccinate synthase cseke et al 1996 bialaphos product soil microbe must degraded phosphinothricin inhibit glutamine synthetase wild zeigler 1989 the strongest validation molecular target site phytotoxin genetic change gene molecular target site renders protein producing plant resistant omics technologies lend shotgun experiments clear biological rationale unlike one might experiment clear biomarker predicts cause effect the amount data complexity omics studies require complicated analytical capabilities often provide clear answers biological questions even advanced omics work done medical field problems challenging institute medicine 2012 pointed jamers et al ( 2009 gap global nucleic acid based omics genomics transcriptomics forms omics large terms analyzing complete array proteins metabolites and/or physiological effects furthermore even though modern instrumentation software reduced cost labor involved generating analyzing huge data bases required rigorous fingerprinting known modes action enterprise still larger independent laboratories bear nevertheless omics methods offer greater insight effects phytotoxin biochemistry genetics target plant in addition seeing compound injures plant one answer questions mechanisms defense compound e.g. baerson et al 2005 potential secondary target sites e.g. zhu et al 2008 sublethal effects plant constituents considering technologies decade old we begun fully employ answer questions related natural phytotoxins chemical ecology	for a little over a decade , omics methods ( transcriptomics , proteomics , metabolomics , and physionomics ) have been used to discover and probe the mode of action of both synthetic and natural phytotoxins . for mode of action discovery , the strategy for each of these approaches is to generate an omics profile for phytotoxins with known molecular targets and to compare this library of responses to the responses of compounds with unknown modes of action . using more than one omics approach enhances the probability of success . generally , compounds with the same mode of action generate similar responses with a particular omics method . stress and detoxification responses to phytotoxins can be much clearer than effects directly related to the target site . clues to new modes of action must be validated with in vitro enzyme effects or genetic approaches . thus far , the only new phytotoxin target site discovered with omics approaches ( metabolomics and physionomics ) is that of cinmethylin and structurally related 5-benzyloxymethyl-1,2-isoxazolines . these omics approaches pointed to tyrosine amino - transferase as the target , which was verified by enzyme assays and genetic methods . in addition to being a useful tool of mode of action discovery , omics methods provide detailed information on genetic and biochemical impacts of phytotoxins . such information can be useful in understanding the full impact of natural phytotoxins in both agricultural and natural ecosystems .
anomaly characterized central corneal opacity corresponding defects posterior stroma descemet membrane endothelium 2 3 4 5 ultrasound biomicroscopy useful tool detecting associated structural abnormalities keratolenticular iridocorneal adhesions however without patients cooperation difficult obtain desirable image using method topical endoscopic imaging tei new tool used examine intraocular findings clear cornea present 2 cases showed corneal opacity examined tei after parents patients given written explanation study provided written informed consent a 20-day old neonatal female referred department corneal opacity although right eye od normal left eye os showed central corneal opacity fig the anterior chamber structures os could partially visualized clear area fundus examination showed normal appearance od os except superior periphery difficult observe corneal opacity thus examine anterior chamber detail performed tei previously reported method 7 8 briefly authors used rigid endoscope otoscope 6.0 cm length outer diameter 4 mm 1215aa karl storz tuttlingen germany crescent shaped illuminating tip xenon lamp xenon nova 175 karl storz ) the endoscope connected digital camera utilizing 400,000-pixel charge coupled device image sensor unit connected monitor turn the patient placed bed supine position topical anesthetic instilled os a spatula placed eyelids hydroxyethyl cellulose solution applied corneal surface protect create interface would improve quality image the endoscope placed proximate contact cornea directed angle could observed as shown figure 1b iris stroma adhered toward back opacified area cornea confirmed diagnosis a 4-month old male referred department bilateral corneal opacity our examination demonstrated presence bilateral central corneal opacity extremely shallow anterior chambers made impossible observe fundus eyes fig the intraocular pressure measured 8 mm hg od 9 mm hg os ultrasonographic investigations showed presence short axial lengths od 16.0 mm os 16.2 mm funnel shaped retinal detachment when tei performed via clear peripheral cornea keratolenticular adhesion surrounding iridocorneal adhesion observed behind area corneal opacity fig a 20-day old neonatal female referred department corneal opacity although right eye od normal left eye os showed central corneal opacity fig the anterior chamber structures os could partially visualized clear area fundus examination showed normal appearance od os except superior periphery difficult observe corneal opacity thus examine anterior chamber detail performed tei previously reported method 7 8 briefly authors used rigid endoscope otoscope 6.0 cm length outer diameter 4 mm 1215aa karl storz tuttlingen germany crescent shaped illuminating tip xenon lamp xenon nova 175 karl storz ) the endoscope connected digital camera utilizing 400,000-pixel charge coupled device image sensor unit connected monitor turn the patient placed bed supine position topical anesthetic instilled os a spatula placed eyelids hydroxyethyl cellulose solution applied corneal surface protect create interface would improve quality image the endoscope placed proximate contact cornea directed angle could observed as shown figure 1b iris stroma adhered toward back opacified area cornea confirmed diagnosis a 4-month old male referred department bilateral corneal opacity our examination demonstrated presence bilateral central corneal opacity extremely shallow anterior chambers made impossible observe fundus eyes fig the intraocular pressure measured 8 mm hg od 9 mm hg os ultrasonographic investigations showed presence short axial lengths od 16.0 mm os 16.2 mm funnel shaped retinal detachment when tei performed via clear peripheral cornea keratolenticular adhesion surrounding iridocorneal adhesion observed behind area corneal opacity fig townsend et al subdivided peters anomaly following three types central corneal leukoma ii central corneal leukoma keratolenticular adhesion iii central corneal leukoma associated axenfeld rieger mesodermal dysgenesis case 1 showed iridocorneal adhesion corresponds type case 2 displayed bilateral corneal opacity iridocorneal keratolenticular adhesions matches type ii case 2 also showed bilateral funnel shaped total retinal detachment short axial length assuming peters anomaly complicated persistent fetal vasculature described previously present cases employed widely used otoscope perform tei utilization method makes possible easily visualize anterior segment structure via small clear area cornea 7 8 when tei used examine case 1 small iridocorneal adhesion positioned toward back corneal lesion observed in contrast prior ultrasound biomicroscopy examination case could detect adhesion moreover utilization method case 2 revealed partially formed extremely narrow anterior chamber iridocorneal keratolenticular adhesions therefore study demonstrates tei novel method capable looking eye small area clear cornea although image obtained system monocular image resolution restricted performance charge coupled device in addition technique may also helpful investigating congenital abnormalities anterior chamber angle iris lens especially patients unable remain sitting position	peters anomaly is characterized by a central corneal opacity with corresponding defects in the posterior stroma , descemet 's membrane , and endothelium . we present 2 cases that showed corneal opacity when examined by topical endoscopic imaging ( tei ) . case 1 was a 20-day - old neonatal female who had a central corneal opacity in the left eye . tei showed that the iris stroma was adhered toward the back of the opacified cornea . case 2 was a 4-month - old male who had a bilateral corneal opacity . tei revealed that both a keratolenticular adhesion and a surrounding iridocorneal adhesion were observed behind the area of corneal opacity . the patient was diagnosed as having peters anomaly with persistent fetal vasculature . this study demonstrates that tei is a novel method capable of looking into an eye from only a small area of the clear cornea .
concept dual energy computed tomography dect based attenuation differential various materials simultaneously exposed low- high energy x rays this reflects difference material interaction low- high energy photons resultant changes compton scatter photoelectric effects compton scatter scattering x rays little absorption predominates 120140 peak kilovoltage kvp energy range in contrast photoelectric effect photon absorption specific element equates energy required eject k shell electron the photoelectric effect proportional cube atomic number inversely proportional incident photon energy z e conventional ct utilizes single polychromatic x ray tube peak energy approximately 120 kvp produces images high signal noise ratio however clear discrimination different high attenuation materials iodine hematoma bone calcium sometimes difficult may require additional acquisitions noncontrast scan one method employs two orthogonal x ray tubes set different kvp levels two separate detectors the second method uses rapid kvp switching single x ray source detector composed two scintillation layers methods the attenuation fundamental materials discernibly different one another cerebrospinal fluid brain parenchyma hematoma iodine calcification a plot behavior energy attenuation x ray tubes results physiological line reflecting graduated increase expected hounsfield units voxel higher density material presence iodine within voxel changes attenuation profile significantly results upward deviation physiological line gradient slope corresponds iodine concentration within voxel higher iodine concentration results larger gradient figure 1 this change attenuation profile reflective binding energy k shell electron k edge iodine 33.2 kev closer mean energy lower energy x ray tube dect scanner typically set either 80 kv 100 kv this translates nearly two fold increase attenuation level iodine 80 kv images compared 140 kv images pathologies result increased iodine concentration either extravasation and/or neovascularity exhibit unique dual energy property complex algorithms developed analyze dect data using material decomposition algorithms based dual energy properties material differentiate brain parenchyma hemorrhage iodine standard multiplanar reconstructions created weighted average image weighting factor 0.4 resembles conventional 120-kvp image single energy ct figure 2 in addition virtual noncontrast vnc image created removal iodine additional radiation exposure closely mimicking noncontrast image obtained single energy ct virtual contrast vc image also known iodine overlay also generated enhance depiction iodine contrast concentration distribution when necessary additional bone calcium subtraction images generated allow better depiction vessel lumens would otherwise obscured bone calcified atheromatous plaque virtual monoenergetic images useful reduce artifact surrounding metallic aneurysm coils clips principle material decomposition algorithm based different attenuation profiles brain parenchyma hematoma iodine cerebrospinal fluid brain parenchyma hematoma show similar hounsfield unit value 80 140 kv images in contrast iodine shows two fold increase hounsfield unit value 80 kv compared 140 kv the gradient slope red arrow correlate iodine concentration increased gradient reflect greater concentration iodine dual energy computed tomography angiogram 80 kvp 140 kvp b weighted average image c simulating 120 kvp image differences hounsfield unit attenuation images illustrated hounsfield unit measurements within left middle cerebral artery the lowest energy 80 kvp image shows greatest hounsfield unit energy level closer k edge iodine in contrast highest energy 140 kvp image b shows lowest hounsfield unit the presence contrast extravasation ct angiography cta within parenchymal hemorrhage also known spot sign shown associated hematoma expansion correlated poor prognosis the accurate depiction spot sign(s therefore potentially serves rapid noninvasive biomarker higher risk hematomas may directly influence decisions medical surgical management currently four phase ii randomized trials underway investigate efficacy early treatment either recombinant activated factor vii tranexamic acid patients high risk hematoma growth depicted presence spot sign ct angiogram stop clinicaltrials.gov nct00810888 spotlight clinicaltrials.gov nct01359202 traige clinicaltrials.gov nct02625948 stop aust clinicaltrials.gov nct01702636 dect improves detection subtle contrast extravasation points increasing conspicuity iodine construction vc image figure 3 this method reduces radiation dose comparison conventional dynamic single energy ct techniques relies separate multiphase acquisitions noncontrast arterial delayed washout phases accurately depict active contrast extravasation similarly dect vc imaging also applied detection active bleeding types extra axial hemorrhage three examples cerebral hematoma active hemorrhage depicted positive spot sign(s arrows dual energy computed tomography angiogram virtual contrast images first row 78-year old male known cerebral amyloid angiopathy second row 50-year old female poorly controlled hypertension e h third row 26-year old male amphetamine abuse l the early recognition hemorrhagic transformation ischemic stroke crucial however accurate interpretation challenging due residual parenchymal staining extravasated iodine contrast preceding diagnostic neurointerventional procedures dect vc imaging overcome problem facilitating accurate differentiation iodinated contrast hemorrhage high sensitivity specificity dect vc images may acquired noncontrast enhanced ct head ct angiogram study latter particularly useful need assess vessel recanalization iodine staining clearly depicted vc image subtracted vnc image interpretation sets postprocessing images may improve diagnostic confidence figure 4 noncontrast computed tomography head shows focal intraparenchymal hyperdensity right lenticular nucleus patient following failed clot retrieval right middle cerebral artery stroke dual energy computed tomography cerebral angiogram virtual noncontrast image b shows subtraction right lenticular nucleus hyperdensity arrows virtual contrast image c confirms hyperdensity arrows represents contrast staining the presence acute intracerebral hemorrhage potential mask underlying lesion neoplasm metastases this ability differentiate hematoma iodine may improve detection lesions accumulate iodine contrast due pathologic breakdown blood dect vc image shown significantly superior conventional single energy weighted average dual energy image detection lesional hemorrhage improved contrast resolution vc image is particularly useful depiction focal tumoral enhancement regional intra- peri tumoral hemorrhage figure 5 50-year old woman melanoma metastasis single energy noncontrast computed tomography image shows acute intraparenchymal hemorrhage right frontal lobe suspicious juxtacortical lesion arrow difficult differentiate surrounding acute hemorrhage computed tomography cerebral angiogram b depicts subtle enhancement suspected juxtacortical lesion arrow virtual contrast image c confirms presence juxtacortical lesion arrow concurrent magnetic resonance imaging brain fluid attenuated inversion recovery pre- post contrast t1-weighted images e f confirms presence enhancing juxtacortical lesion assessment head neck vascular anatomy ct angiogram venogram often obscured calcified atheromatous plaque beam hardening artifact skull base figure 6 often proves problematic assessing crucial vessels pathology using material decomposition analysis dect postprocessing software allows automated subtraction osseous calcified plaques optimal depiction vessel lumen this technique offers wide range clinical applications particular evaluation carotid plaque morphology quantification luminal stenosis dect also used characterize material composition atheromatous plaques subtraction calcium deposits within plaque lesions improve assessment luminal caliber figure 7 dual energy computed tomography venogram bone subtraction images c shows extensive right dural venous sinus thrombosis involving distal transverse sinus sigmoid sinus proximal internal jugular vein arrows dual energy computed tomography venogram without bone subtraction images f provided comparison showing dural venous thrombosis less conspicuous especially skull base arrows ) dual energy computed tomography neck angiogram axial images automatic hard plaque subtraction e h shows moderate high grade stenosis right proximal internal carotid artery hard plaque arrow note automatic hard plaque subtraction images e h better depict degree luminal stenosis standard axial images rotating maximum intensity projections image automatic hard plaque subtraction j shows clear visualization internal carotid artery otherwise obscured hard plaque arrow imaging features atheromatous plaque often considered important risk assessment stroke include presence severe stenosis figure 8 plaque ulceration vasa vasorum enhancement subtle plaque ulceration may obscured view adjacent hard calcified plaque automated calcium subtraction improves visual assessment figure 9 although carotid digital subtraction angiography remains gold standard quantification internal carotid artery stenosis cta become popular accessible imaging modality recent data shown dect automated plaque bone removal images maximum intensity projections improve accuracy cta closely correlate digital subtraction angiography compared standard single energy cta an interpretation pitfall may encountered high grade critical stenotic lesions subtracted images overestimate severity stenosis this avoided careful evaluation subtracted unsubtracted dect images correlating standard reconstructions dual energy computed tomography neck angiogram axial images automatic hard plaque subtraction e h shows high grade stenosis left proximal internal carotid artery circumferential hard plaque arrow note automatic hard plaque subtraction image overestimated degree stenosis compared standard axial image rotating maximum intensity projections image automatic hard plaque subtraction j shows proximal internal carotid artery otherwise obscured hard plaque arrow 38-year old female acute right middle cerebral artery ischemic stroke dual energy computed tomography neck angiogram automatic hard plaque subtraction uncovering fissured soft plaque flanked adjacent calcified hard plaque ( show mixed morphology plaque carotid bifurcation fissuring soft plaque arising posterior wall arrow oblique sagittal reformation demonstrates raised soft plaque posterior wall arrow e irregular central fissure arrow f rotation maximum intensity projections automatic bone hard plaque subtraction clearly display fissured soft plaque arrow g metal streak artifacts aneurysm clips coils greatly degrades image quality limits accurate assessment regional luminal enhancement streak artifacts result beam hardening photon starvation severity artifact dependent thickness composition metal alloy conventional ct techniques attempted reduce metallic artifacts altering gantry angulation multidetector scanning techniques iterative reconstruction helical scanning 3d denoising filter however overall impact improving image quality remained minimal postprocessing dect angiography data allows extraction virtual monoenergetic images arbitrary photon energies ranging 30 kev 130 kev the hounsfield unit hu values within voxel monochromatic energy image reflect attenuation beam single energy contrast hu values derived polychromatic spectrum single energy multidetector ct the imaging processing algorithm based material decomposition specific mass attenuation materials theoretically true monochromatic image contain beam hardening artifacts absence spectral shifts virtual monochromatic image however may still hampered scatter radiation photon starvation although noise level significantly reduced compared single energy multidetector ct polychromatic energy beam hence reducing beam hardening artifacts providing quantitatively accurate attenuation measurements considered main benefits virtual monoenergetic images at lower kev energy levels virtual monoenergetic images show greater contrast enhancement vasculature experience greater degree beam hardening scatter effects figure 10 higher kev the trade metal artifact reduction contrast enhancement implies optimal virtual monoenergetic images lie within 90140 kev range median energy level 113 kev selected lowest noise value area maximum streak artifact figure 11 imaging aneurysm clips notably benefited reduced noise level however artifact aneurysm coiling less affected kev changes cta assessment surveillance post aneurysm coiling clipping set benefit technique alternative imaging modality magnetic resonance angiogram also frequently hampered metal blooming artifact limiting detailed luminal assessment representative dual energy computed tomography angiogram images 49-year old female post left middle cerebral artery aneurysm clipping images h reformatted monoenergetic images 50 kev 60 kev 70 kev 80 kev 90 kev 100 kev 120 kev 130 kev beam hardening artifact reduced 100 130 kev however higher kev contrast attenuation vessel reduced 49-year old female left middle cerebral artery bifurcation preoperative dual energy computed tomography angiogram maximum intensity projections image shows left middle cerebral artery aneurysm m1/m2 junction arrow immediate postoperative dual energy computed tomography angiogram weighted average 120 kvp image b virtual monoenergetic 113 kev image c show aneurysm clip arrow head improved metal artifact reduction resolution adjacent vessel lumen using virtual monoenergetic images arrow c knowledge principles routine application dect clinical practice invaluable problem solving diverse range cerebrovascular diseases the postprocessing steps also incorporated certain routine ct protocols improve diagnostic accuracy especially clinical scenarios carotid plaque assessments post treatment surveillance cerebral aneurysms dect techniques emerge inception development implementation clinical use practice	dual - energy computed tomography ( dect ) simultaneously acquires images at two x - ray energy levels , at both high- and low - peak voltages ( kvp ) . the material attenuation difference obtained from the two x - ray energies can be processed by software to analyze material decomposition and to create additional image datasets , namely , virtual noncontrast , virtual contrast also known as iodine overlay , and bone / calcium subtraction images . dect has a vast array of clinical applications in imaging cerebrovascular diseases , which includes : ( 1 ) identification of active extravasation of iodinated contrast in various types of intracranial hemorrhage ; ( 2 ) differentiation between hemorrhagic transformation and iodine staining in acute ischemic stroke following diagnostic and/or therapeutic catheter angiography ; ( 3 ) identification of culprit lesions in intra - axial hemorrhage ; ( 4 ) calcium subtraction from atheromatous plaque for the assessment of plaque morphology and improved quantification of luminal stenosis ; ( 5 ) bone subtraction to improve the depiction of vascular anatomy with more clarity , especially at the skull base ; ( 6 ) metal artifact reduction utilizing virtual monoenergetic reconstructions for improved luminal assessment postaneurysm coiling or clipping . we discuss the physical principles of dect and review the clinical applications of dect for the evaluation of cerebrovascular diseases .
depressive state frequently observed patients alzheimer type dementia mild cognitive impairment.13 known depression risk factor development alzheimer disease.13 therefore depression middle aged older patients may associated organic brain changes corticobasal degeneration cbd rare progressive neurodegenerative disease characterized progressive asymmetrical rigidity apraxia.4 addition cbd often present complex cognitive difficulties neuropsychiatric disturbances.4,5 symptoms depression apathy agitation subtle often overlooked reactions receiving new diagnosis parkinsonism.46 report case exacerbated depression cognitive impairment later diagnosed cbd receiving full description study patient provided written informed consent case published a 60-year old right handed female depression treated antidepressant paroxetine 20 mg day 13 years presented hospital her mental status remained relatively stable primary treatment prescribed dose paroxetine the patient experienced clumsiness mild rigidity left hand agraphia mild subjective memory complaints 3 years prior admission hospital another hospital diagnosed parkinson disease pd dementia administered anti parkinsonian levodopa l dopa 200 mg day anti dementia donepezil 5 mg day medications addition antidepressant paroxetine 20 mg day she admitted hospital 2 years prior admission present case presented exacerbated depression included worsened depressive mood lowered motivation suicidal ideation without stressful life events admission cognitive impairment well depression observed thus performed head magnetic resonance imaging mri revealed cerebral atrophy figure 1a including within parahippocampal gyrus dopamine transporter dat imaging showed reduction nigrostriatal dat accumulation hand single photon emission computed tomography neuroimaging showed mild decrease blood flow bilateral parietal lobes posterior cingulate gyrus wedge neurobehavioural cognitive status examination cognistat indicated normal range naming judgment mild impairment repetition moderate impairment similarity severe impairment orientation attention comprehension constructional ability memory calculation based findings she diagnosed alzheimer disease anti parkinsonian medication l dopa decarboxylase stopped replaced another anti dementia drug memantine dosage 10 mg day although dosage antidepressant paroxetine increased 20 30 mg day patient depressive status unchanged after discharge developed myoclonus pain left arm depression worsened thus reexamined head mri revealed diffuse atrophy right parietal lobe atrophy figure 1b in addition dat imaging showed right sided decrease accumulation metaiodobenzylguanidine myocardial scintigraphy showed deficit accumulation she finally diagnosed probable cbd according armstrong criteria cbd.7 patient prescribed l dopa 300 mg day left arm myoclonus depression improved date patient cognitive function decreased mental status remained stable although depressive episode occurred 13 years prior admission associated cbd likely depressive episode experienced 2 years prior admission caused cbd depression improve increased dose paroxetine improved l dopa administered cbd based clinical course the depressive episode probably recurred due development cbd despite treated antidepressant therefore first case recurrent depression caused cbd when depression associated neurological symptoms cognitive dysfunction elderly patients cbd considered differential diagnosis psychiatric symptoms cbd shown include depression indifference irritability it reported total frequency apathy irritability disinhibition 58% whereas depression 38%.8 eight 36 autopsied cbd cases 22% psychiatric symptoms including behavioral dyscontrol 8.3% depression 8.3% compulsive behavior 8.3% irritability 2.8% disinhibition 2.8%).9 another study showed social withdrawal common behavioral symptom autopsy confirmed cbd cases fulfilled diagnostic criteria behavioral variant frontotemporal degeneration life.10 disinhibition stereotypy depression frequent psychiatric symptoms followed aggression apathy self centered behavior social withdrawal euphoria.11 nonetheless cognitive psychiatric disturbances common even early stages disease although guidelines treatment depression cbd clear recommendations diagnosis depression pd.1214 antidepressant therapies include tricyclic antidepressants selective serotonin reuptake inhibitors ssris however noted ssris could worsen pd symptoms rapid eye movement sleep behavior disorder periodic limb movement restless legs syndrome.15,16 evidence suggesting administration dopamine agonists mono amine oxidase inhibitors treatment depression pd.12,15,16 pramipexole selegiline suggested antidepressant effects addition motor effects.15,16 mood symptoms present periods patients might benefit drugs targeting motor symptoms.12 however little evidence l dopa alone affects mood,16 although case showed efficacy least it challenging distinguish early pd presenting mild bradykinesia dopamine deficiency depressive symptoms standard ssri responsive depression associated psychomotor retardation asymmetrical mild early pd motor signs subtle asymmetry dat imaging help us distinguish two conditions determine depression motor slowing treated ssri versus l dopa the present case suggests l dopa may effective treatment depression associated cbd although little evidence date regarding address psychiatric symptoms cbd	a 60-year - old female was treated for depression with the antidepressant paroxetine for 13 years . the patient had experienced clumsiness and mild rigidity in the left hand , and had agraphia and mild subjective memory complaints for 3 years prior to admission in our hospital . she experienced exacerbated depression that included worsened depressive mood , lowered motivation , and suicidal ideation without precipitating stressful life events for 2 years prior to admission , and although she had continued taking the antidepressant , these symptoms were not ameliorated by increasing the dose of paroxetine . following the development of myoclonus and pain in her left arm , we performed magnetic resonance imaging of her head , that revealed diffuse atrophy and right parietal lobe atrophy . the patient was ultimately diagnosed with corticobasal degeneration ( cbd ) . her left arm myoclonus and depression improved following levodopa administration . therefore , we concluded that the recurrent depression may have been induced by cbd .
recently endoscopic submucosal dissection esd become standard procedure treating gastric intraepithelial neoplasms gastric adenoma early gastric cancer esd allows en bloc resection large lesions compared endoscopic mucosal resection emr sizes artificial ulcers induced procedure proportionately large kakushima et al reported post esd gastric ulcers heal within 8 weeks regardless size location status helicobacter pylori infection extent gastric atrophy artificial ulcers theoretically remaining submucosal layer thought heal faster peptic ulcers several studies reported proton pump inhibitors ppis effective preventing bleeding procedure prompt healing artificial ulcers oh et al reported initial ulcer size affects ulcer healing status ppi week 4 esd if size post esd ulcer larger predicted ppi administration alone may sufficient treating ulcers kato et al reported combination ppi rebamipide effective ppi alone treating ulcers larger 20 mm within 4 weeks esd esomeprazole isomer omeprazole new form ppi reported show stronger inhibition gastric acid secretion conventional ppis the aim study evaluate efficacy esomeprazole alone artificial ulcers induced esd a total 185 patients underwent esd gastric neoplasms tsuchiura kyodo general hospital january 2013 june 2015 among 185 patients written informed consent obtained entry trial oral dose esomeprazole 20 mg ) the primary endpoints ratio delayed bleeding ulcer scarring rates 4 8 weeks procedure figure 1figure 1study design more one week procedure patient orally administered 20 mg day esomeprazole drug also administered 8 weeks procedure delayed bleeding defined clinically evident bleeding required emergency endoscopic hemostasis and/or blood transfusion decline 2 g dl hemoglobin we evaluated ulcer scarring rates using gastric ulcer staging system table 1table 1gastric ulcer stages classified using 6-stage systemstageendoscopic definitiona1 active stage 1)ulcer contains mucus coating marginal elevation edemaa2 active stage 2)mucus coated ulcer discretemargin less edema active stage 1h1 healing stage 1)unhealed ulcer covered less 50% regenerating epithelium without converging foldsh2 healing stage 2)ulcer mucosal break almost covered regenerating epitheliums1 scar stage 1)red scar rough epithelization without mucosal breaks2 scar stage 2)white scar complete epithelization weeks 4 8 procedure more one week procedure patient orally administered 20 mg day esomeprazole drug also administered 8 weeks procedure esds performed using conventional singe channel endoscope forward water supply function gif h260z q260j olympus tokyo japan the endoscopy device use mainly dual knife kd-650l olympus hyaluronic acid solution injected submucosal layer mucosal incision physiological salt solution used submucosal dissection the ulcer induced esd carefully examined visible vessels coagulated hemostatic forceps fd-410l olympus all statistical analyses performed using jmp version 10.0 software sas institute cary nc usa data expressed mean range minimum maximum level significance set p 0.05 data regarding clinical endoscopic features patients shown table 2table 2characteristics patientssex male female)39/10age years)mean 73.3 range 5887)comorbiditieshypertension28diabetes mellitus5liver cirrhosis2hemodialysis2anticoagulant4antiplatelet drug13h pylori infection yes unknown)20/22/7macroscopic typeprotruded type 0-i 0-ii 28depressed type 0-iic)20flat type 0-iib)1location upper middle lower)6/17/26lesion adenoma cancer)11/38tumor size mm)16.6 range 442)size resected specimen mm)33.6 range 1058)en bloc resection46 93.4%)operating time min)76.7 range 15180 h. pylori infection status evaluated serological testing patients received h. pylori eradication therapy study the mean tumor size 16.6 range 442 mm mean size resected specimens 33.6 range 1058 mm diameter en bloc resection attained 93.4 46/49)% cases complications including perforation occurred trial except one case delayed bleeding there one case delayed bleeding ratio 2.0% 95% confidence interval ci 2.16.1% we defined ulcer scarring s1/s2 stage ulcer scarring rates 4 8 weeks 28.6% 95%ci 17.842.4% 98% 95%ci 89.399.6% respectively figure 2figure 2ulcer stage weeks 4 8 esd ulcer scarring rates s1/s2 weeks 4 8 esd 28.6% 95%ci 17.842.4% 98% 95%ci 89.399.6% respectively we assessed background factor identify correlations ulcer scarring week 4 procedure multiplex logistic analysis significant factors identified table 3table 3factors involved ulcer scarring week 4odds ratiop value95% confidence intervalage1.020.990.891.18location0.980.980.128.67size resected specimen0.020.880.890.13operating time1.000.540.981.05hypertension0.230.190.021.96diabetes mellitus77600.99liver cirrhosis15520.99hemodialysis0.731.00anticoagulant0.000.990.0032.8antiplatelet drug0.470.750.025.87h ulcer scarring rates s1/s2 weeks 4 8 esd 28.6% 95%ci 17.842.4% 98% 95%ci 89.399.6% respectively in japan gastric cancer one common cancers second leading cause cancer related death among men third leading cause among women 2013 the incidence early gastric cancer higher japan countries emr fast simple procedure difficult achieve en block resection lesions larger 20 mm diameter the incidence procedure related complications perforation bleeding higher cases treated esd cases treated emr delayed bleedings occur 05% endoscopically treated patients prevent delayed bleeding post esd preventive coagulation effective oral intake ppi compared histamine-2-receptor antagonist h2-ra thought highly effective bleeding ulcers considered one serious challenging complications esd green et al suggested intragastric ph greater six order allow platelet aggregation prevent platelet disaggregation inhibitors gastric acid secretion ppi h2-ra indispensable ulcer healing prevention post esd hemorrhage ppis commonly used treating post esd ulcers therapies furthermore authors reported beneficial effects combination ppis anti ulcer agents rebamipide mucosal protective antiulcer drug effective healing process artificial ulcers kato et al reported combination ppi rebamipide effective ppi alone ulcers larger 20 mm diameter week 4 esd inaba et al reported patients treated lansoprazole plus polaprezinc ulcer healing significantly faster incidence protrusion ulcer base significantly lower patients treated lansoprazole alone to evaluate effectiveness esomeprazole ulcer healing patients administered mono therapy esomeprazole reported 4 weeks ppi sufficient healing large post esd ulcers concluded 8 weeks treatment required arai et al reported 2 weeks ppi administration may sufficient ulcer healing however consensus regarding proper duration ppi administration esd esomeprazole developed single optical isomer racemic omeprazole shown pharmacological advantages a higher oral bioavailability contributes greater degree acid suppression compared omeprazole the lower interpatient variability likely related unique metabolic pathway drug furuta et al reported number patients refractory ppis depending cyp2c19 genotypes patients grouped three types rapid metabolizer intermediate metabolizer poor metabolizer esomeprazole appears less dependent cyp2c19 thus functions stronger gastric acid secretion inhibitor there reports impact esomeprazole healing artificial ulcers reported s1 stage achieved week 4 esd 27.6% 38.7% patients treated esomeprazole plus rebamipide omeprazole plus rebamipide respectively arai et al compared staging post esd ulcers week patients receiving esomeprazole plus rebamipide 2 weeks 4 weeks found number patients ulcers healing scar stage 20/6 28/5 respectively studies patients received intravenous administration 20 mg omeprazole one two days procedure reported significant differences patients receiving intravenous receiving oral administration esomeprazole respect amount time mean intragastric ph greater 4 day 1 day 5 treatment following administration 20 40 mg therefore results suggest esomeprazole administered one week endoscopic therapy kakushima et al reported gastric ulcers induced esd heal within 8 weeks remain healing stage 4 weeks in trial week 4 ulcers reaching scarring stage detected 28.6% cases irrespective specimen size delayed bleeding rate 2.0% this result may related strong inhibitory potential esomeprazole gastric acid secretion use proper concentration esomeprazole procedure pre administering agents one week endoscopic therapy thus oral esomeprazole administration alone may sufficient preventing delayed bleeding ulcer healing our results suggest single agent therapy esomeprazole used standard therapeutic approach treating artificial gastric ulcers induced esd omission intravenous administration ppi may also reduce burden doctors nurses pharmacists patient admission	objectives : gastric endoscopic submucosal dissection ( esd ) is currently a standard procedure . esd enables en - bloc resection of large lesions , while inducing larger artificial ulcers to a greater extent than conventional procedures . several studies have reported that proton pump inhibitors ( ppis ) prevent delayed bleeding and expedite the artificial ulcer healing process . esomeprazole , an s - isomer of omeprazole , is reportedly one of strongest inhibitors of gastric acid secretion . previous studies have examined the effectiveness of esomeprazole . our goal was to verify the effects of esomeprazole on artificial ulcers in a prospective study.methods : a total of 185 patients underwent esd for gastric neoplasms at our hospital between january 2013 and june 2015 . among these 185 patients , 49 post - esd scar lesions were included in this prospective trial . first , 20 mg esomeprazole was orally administered to all subjects before and after the procedure . we then evaluated the delayed bleeding rate and ulcer scarring rates at 4 weeks and 8 weeks after the procedure by using a gastric ulcer stage system.results : there was one case of delayed bleeding ( 2.0% ) . regardless of helicobacter pylori infection status , ulcer scarring rates at weeks 4 and 8 were respectively 28.6% ( 14/49 ) and 98% ( 48/49).conclusions : our results suggest that oral administration of esomeprazole alone may be sufficient for prompt healing of artificial gastric ulcers induced by esd ( umin000009367 ) .
chronic myeloid leukemia cml one myeloproliferative diseases represents 1520% adult leukemia types depending clinical aspects laboratory findings cml divided three phases typically cml begins chronic phase several years progresses accelerated phase finally blast crisis introduction bcr abl tyrosine kinase inhibitor tki imatinib second generation tkis dasatinib nilotinib nevertheless resistance incompatibilities tkis well known molecular remission difficult achieve curing patients cml chronic lymphocytic leukemia cll belonging indolent b non hodgkin lymphoma b nhl common leukemia adult the treatment cll mainly depends clinical stage disease determined binet staging system c early stage watch wait strategy recommended progress cll the application fludarabine cyclophosphamide rituximab fcr one treatment standards first line therapy cll further alternative therapeutic options particularly progress relapse consideration several clinical aspects established these include application bendamustin rituximab r benda chlorambucil alemtuzumab despite progress made developing effective chemotherapeutic regimes the wingless int wnt signaling pathway plays essential role embryogenesis proliferation survival differentiation hematopoietic stem cells hscs 3 4 it represents complex network mechanisms self regulation positive negative feedback there described large number wnt proteins activate various pathways cells categorized canonical noncanonical wnt pathways paper primarily wnt/-catenin signaling pathway focused influencing expression genes involved cell proliferation differentiation apoptosis are primarily due activation canonical -catenin lymphoid enhancer factor lef)/t cell factor tcf pathway wnt proteins mainly stabilize cytoplasmic -catenin two essential functions important element many intracellular signaling pathways including wnt pathway also takes part creating intercellular adhesive junctions signaling -catenin a number proteins adenomatous polyposis coli apc axin glycogen synthase kinase 3 gsk3 casein kinase alpha ck1 -catenin form destruction complex 8 9 absence activating signal phosphorylation -catenin gsk3 acting conjunction apc axin causes -catenin interact ligase -transducin repeat containing protein -trcp results ubiquitination degradation executed proteasome here transcription factor lef tcf family together proteins groucho binds dna inhibits gene expression transcriptional repressor figure 1 these secreted glycoproteins act ligands membrane receptors belonging frizzled fzd family proteins coreceptors lipoprotein receptor related protein 5 6 lrp 5 6 consequently protein disheveled dvl ) thereby activity gsk3 inhibited increase free pool -catenin stabilization translocation nucleus developed 8 11 nucleus -catenin acts transcriptional coactivator lef tcf family transcription factors final step -catenin lef / tcf signaling pathway nuclear -catenin binds pontin52-tata binding protein displaces groucho related gene creb binding protein corepressors lef tcf resulting stimulation transcription important growth regulatory genes including cyclin d1 c myc 8 13 figure 2 there defined many agents work physiological promoters wnt pathway dishevelled associated kinase dak casein kinase epsilon ck casein kinase ii ck ii integrin linked kinase ilk b cell lymphoma 9 bcl9 bcl9 2/bcl9-like b9l together pygopus 8 10 1416 these agents involved different parts wnt/-catenin pathway lead increased accumulation cellular -catenin augmented assembly wnt target genes axin1 axin2 hmg box transcriptional factor hbp1 dapper1 dpr1 chibby inhibitor -catenin tcf icat contrary represent complex negative regulators wntsignaling pathway they antagonize wnt pathway decreasing cellular -catenin disrupting -catenin lef-1 complexes repressing wnt target genes 7 13 1719 there strong evidence defects wnt pathway involved development several types solid tumors example colorectal prostate breast cancer 8 2022 it known long time hematological malignancies chronic myeloid lymphocytic leukemia mantle cell lymphoma multiple myeloma acute myeloid leukemia may occur partly constitutive activation wnt/-catenin canonical signaling pathway 23 24 especially mutations downstream components wnt pathway apc axin -catenin found responsible genesis human cancers due aberrant signaling activity 9 25 apc protein binds -catenin retains cytoplasm facilitates proteolytic degradation -catenin abrogation negative regulation allows -catenin translocate nucleus form transcriptional activator complex dna binding protein lef-1 expression mutant oncogenic forms -catenin identified cancer cells resulted higher levels transcriptional activity the results suggest cancer pathway driven wnt proteins mutant forms -catenin may involve formation persistent transcriptionally active complex -catenin lef-1 the treatment philadelphia chromosome positive cml highly effective due inhibition bcr abl kinase activity tk inhibitor imatinib nevertheless difficult achieve molecular remission suggesting leukemia stem cells lscs remain patient vivo imatinib treatment lscs remained also accumulated increasingly bone marrow cml mice context it discussed wnt pathway plays vital role survival self renewal lsc zhao et al revealed -catenin deletion causes reduction ability mice develop bcr abl induced cml intriguingly genetic analysis transformed blasts patients blast crisis identified numerous members wnt/-catenin pathway activated in addition data evidence emerging associating survival blast cell wnt activity leading hope wnt inhibitors increase likelihood eradicating cells a comparison gene signatures chronic accelerated blast phases suggests progression chronic phase advanced phase cml accelerated phase blast crisis two step process new gene expression changes occurring early accelerated phase accumulation increased numbers leukemia blast cells process deregulation wnt/-catenin pathway seems represent important aspect it demonstrated wnt signaling pathway activated cll cells uncontrolled wnt/-catenin signaling may contribute defect apoptosis characterizes malignancy it thought responsible extended survival cll cells vivo primary cll cells after upregulation -catenin due wnt stimulation cooperates transcription factor lef-1 overly expressed cll three thousand fold compared normal b cells furthermore lef-1 regarded essential regulator pathophysiological relevant genes cll several wnt/-catenin signaling components fundamentally influence cll cell survival 14 33 similar findings made gutierrez et al analyzing wnt pathway using gene expression profiling result aberrant regulation wnt pathway target genes ligands signaling members could identified especially constitutive wnt pathway activation aberrant protein expression lef-1 cll remarkable even patients monoclonal b cell lymphocytosis that regarded premalignant condition cll expression lef-1 cd19+/cd5 cells could identified it revealed certain wnt wnt network target genes expressed higher lower levels cll compared normal b cells this includes upregulation nuclear complex genes well genes cytoplasmatic proteins wnt ligands related receptors the balance epigenetic downregulation negative effector genes increased expression positive effector genes plays outstanding role pathogenesis cll especially epigenetic downregulation wnt antagonists dickkopf dkk wif1 hypermethylation one mechanism perhaps main mechanism permissive active wnt signaling cll 25 34 furthermore overexpression positive effectors wnt pathway also involved pathogenesis cll model dna methylation histone modifications altered expression microrna molecules interact allow continuous wnt signaling all mechanisms result common consequence activation lef-1/tcf transcription factors subsequent target gene expression large number wnt proteins wnt3 wnt5b wnt6 wnt10a well wnt receptor fzd3 furthermore wnt/-catenin regulated transcription factor lef-1 downstream target cyclin d1 overexpressed cll were able demonstrate pharmacological inhibitor gsk3 sb-216763 activated -catenin mediated transcription enhanced survival cll lymphocytes taken together results indicate wnt signaling genes overexpressed active cll dickkopf1 dkk1 known antagonize wnt signaling direct high affinity binding extracellular domain wnt coreceptor lrp6 b cells patients cll added dkk1 inactivate wnt pathway it estimated cll cells every 6th lrp6 receptor lacking extracellular domain normal b cells proved significantly higher levels extracellular dkk1-binding domain lrp6 hand truncated lrp6 without extracellular dkk1-binding domain could lead uncontrollable activation wnt signaling cll cancer stem cells cscs play significant role development recurrence several cancers time while substantial progress made developing therapeutics targeting signal pathways wnt pathway remained elusive therapeutic target however recent years specific inhibitors pathway keenly researched developed the variety possible underlying mechanisms leading -catenin lef-1/tcf activation offers multiple options target aberrantly activated pathway order prevent target gene expression gene products exert tumorigenic function last decade numerous approaches developed target wnt/-catenin pathway tumor cells antagonizing wnt ligand secretion binding promoting -catenin degradation specifically blocking -catenin mediated transcriptional activity the binding secreted wnt ligands receptors offers attractive accessible target therapeutic regulation signaling pathways wnt proteins wnt receptors secreted wnt inhibitors attractive potential therapeutic agents targets due extracellular location wnt signaling results diverse array downstream intracellular events many fully understood the targeting pathway upstream site pathway activation also provides strategic advantage therapy there done promising researches efforts targeting wnt pathway solid tumors hematology malignancies example colorectal breast prostate cancer multiple myeloma acute myeloid leukemia 21 22 3941 based current knowledge made breakthrough advances targeting wnt pathway cml however fact remains -catenin wnt signaling pathway essential survival self renewal lscs cml providing new strategy targeting cells particularly patients progress relapse incompatibilities treatment tk inhibitors therapeutic developments made wnt pathway could play fundamental role in contrast recent researches indicate wnt pathway attractive candidate developing targeted therapies cll one first lu et al successfully targeted wnt pathway cll lymphocytes using r etodolac analog nonsteroidal anti inflammatory drug diminished wnt/-catenin signaling furthermore lu et al identified diuretic agent ethacrynic acid ea wnt inhibitor vitro assays confirmed inhibitory effect ea wnt/-catenin signaling exposure cll cells ea decreased expression wnt/-catenin target genes including lef-1 cyclin d1 fibronectin immune coprecipitation experiments revealed ea could directly bind lef-1 protein destabilize lef-1/-catenin complex : series amides ethacrynic acid prepared evaluated ability inhibit wnt signaling decrease survival cll cells reduction alpha- beta unsaturated carbon carbon double bond ea abrogated inhibition wnt signaling well decrease cll survival preliminary mechanism action studies suggests derivatives covalently modify sulfhydryl groups present transcription factors important wnt/-catenin signaling table 1 another approach inhibition wnt pathway cascade upwards using salinomycin salinomycin antibiotic potassium ionophore ability inhibit development breast cancer stem cells wnt transfected hek293 cells ingrain another potassium ionophore activity cscs revealed similar effects cll cells constitutive wnt activation nanomolar concentrations salinomycin decreased expression wnt target genes lef-1 cyclin d1 fibronectin depressed lrp6 levels limited cell survival these results indicate ionic changes induced salinomycin related drugs inhibit proximal wnt signaling interfering lpr6 phosphorylation thus impair survival cells depend wnt signaling plasma membrane nitric oxide donating acetylsalicylic acid asa ) the effect paraisomer asa cll cell survival vitro cll like xenograft mouse model analyzed razavi et al apoptosis primary cll cells determined interference asa wnt/-catenin signaling analyzed immunoblots different pathway members cll like jvm3 cells subcutaneously inoculated irradiated nude mice treated 100 mg para asa kg body weight p.o 21 days para asa induced apoptosis cll cells whereas healthy blood cells affected in addition cleavage -catenin downregulation -catenin lef-1 targets observed para asa exhibited strong antitumor efficacy xenograft mouse model tumor inhibition rate 83.4% para asa selectively induces apoptosis primary cll cells efficiently reduces tumor growth cll like xenograft model asa orally available generally well tolerated might promising novel agent cll therapy used two small molecule inhibitors wnt/-catenin lef-1 pathway cgp049090 pkf115 584 vitro vivo studies order antagonize lef-1 using nucleofection small interfering rna- sirna- ) then lc50 two small molecules evaluated using atp based cell viability assay inhibition lef-1 sirna leads increased apoptosis cll cells inhibited proliferation jvm-3 cell lines subcutaneous xenograft model the two small molecule inhibitors efficiently killed cll cells whereas normal b cells significantly affected in vivo studies exhibited tumor inhibition 69% cgp049090 57% pkf115 584 the wnt/-catenin signaling pathway plays outstanding role development chronic leukemia large number aberrant regulation mechanisms wnt pathway lead maintenance progress relapse chronic leukemia revealed furthermore recent years made promising experimental preclinical researches targeting wnt pathway particularly successfully cll	it has been revealed that the wnt/-catenin signaling pathway plays an important role in the development of solid tumors and hematological malignancies , particularly in b - cell neoplasia and leukemia . in the last decade there have been made experimental approaches targeting the wnt pathway in chronic leukemia . in this paper we provide an overview about the current state of knowledge regarding the wnt/-catenin signaling pathway in chronic leukemia with special focus on therapeutic options and strategies .
sarcopenia originally defined age related loss appendicular lean muscle mass relative height squared recently sarcopenia redefined either loss muscle strength and/or impaired physical performance added loss muscle mass.2 3 4 although reductions muscle mass strength positively associated reduction muscle strength exceeds mass therefore clark manini proposed define loss muscle strength dynapenia previous studies shown dynapenia combined obesity associated increased cardiovascular risk.8 9 10 furthermore obesity increases risk death older adults dynapenia by contrast high muscle strength reduces mortality risk individuals aged 5069 years these findings suggest maintaining muscle strength may attenuate extent adverse cardiovascular risk associated aging obesity another important age related process increased arterial stiffness pulse wave velocity pwv occurs primarily aorta the age related increase pwv leads isolated systolic hypertension due impaired buffering function aorta growing evidence suggests strong negative relationship increased pwv reduced muscle mass especially legs abbatecola et al demonstrated increased carotid femoral pwv cfpwv gold standard measure aortic stiffness associated limb muscle mass reduction this negative relationship thoroughly investigated asian populations using brachial ankle pwv bapwv rather cfpwv bapwv composite peripheral leg femoral ankle pwv fapwv cfpwv thereby marker systemic arterial stiffness each increase 1 bapwv associated increase cardiovascular event mortality 12% 13% respectively a higher bapwv found women greater sarcopenic class based appendicular skeletal mass height.2 16 specifically reduced thigh muscle mass negatively associated bapwv nonobese middle aged older men importantly low muscle mass obese adults condition termed sarcopenic obesity additive adverse effect bapwv.18 19 although little evidence exists inverse relationship upper body muscle strength cfpwv young healthy men association handgrip leg muscle strength pwv unknown older adults currently optimal exercise training improving muscle mass strength concurrently arterial stiffness determined high intensity rt shown effective increasing muscle mass muscle strength older adults.21 22 american college sports medicine recommends rt 6080% 1 repetition maximum 1rm improving muscle strength mass quality older adults.23 24 although high intensity rt shown effective improving muscle quality concerns regarding possible adverse effect pwv.25 26 studies found rt increases arterial stiffness young adults.27 28 meta analysis increase pwv 0.7 rt may important clinical adverse implications young healthy adults contrast studies demonstrated pwv changed rt young older men women.21 29 30 31 32 apparently upper body exercises high intensity training would factors involved potential increase bapwv induced rt.25 33 nevertheless reported low intensity rt including leg exercises change pwv systemic aortic leg postmenopausal women collectively data suggest rt may reduce pwv older adults exercise modalities targeting functional structural improvements vascular muscular systems fundamental prevention treatment cardiovascular events when integrating lifestyle modifications order attenuate likelihood risk factors individuals consider overall health benefit expectations also practicality adhere program e.g. motivation time commitment effort perception past 1520 years whole body vibration wbv exercise become attractive strength training modality many healthcare providers since incorporation clinical therapies performance based settings additionally incorporation vibration stimulus passive wbv populations unable perform intense exercise modalities may time efficient alternative reducing risk vascular dysfunction while passive vibration pv propagates vibration induced oscillations exposed area without involving voluntary muscle contractions wbv requires individual maintain target respective joint angles performing static dynamic exercises vibrating platform it previously shown wbv promotes additional muscle contractions excitability spinal reflex via muscle spindles -motor neurons this may mechanism wbv exercise elicits important effect muscle strength wbv training wbvt shown effective modality improvement muscle strength young older adults table 1).35 36 37 38 studies reported increases muscle strength wbvt comparable observed conventional rt healthy young males females well older men postmenopausal women.35 37 39 40 41 44 45 46 one first studies demonstrated 12 weeks wbvt rt induced comparable increases isometric 16.6% dynamic 9% knee extensor strength young untrained lean females strength improvements significant compared participants performed similar exercise protocol vibration nonexercising control group roelants et al increased duration study 24 weeks found greater increase isometric knee extensor strength 24.4% similar population in overweight obese young women found 6 weeks wbvt induced 6.5% increase knee extensor strength these findings furthered milanese et al increased training duration 10 weeks longer wbvt effectively increased knee extensor 14.2% flexor 12.7% press 15.8% strength while previous studies noted similar results wbvt rt conducted young untrained lean adults it known high intensity exercise training decreases adherence lower intensity low perceived effort successful exercise program obese participants.46 53 obese postmenopausal women perform 20 repetitions per set squat exercise therefore low intensity explains high adherence 98% wbvt population figueroa et al milanese et al examined effects wbvt young 21 years middle aged 47 years overweight obese adult females a significant increase leg extension 6.5% observed young overweight obese population 6 weeks wbvt compared nonexercising controls after 10 weeks wbvt milanese et al observed increase leg extension 14.2% leg curl 12.7% leg press 15.8% middle aged women we groups found short term 812 weeks wbvt increased leg muscle strength overweight obese postmenopausal women.36 46 49 54 55 due improvements muscle strength wbvt several recent studies conducted older adults counteract deleterious impact aging physical inactivity disease muscle strength community dwelling healthy older adults 6278 years the increases muscle strength 848 weeks wbvt similar observed rt 4.938.8% significantly greater compared sham nonexercise controls.35 36 37 45 46 55 similarly wbvt increased muscle strength patients chronic stroke diabetic neuropathy 22%).50 51 52 taken together findings suggest beneficial effect wbvt muscle strength gains greater populations muscle weakness result aging and/or diseases several studies assessed effects pv wbv exercise muscle strength bone mineral density cardiorespiratory function limited number studies assessed acute chronic effects exercise modality arterial stiffness acute reductions systemic arterial stiffness bapwv young healthy males previously observed otsuki et al figueroa et al following 10 1-minute sets static squats table 2 otsuki et al initially evaluated acute effects bapwv found significant decreases 20 minutes 40 minutes following single session wbv values recovering baseline 60 minutes last set subsequently figueroa et al examined acute effects wbv protocol used otsuki et al aortic cfpwv leg fapwv bapwv we observed significant reductions fapwv within 30 minutes wbv protocol yet detected cfpwv bapwv furthermore wong et al koutnik et al examined effects acute pv applied posterior side legs ankles glutes healthy young men post stroke patients respectively laying supine vibration platform wong et al examined session 10 continuous minutes pv found decreases bapwv fapwv koutnik et al utilized pv exposure legs assessed fapwv bapwv 5 minutes 15 minutes 30 minutes stimulus pwvs significantly decreased paretic nonparetic sides 5 minutes pv after 15 minutes paretic nonparetic fapwv remained significantly lower baseline yet nonparetic fapwv different control practically previous findings suggest acute exposure either pv exercise wbv acutely decrease bapwv local arterial effects independent aortic stiffness the effects wbvt pwv assessed following 6 weeks 8 weeks 12 weeks populations exhibit heightened risks developing cardiovascular diseases physical disability e.g. obesity aging hypertension table 2 figueroa et al assigned young sedentary overweight obese women 6 weeks wbvt three times week following wbvt bapwv significantly decreased 0.9 0.3 compared nonexercising control period cross study interestingly study combined static dynamic semi squats wide stand semi squat calf raise exercises vibrating platform the dynamic exercises performed slow movements rate 2 second concentric 3 second eccentric phases static movements performed maintaining desired joint angle moreover figueroa et al48 54 examined effects 12 weeks wbvt postmenopausal women pre- stage 1-hypertension participants underwent exercises exception wide stance performed lunges instead importantly significant decreases bapwv 1.23 fapwv 0.81 observed moreover lai et al investigated effect 12-week wbvt program bapwv middle aged older adults notably participants study performed natural full standing postures set frequency 30 hz utilized previously addressed studies a recent study figueroa et al evaluated effects combining wbvt l citrulline supplementation postmenopausal women in addition well known reductions bapwv fapwv induced wbvt alone combining wbvt vasodilatory amino acid supplementation resulted significant decreases cfpwv 0.91 reduction previously observed low intensity high intensity rt.32 33 wbv training wbvt shown effective modality improvement muscle strength young older adults table 1).35 36 37 38 studies reported increases muscle strength wbvt comparable observed conventional rt healthy young males females well older men postmenopausal women.35 37 39 40 41 44 45 46 one first studies demonstrated 12 weeks wbvt rt induced comparable increases isometric 16.6% dynamic 9% knee extensor strength young untrained lean females strength improvements significant compared participants performed similar exercise protocol vibration nonexercising control group roelants et al increased duration study 24 weeks found greater increase isometric knee extensor strength 24.4% similar population in overweight obese young women found 6 weeks wbvt induced 6.5% increase knee extensor strength these findings furthered milanese et al increased training duration 10 weeks longer wbvt effectively increased knee extensor 14.2% flexor 12.7% press 15.8% strength while previous studies noted similar results wbvt rt conducted young untrained lean adults it known high intensity exercise training decreases adherence lower intensity low perceived effort successful exercise program obese participants.46 53 obese postmenopausal women perform 20 repetitions per set squat exercise therefore low intensity explains high adherence 98% wbvt population figueroa et al milanese et al examined effects wbvt young 21 years middle aged 47 years overweight obese adult females a significant increase leg extension 6.5% observed young overweight obese population 6 weeks wbvt compared nonexercising controls after 10 weeks wbvt milanese et al observed increase leg extension 14.2% leg curl 12.7% leg press 15.8% middle aged women we groups found short term 812 weeks wbvt increased leg muscle strength overweight obese postmenopausal women.36 46 49 54 55 due improvements muscle strength wbvt several recent studies conducted older adults counteract deleterious impact aging physical inactivity disease muscle strength community dwelling healthy older adults 6278 years the increases muscle strength 848 weeks wbvt similar observed rt 4.938.8% significantly greater compared sham nonexercise controls.35 36 37 45 46 55 similarly wbvt increased muscle strength patients chronic stroke diabetic neuropathy 22%).50 51 52 taken together findings suggest beneficial effect wbvt muscle strength gains greater populations muscle weakness result aging and/or diseases while several studies assessed effects pv wbv exercise muscle strength bone mineral density cardiorespiratory function limited number studies assessed acute chronic effects exercise modality arterial stiffness acute reductions systemic arterial stiffness bapwv young healthy males previously observed otsuki et al figueroa et al following 10 1-minute sets static squats table 2 otsuki et al initially evaluated acute effects bapwv found significant decreases 20 minutes 40 minutes following single session wbv values recovering baseline 60 minutes last set subsequently figueroa et al examined acute effects wbv protocol used otsuki et al aortic cfpwv leg fapwv bapwv we observed significant reductions fapwv within 30 minutes wbv protocol yet detected cfpwv bapwv furthermore wong et al koutnik et al examined effects acute pv applied posterior side legs ankles glutes healthy young men post stroke patients respectively laying supine vibration platform wong et al examined session 10 continuous minutes pv found decreases bapwv fapwv koutnik et al utilized pv exposure legs assessed fapwv bapwv 5 minutes 15 minutes 30 minutes stimulus pwvs significantly decreased paretic nonparetic sides 5 minutes pv after 15 minutes paretic nonparetic fapwv remained significantly lower baseline yet nonparetic fapwv different control practically previous findings suggest acute exposure either pv exercise wbv acutely decrease bapwv local arterial effects independent aortic stiffness the effects wbvt pwv assessed following 6 weeks 8 weeks 12 weeks populations exhibit heightened risks developing cardiovascular diseases physical disability e.g. obesity aging hypertension table 2 figueroa et al assigned young sedentary overweight obese women 6 weeks wbvt three times week following wbvt bapwv significantly decreased 0.9 0.3 compared nonexercising control period cross study interestingly study combined static dynamic semi squats wide stand semi squat calf raise exercises vibrating platform the dynamic exercises performed slow movements rate 2 second concentric 3 second eccentric phases static movements performed maintaining desired joint angle moreover figueroa et al48 54 examined effects 12 weeks wbvt postmenopausal women pre- stage 1-hypertension participants underwent exercises exception wide stance performed lunges instead importantly significant decreases bapwv 1.23 fapwv 0.81 observed moreover lai et al investigated effect 12-week wbvt program bapwv middle aged older adults notably participants study performed natural full standing postures set frequency 30 hz utilized previously addressed studies a recent study figueroa et al evaluated effects combining wbvt l citrulline supplementation postmenopausal women in addition well known reductions bapwv fapwv induced wbvt alone combining wbvt vasodilatory amino acid supplementation resulted significant decreases cfpwv 0.91 reduction previously observed low intensity high intensity rt.32 33 rt wbvt improve muscle strength older adults however potential adverse effect rt pwv exists contrast wbvt associated decrease systemic leg arterial stiffness young older adults further studies needed examine long term 6 months effects wbvt muscle mass aortic pwv individuals high cardiovascular risk	age - related decreases in muscle mass and strength are associated with decreased mobility , quality of life , and increased cardiovascular risk . coupled with the prevalence of obesity , the risk of death becomes substantially greater . resistance training ( rt ) has a well - documented beneficial impact on muscle mass and strength in young and older adults , although the high - intensity needed to elicit these adaptations may have a detrimental or negligible impact on vascular function , specifically on arterial stiffness . increased arterial stiffness is associated with systolic hypertension , left ventricular hypertrophy , and myocardial ischemia . therefore , improvements of muscle strength and arterial function are important in older adults . recently , whole - body vibration ( wbv ) exercise , a novel modality of strength training , has shown to exhibit similar results on muscle strength as rt in a wide - variety of populations , with the greatest impact in elderly individuals with limited muscle function . additionally , wbv training has been shown to have beneficial effects on vascular function by reducing arterial stiffness . this article reviews relevant publications reporting the effects of wbv on muscle strength and/or arterial stiffness . findings from current studies suggest the use of wbv training as an alternative modality to traditional rt to countermeasure the age - related detriments in muscle strength and arterial stiffness in older adults .
chronic subdural hematoma csdh common clinical entity treated neurosurgeons good cure rates recurrence hematoma infection seizure cerebral edema tension pneumocephalus failure brain expand well recognized complications following surgery csdh an intracerebral intraventricular hemorrhage following evacuation rarely observed incidence ~0.7 5% albeit devastating consequences we report finding subependymal hemorrhage evacuation csdh discuss probable causative mechanisms underlying rare occurrence prevention strategies avoid past history revealed minor fall head injury 1 month ago medical attention sought examination unremarkable except presence pronator drift left side ct computed tomography head showed right csdh measuring 15 mm thickness causing 7 mm midline shift left figure 1a b after baseline investigations documented normal coagulation profile patient taken right frontal parietal burr holes drainage subdural hematoma mac monitored anesthesia care conscious sedation after making burr holes dura coagulated bipolar cautery incised cruciate manner the cut edges dura cauterized shrink dura keep dural opening patent the subdural collection allowed drain without negative pressure applied subdural cavity subdural hematoma drained accord owing pressure differential cavity gently irrigated normal saline till returning fluid clear ct head done immediately post surgery revealed subependymal bleed right lateral ventricle extending laterally thalamus medially body lateral ventricle figure 1c spite findings post operative ct the patient well post operative period complete resolution headache improvement subtle pyramidal deficit left side ( b pre operative ct head showing right chronic subdural hematoma ( c post operative ct head showing subependymal bleed right thalamus extension lateral ventricle as mentioned tend jeopardize good outcome normally expected patients none devastating rare complication intracerebral hemorrhage ich evacuation csdh several causative mechanisms postulated explain complication following simple surgical procedure beneath csdh focal cerebral edema due impeded venous drainage chronic dilatation small arterial vessels loss carbon dioxide reactivity ischemic hemisphere could also contribute pathogenesis possible pathogenic mechanisms ich thus compromised brain include hemorrhage previously undetected areas contusion damage cerebral vasculature secondary rapid peri operative parenchymal shift sudden increase cerebral blood flow post decompression combined focal disruption autoregulation compression extra axial collection decreases cerebral blood flow affected hemisphere alters vascular self adjustment some authors hypothesize rapid increase cerebral blood flow drainage areas brain altered vascular self adjustment may likely precipitating mechanism intracerebral hemorrhage surgical evacuation csdhs compressed brain toward surface mechanism likely explain superficial lobar hematomas we hypothesize sudden decompression brain differential expansile qualities solid brain liquid csf components cranium may result mechanical stress interface turn may cause rupture engorged subependymal veins due prolonged compression chronic sdh benign entity neurosurgical outcome optimized entity considering that intracerebral hemorrhage inadvertently portends poor outcome affected patients preventive steps imperative these include gradual graded decompression chronic sdh especially large collections use closed drainage system facilitates slow expansion brain careful control blood pressure lability peri operative period the gradual graded decompression achieved covering dural aperture cottonoid draining around 15 20 ml subdural hematoma waiting approximately 5 min this procedure continued till subdural pressures equalize atmospheric pressures juncture saline washes instituted this especially holds true large subdural hematomas presenting raised intra cranial pressure our patient fortunate good outcome bleed moderate size however advocate taking steps prevent complications altogether	chronic subdural hematoma ( csdh ) is a common clinical entity treated by neurosurgeons with good cure rates . recurrence of the hematoma and failure of the brain to re - expand are commonly observed complications following surgery for csdh . an intracerebral or intraventricular hemorrhage following evacuation of csdh is very rarely observed , albeit with devastating consequences . we report the finding of a subependymal hemorrhage after evacuation of a csdh and discuss the probable causative mechanisms underlying this rare occurrence and the prevention strategies to avoid it .